REVIEW

CURRENT
OPINION Intravenous fluids in sepsis: what to use and what
to avoid
Nithin Karakala a, Karthik Raghunathan b, and Andrew D. Shaw b

Purpose of review
Septic shock is one of the most common and life-threatening conditions afflicting critically ill patients.
Intravenous volume resuscitation is considered an initial and very important step in management. The most
suitable fluid for volume expansion during septic shock remains unclear. In this review, we focus on the
benefits and adverse effects of the most commonly used intravenous fluids in critically ill septic patients.
Recent findings
The debate about the benefits of colloids over crystalloids has been ongoing for the last few decades. With
recent literature showing apparent harm from the use of hydroxyethyl starches (HESs), and given the
growing concerns of adverse renal and acid–base abnormalities associated with 0.9% saline compared
with balanced crystalloid solutions, it may be time to change the nature of the ‘fluid debate’.
Summary
Crystalloids should still be considered as the first-choice drug for volume resuscitation in patients with septic
shock. Colloids such as albumin can be considered in some clinical settings. HES should be avoided.
Balanced crystalloids might have an important role to play in the management of septic shock.
Keywords
albumin, balanced crystalloids, fluid resuscitation, hydroxyethyl starch, sepsis

INTRODUCTION
Sepsis is a global problem, associated with very high
mortality among those affected, both in underde-
veloped and in industrialized countries. The esti-
mated incidence is around 300 cases per 100 000
population in the USA, accounting for 2.26% of all
hospital admissions [1]. Even though mortality rates
associated with sepsis have improved over the last 2
decades, they are still above 20% [2]. Hypotension is
seen in about half of all septic patients, and
mortality in patients with hemodynamic instability
is approximately 50% [3]. Protocol-driven volume
resuscitation is considered an important initial step
in the management of septic shock. Early aggressive
volume resuscitation to achieve hemodynamic
stability has been associated with significant
improvement in mortality [4,5]. Though the goal
is to achieve and maintain hemodynamic stability,
the choice of fluids used to attain this goal could
determine the outcome of management. The crys-
talloids vs. colloids contrast has been studied for
many years. There are still significant differences in
the preference for specific intravenous fluids world-
wide, and crystalloids are preferred in the USA,
whereas colloids are still the fluids of choice in
Europe [6]. In the last few years, there has been
increased use of hydroxyethyl starch (HES) prod-
ucts, but recent publications have shown possible
adverse renal outcomes associated with HES. 0.9%
(Normal) saline is still the most frequently used fluid
in the USA, and there are growing concerns about
the use of chloride-rich fluids, mainly because of
effects on renal function.
DOSE OF FLUID RESUSCITATION
Intravenous fluids are the most commonly pre-
scribed drugs in the hospital. Since Emanuel Rivers
a
Division of Nephrology, Department of Medicine, Medical University of
South Carolina, Charleston, South Carolina and bDepartment of Anes-
thesiology, Duke University Medical Center, Durham VAMC, Durham,
North Carolina, USA
Correspondence to Andrew D. Shaw, MBBS, FRCA, FCCM, Associate
Professor, Department of Anesthesiology and Critical Care Medicine,
Duke University Medical Center, Durham VAMC, Durham, North Carolina,
USA. Tel: +1 919 286 0411 x5091; fax: +1 919 286 6853; e-mail:
andrew.shaw@duke.edu
Curr Opin Crit Care 2013, 19:537–543
DOI:10.1097/MCC.0000000000000028

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 Renal system
KEY POINTS

Crystalloids are the fluids of choice in sepsis.

Use albumin in hypoalbuminemic patients during
critical illness with compromised endothelial integrity.

HES is associated with increased renal injury and
should be avoided during fluid resuscitation in patients
with septic shock.

