Balanced salt solutions

Resuscitation fluids
History of resuscitation fluids

1832- Robert Lewins - intravenous

administration of an alkalinized salt
solution in treating patients during the
cholera pandemic.
1885 - Sidney ringer developed the
physiological salt solution
• Alexis Hartmann - Modified physiological
solution for rehydration of children with
gastroenteritis
1941 - Fractionation of blood - Albumin

In the same year, albumin was used in

large quantities in burn victims of pearl
harbour bombing.
• Fluid therapy is only one component of a
complex hemodynamic resuscitation strategy

• It is targeted primarily at restoring

intravascular volume.

• Since venous return is in equilibrium with

cardiac output, sympathetically mediated
responses regulate both venous(capacitance)
and arterial (conductance) in addition to
myocardial contractility.

•
• Adjunctive therapies to fluid resuscitation,
such as the use of catecholamines to
augment cardiac contraction and venous
return, need to be considered early to
support the failing circulation.
•
Changes to the microcirculation in vital organs
vary widely over time and under different
pathologic states, and the effects of fluid
administration on end-organ function
should be considered along with effects on
intravascular volume.
Ideal resuscitation fluid?
• Predictable and sustained increase in intravascular
volume

• Chemical composition similar/close to ECF

• Metabolised and completely excreted without

accumulation in tissues

• Doesn’t produce adverse metabolic or systemic

effects

• Cost effective in terms of improving patient

outcomes
No such fluid available for clinical use
 Classification of fluids for fluid therapy

Volume Replacement fluids

Crystalloids Colloids Blood Products

e.g. NaCl, Ringer’s Platelets, Plasma, Blood
Harmann’s...

Artificial colloids Natural colloids

Gelatines Starches Dextrans Albumin

• Endothelial glycocalyx :

• A web of membrane bound

glycoproteins and
proteoglycans - Key
determinants of membrane
permeability.

• Glycocalyx degradation
occurs in various conditions
- Fluid overload(x2), septic
shock(x10), aortic
surgery(x40)-(Serum
glycocalyx components)
• ANP

• Circulating enzymes - e.g Heparinase

• Pro-inflammatory cytokines

• Increased shear stress

• Reactive oxygen species

 Colloids
Infusion fluids - that contain large molecules
which are meant to keep the infusate in the
intravascular space for a longer time by exerting
an oncotic pressure.

Albumin, Gelatin, Dextran, HES

Serious concerns have risen over deleterious
effects of semisynthetic colloids on specific
systems, such as haemostasis and renal function.

Evidence of a survival benefit of semisynthetic

colloids over crystalloids has been lacking.

Increased risk of death and the use of renal

replacement therapy in the groups assigned to
receive HES.
These detrimental effects only became visible after
exclusion of seven pre-1999 trials initiated by Dr
Joachim Boldt, whose subsequent publications
have been retracted because of scientific
misconduct.
• FDA black box warning - use of HES on CPB
increases mortality and use of RRT
Albumin - Detrimental in traumatic brain injury
 Crystalloids

Buffered Unbuffered
Ringer’s lactate Sodium chloride
Hartmann
solution
Plasmalyte
Sterofundin
kabilyte
 Normal Saline
The term “normal saline” comes from the
studies of red-cell lysis by Dutch
physiologist Hartog Hamburger in 1882 and
1883, which suggested that 0.9% was the
concentration of salt in human blood, rather
than the actual concentration of 0.6%.
 0.9% NaCl: “Normal saline”

Composition: 1 liter of fluid contains Na= 154mEq,

Cl= 154mEq,

Indications:
As a source of water and electrolytes in depletion
as in diarrhea, alkalosis (vomiting), excessive
diuresis
As a priming solution in hemodialysis procedures.
Hypovolemic shock – In trauma patients when
patients glycemic status not known.
Initial fluid therapy in Diabetic ketoacidosis,
hyponatremia
 ‘Abnormal’ Saline

• Most prominent problem of NS is that the

concentration of chloride is 50% higher than
in plasma.
• Electrolytes such as potassium, calcium, and
magnesium, and also a buffer, are lacking.
• Osmolality and concentration of sodium are
marginally higher than those of plasma.
Its infusion increases plasma chloride
concentrations, which is associated with renal
vasoconstriction and decreased glomerular
filtration rate (GFR).

The administration of large volumes of saline

results in a hyperchloremic metabolic acidosis.
 Why saline causes acidosis?
• Correct view is given by Stewart model, ‘strong ion
difference’ (SID)
• Strong ion difference (mmol/l) = [Na+] + [K+] – [Cl–]
• Normally, SID is approximately +40 in ECF, but zero in 0.9%
saline.
• Therefore, an infusion of 0.9% saline causes acidosis by
decreasing SID, rather than by diluting the bicarbonate
buffer.
• When plasma positive charge is reduced, as commonly
occurs with significant chloride loading (reduced SID), a
compensatory response is proton i.e. H+ generation to
restore charge equilibrium.
• Clinician identifies this physiologic process as a decreased
pH
 Simplified diagram showing SID in a patient with normal plasma Na+ and Cl−
concentations (A) and in a patient with a hyperchloraemic metabolic acidosis (B).

Skellett S et al. Arch Dis Child 2000;83:514-516

Crystalloids with a chemical composition that
approximates extracellular fluid have been termed
“balanced” or “physiologic” solutions.

They are derivatives of the original Hartmann’s

and Ringer’s solutions.

However, none of the proprietary solutions are

either truly balanced or physiologic
 Why Balanced Solutions?

• A balanced electrolyte solution has

Physiological electrolyte pattern of plasma in terms of

cation and anion concentrations and osmolality

Achieves a physiological acid-base balance with

bicarbonate or metabolizable anions such as acetate,
lactate, malate and citrate.

Infusion of such a balanced solution is devoid of the risk

of iatrogenic disruptions except for potential volume
overload.

Examples of more balanced crystalloid solutions are

lactated Ringer’s solution, Plasma-Lyte, Sterofundin and
Kabilyte
Electrolyte Plasma 0.9% RL Plasma- Sterofundin Kabilyte
NaCl Hartmann’s Lyte
Sodium 135-145 154 131 140 140 140
Potassium 5 0 5 5 4 5
Chloride 95-105 154 111 98 127 98
Calcium 2.2 0 2 0 2.5 0
Magnesium 1 0 1 1.5 1 1.5
HCO3- 24 0 0 0 0 0
Lactate 1 0 29 0 0 0
Acetate 0 0 0 27 24 27
Gluconate 0 0 0 23 0 23
Maleate 0 0 0 0 5 0
Osmolarity 275-295 308 274 294 309 294
pH 7.4 5 6.5 7.4 5.1-5.9 7.4
Because of the instability of bicarbonate-containing
solutions in plastic containers, alternative anions,
such as lactate, acetate, gluconate, and malate,
have been used.
Advantages of acetate over lactate
• The key point to remember is that lactic acid
is an acid but lactate is a base.

• The administration of lactate in Hartmann’s

solution can never result in a lactic acidosis
because it is a base and not an acid.

• The solution contains sodium lactate and not

lactic acid.

• The lactate anion is the conjugate base of

lactic acid and represents potential
bicarbonate and not potential H+.
• large volumes of ringer’s lactate cause
Hyper lactatemia(not lactic acidosis) and
hypotonicity.

• Calcium, along with citrated blood may

cause formation of micro thrombi.

• Large volumes of Acetate(kabilyte)cause

cardio toxicity.