Identify chloride-rich fluids as a possible cause for
undesirable hyperchloremic metabolic acidosis.
introduced the Early Goal Directed Therapy in 2001
[4], there has been a push for aggressive volume
resuscitation in patients with septic shock. Volume
resuscitation in septic patients is aimed at improv-
ing tissue perfusion by increasing the cardiac
output. It is both crucial and challenging to deter-
mine how much volume is needed to maintain peak
cardiac performance as myocardial contractility and
compliance is affected in sepsis. Recent studies have
demonstrated that overaggressive fluid resuscitation
is not beneficial in the management of critically ill
patients, but is detrimental to their outcome. Net
positive fluid balance in resuscitated patients with
septic shock is associated with increased mortality.
The risk of mortality from positive fluid balance
starts within 12 h of resuscitation [7]. It is important
to recognize that fluid management in septic
patients is time dependent and should be done
aggressively during the first 4–6 h, which is associ-
ated with significantly better outcomes compared
with those who are inadequately resuscitated [8].
Following the initial period of aggressive resuscita-
tion, it becomes important to focus on maintaining
net-even fluid balance, as late liberal fluid adminis-
tration is associated with significantly worse out-
comes [8]. Though not widely practiced, measures to
correct volume overload that occur during the
initial fluid resuscitation within the first 72 h sig-
nificantly improve outcomes [9].
It is important to realize that fluid resuscitation
is arguably the most important step in the manage-
ment of septic patients, but the physiological basis
of this intervention should be clearly understood.
Clinicians need to identify intravenous fluids as
drugs that have a therapeutic index, and patient
comorbidities and the clinical scenario determine
the toxic dose of these drugs.
ALBUMIN VS. CRYSTALLOID
Albumin is the most abundant plasma protein,
accounting for 50–60% of measured protein, and
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involved in many biological processes. Albumin is
one of the most commonly used colloidal solutions
for volume expansion in critically ill patients. The
benefit and harm of albumin use have been exten-
sively debated and there was concern of increased
mortality in critically ill patients [10,11]. A system-
atic review by the Cochrane group demonstrated
relative risk (RR) of mortality of 1.46 [95% confi-
dence interval (CI) 0.97–2.22] in hypovolemic
patients who received albumin compared to crys-
talloid fluids [12], which led to a significant decrease
in albumin use [13]. In the last few years, evidence
demonstrating improved safety associated with
albumin use was published [14,15]. A large random-
ized controlled trial in ICU patients failed to show
an increase in mortality in patients treated with
4% albumin when compared to patients treated
with normal saline (20.9 vs. 21.1%, P ¼ 0.87) [16].
Mortality in patients with septic shock decreased
with albumin therapy (30.7 vs. 35.5%, P ¼ 0.09)
compared with normal saline. Patients treated with
albumin received significantly lower volumes of
fluid and had lower total fluid gains during the first
3 days of treatment. There appears to be no differ-
ence in the use of renal replacement therapy (RRT)
or days on ventilator support in patients treated
with albumin [17]. Hyperoncotic albumin use
may play an important role in patient outcomes.
Evidence from a large meta-analysis showed that
patients treated with hyperoncotic albumin
solutions (20–25% albumin) had decreased risk of
mortality [odds ratio (OR) 0.52, CI 0.28–0.95,
P ¼ 0.03] and risk of developing acute kidney injury
(AKI; OR 0.24, CI 0.12–0.48, P < 0.001) when com-
pared with hypooncotic albumin or crystalloids
[18]. Even with some studies showing evidence of
possible harm associated with albumin infusions,
benefits of albumin infusion have been seen in
certain subgroups of patients.
Hypoalbuminemia is common in critically ill
patients and is associated with increased mortality
[19]. In patients with albumin concentration less
than 3.1 mg/dl, there was significantly better
improvement in Sequential Organ Failure Assess-
ment (SOFA) scores from baseline in patients treated
with 20% albumin compared with Ringer’s lactate
(3.1 vs. 1.4, P ¼ 0.03) [11]. The improvement in
SOFA score was vastly contributed to improvement
in cardiovascular status in these patients. Albumin
treatment is shown to improve mortality in patients
with peritonitis-induced septic shock [20,21].
Patients treated with 5% albumin at a dose of 25 g
three times a day had lower rate of in-hospital
mortality compared with those treated with normal
saline (45 vs. 76%, P ¼ 0.03), but the mortality
benefit was evident only in patients whose baseline
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Number 6
December 2013

albumin was 20 g/dl or less (OR 0.23, P ¼ 0.023).
There was no benefit in patients with serum albu-
min greater than 20 g/dl (OR 1.99, P ¼ 0.255) [20].
Few studies have evaluated the direct effect of
albumin infusion on renal outcomes and the inci-
dence of AKI in patients with septic shock. Albumin
infusion appears to improve renal function in
patients with cirrhosis and spontaneous bacterial
peritonitis [21]. When such patients were given
1.5 g/kg body weight during the first 6 h followed
by 1 g/kg on day 3, they had significantly lower
mortality during the hospitalization (10 vs. 29%,
P ¼ 0.01). Patients treated with albumin had a lower
incidence of renal impairment and lower mean
serum creatinine values compared with controls
(10 vs. 33%, P ¼ 0.002). Improved renal outcome,
therefore, appears to be a result of improved hemo-
dynamics. AKI in cirrhotic patients occurs because
of severe renal vasoconstriction, and albumin infu-
sion is known to decrease plasma renin activity,
ameliorating the renal vasoconstriction and thus
improving renal blood flow (RBF). Diuretics are
known to cause AKI and are associated with wors-
ened renal recovery in patients with AKI [22]. In a
randomized controlled study in hypoproteinemic
patients with acute lung injury (ALI) or acute respir-
atory distress syndrome (ARDS) [23], patients
treated with furosemide and albumin had signifi-
cantly improved oxygenation, cardiac output and
mean arterial pressure when compared with those
treated with furosemide alone. Albumin treatment
could thus aid in aggressive diuresis, while still
maintaining stable renal function. In a small study
comparing urine biomarkers of AKI in patients with
early sepsis, randomized to receive normal saline vs.
albumin [24], patients treated with albumin had a
smaller increase in urine neutrophil gelatinase
associated lipocalin (NGAL), perhaps indicating a
milder degree of tubular injury.
Albumin infusion may be a useful substitute to
crystalloids in hypoalbuminemic patients with septic
shock. In patients with cirrhosis and peritonitis with
hypoalbuminemia, albumin should be considered
for volume resuscitation. The benefits of albumin
may extend beyond improving hemodynamic
stability by possibly playing a role in limiting capil-
lary leak by maintaining endothelial cell integrity
[25,26]. Albumin treatment also increases the plasma
clearance of reactive oxygen species, attenuating the
inflammatory injury in septic patients [27].
HYDROXYETHYL STARCH VS.
CRYSTALLOIDS
HESs are synthetic colloids used for volume resusci-
tation around the world until the recent suspensions
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Intravenous fluids in sepsis Karakala et al.
in Europe and FDA warnings in the USA. HES is
extensively used in the ICU for volume resuscitation
in septic patients and in the operating rooms in
Europe. HES is derived from waxy maize or potato
starch, and is a modification of amylopectin mol-
ecules by hydroxyethylation of the glucose subunits
preventing rapid hydrolysis by plasma alpha-amylase
&&
[28,29 ]. Schortgen et al. [30] compared HES to gel-
atin in patients with septic shock. Patients assigned to
the HES group received 6% HES (200 kDa, 0.60–0.66)
at an initial dose of 35 ml/kg in the first 24 h and
20 ml/kg/day, total dose not exceeding 80 ml/kg. The
gelatin group was treated with 3% fluid-modified
gelatin as needed with no dose limitation. A higher
incidence of renal failure, defined as a two-fold
increase in serum creatinine from inclusion (i.e.
KDIGO 2) or use of RRT, was observed in patients
treated with HES compared with those treated with
gelatin (42 vs. 23%, P ¼ 0.023), and the OR for renal
failure was 2.32 (95% CI 1.02–5.34) in the HES group.
Significantly higher numbers of patients in the HES
group developed oliguria when compared with the
gelatin group (56 vs. 36.5%, P ¼ 0.025). Treatment
with HES was an independent predictor of AKI (OR
2.57, P ¼ 0.026). The Efficacy of Volume Substitution
and Insulin Therapy in Severe Sepsis (VISEP) trial
compared the effects of HES (10%, 200/0.45–0.55)
vs. Ringer’s Lactate (Table 1) on renal outcome and
survival in patients with severe sepsis [31]. Patients
randomized to the HES group received 10% HES
(200 kDa, 0.45–0.55) and the other group received
Ringer’s lactate. Patients in the HES group received a
median of 70.4 ml/kg body weight of study drug.
There was a trend toward increased 90-day mortality
in the HES group (41 vs. 33.9%, P ¼ 0.09). The most
striking difference was in the incidence of AKI (34.9
vs. 22.8%, P ¼ 0.002) and days on which RRT was
required (18.3 vs. 9.2%) in the HES group compared
with the Ringer’s lactate group. The dose of HES was
an independent predictor of need for RRT. It is
unclear whether this is a true dose–response effect
of HES or if sicker patients needed higher doses of HES
to maintain hemodynamic stability. Whatever the
relationship, the VISEP trial clearly demonstrated a
potential for adverse renal outcomes to occur after
therapy with HES. The high osmolality of the HES
solution used in this trial may also have contributed
to the adverse renal outcomes [18].
In the last few years, newer preparations of HES
(Table 2) have been introduced that have lower
molecular weight, are iso-osmolar, and have a lower
molar substitution (degree of hydroxyethylation)
ratio. When medium-to-high molecular weight
(200 kDa) HES solution is used, the plasma clear-
ance of HES is significantly decreased with increas-
ing osmolality, and there is increased plasma and
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 Renal system

Table 1. Chemical characteristics of commonly used fluids

Plasma Normal saline Lactated Ringer’s Ringer’s scetate Plasma-Lyte 148 Albumin 4% Albumin 20%

Osmolality (mOsm/l) 290 308 273 277 294 260 130

Na (mEq/l) 140 154 130 145 140 140 48–100
Cl (mEq/l) 100 154 109 127 98 128 19
K (mEq/l) 4 0 4 4 5 0 0
Ca (mEq/l) 5 0 3 5 0 0 0
Mg (mEq/l) 3 0 0 2 3 0 0
Lactate (mEq/l) 2 0 28 0 0 0 0
Gluconate (mEq/l) 0 0 0 0 23 0 0
Acetate (mmol/l) 0 0 0 24 27 0 0
Octanoate (mmol/l) 6.4 32

tissue accumulation after multiple doses [32]. Older
HES preparations appear to accumulate more in the
plasma when compared to newer, lower substitution
HES preparations [33]. HES 130/0.4 (tetrastarch) has
relatively low plasma accumulation even after
repeated doses [34,35]. Peak plasma concentrations
and renal elimination of tetrastarch are not signifi-
cantly different in patients with moderate-to-severe
renal failure compared to those with normal renal
function, apparently decreasing the risk of accumu-
lation in patients with renal impairment [36].
The Crystalloid Versus Hydroxyethyl Starch Trial
(CHEST), Effects of Voluven on Hemodynamics
and Tolerability of Enteral Nutrition in Patients
With Severe Sepsis Trial and Scandinavian Starch
for Severe Sepsis/Septic Shock Trial (6S) trials eval-
uated the safety and efficacy of the latest HES pre-
paration (tetrastarch), HES 6% (130 kDa, 0.4). In
&&
the CHEST trial [37 ], 7000 patients were rando-
mized to receive HES or 0.9% (normal) saline.
Mortality at 90 days was not significantly higher
in the HES group (RR 1.06, CI 0.96–1.18, P ¼ 0.26).
During the first 7 days of treatment, the HES group
had significantly elevated serum creatinine values
and decreased urine output; further, the risk of RRT
was higher in the group treated with HES (RR 1.21,
CI 1–1.45, P ¼ 0.04). There were contrasting results
in the incidence of Risk-Injury-Failure-Loss-End
stage (RIFLE) Risk (R) and Injury (I) when only serum
creatinine or urine output were used to define AKI.
When RIFLE-R and I was defined by increase in
creatinine, the HES group had significantly higher
risk of developing AKI, but the normal saline group
had significantly lower urine output with higher
incidence of AKI defined by the urine output
criteria. This disparity in the incidence of AKI when
only creatinine was considered could be secondary
to the hemodilution in patients treated with normal
saline, as they needed significantly higher volume of
resuscitative fluid compared with HES [38]. The
CRYSTMAS trial evaluated the efficacy of HES in
maintaining the hemodynamic status and safety
&&
in patients with septic shock [39 ]. In this trial, a
significantly lower volume of HES was needed to
maintain hemodynamic stability (1379  886 vs.
1709  1164 ml, P ¼ 0.018). Both groups had no
significant differences in the incidence of AKI by
RIFLE (P ¼ 0.81) and Acute Kidney Injury Network
(P ¼ 0.59) classification. Mean peak creatinine was
1.8  1.2 and 1.7  1.2 mg/dl (P ¼ 0.93) in HES and
normal saline groups, and levels of urine biomarkers
of AKI (alpha 1 microglobulin, beta-NAG, and

Table 2. Chemical characteristics of commercially available hydroxyethyl starch solutions

Hetastarch Pentastarch Tetraspan Tetrastarch

HES% 6 10 6 6
Oncotic pressure (mmHg) 25–30 55–60 36 36
Molecular weight (Daltons) 670 000 200 000 130 000 130 000
Substitution 0.75 0.45–0.55 0.42 0.4
Na (mEq/l) 154 154 140 154
Cl (mEq/l) 154 154 118 154

HES, hydroxyethyl starch.

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NGAL) were similar in both the groups. However,
the study was not adequately powered to detect an
adverse safety outcome. The 6S trial compared HES
130/0.4 solution dissolved in Ringer’s acetate to
&&
Ringer’s acetate alone in severe sepsis [40 ]. There
was no significant difference in either volume of
trial fluid or total volume of fluid administered
between the groups, suggesting that in those
patients HES was not more efficient than crystalloids
in terms of volume expansion. This may also reflect
that overall enrollment in the study occurred after
the need for initial volume resuscitation had passed.
The incidence of the combined primary outcome
of death or dependence on dialysis at 90 days was
significantly higher in the HES group compared
with the Ringer’s acetate group (51 vs. 43%,
P ¼ 0.03). The number of patients needing RRT at
any time during 90 days was also significantly
higher in the HES group (22 vs. 16%, P ¼ 0.04).
HES appears to be more harmful when given to
sicker patients therefore.
The pathology of the renal injury caused by HES
is unclear in humans, but in animal experiments,
the cause appears to be osmotic nephrosis and not
acute tubular necrosis or acute interstitial nephrosis,
even when a low osmolality solution is used [41].
HES has not been shown to be a better alternative to
crystalloids for volume resuscitation; in contrary,
the evidence from CHEST and 6S shows that HES
appears to be associated with worse renal outcomes
(increased risk of RRT up to 90 days after the use of
the drug).
BALANCED VS. UNBALANCED FLUIDS
Normal saline is the most commonly used fluid for
&&
volume resuscitation in the USA [42,43 ]. Normal
saline was initially called ‘Indifferent’ saline by
Hartold Jacob Hamburger in 1892, when he recog-
nized that erythrocytes did not lyse when placed in
0.9% saline solution [44]. Is normal saline truly
‘normal’ or ‘physiological’? Normal saline has a ‘near
physiological’ concentration of sodium (154 meq/l),
but 1.5 times the normal serum concentration of
chloride (154 meq/l). High renal tubular chloride
concentrations cause significant alterations in renal
hemodynamics [45,46]. In a micropuncture exper-
iment, Wilcox [47] demonstrated renal afferent vaso-
constriction in response to a rise in plasma chloride
concentration in dogs. Infusion of chloride contain-
ing solutions (NaCl and NH4Cl) was associated with
reduced RBF over a period of 1–30 min after the start
of infusion. There was no significant change in RBF
and glomerular filtration rate (GFR) in correlation to
sodium concentration (r ¼ 0.45, P > 0.05). RBF and
GFR were closely correlated to fractional excretion of
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Intravenous fluids in sepsis Karakala et al.
chloride (r ¼ 0.81, P < 0.05). The reductions in RBF
and GFR in salt and volume depleted dogs (treated
with NaCl infusion) were more than twice as great as
&&
in euvolemic dogs. Chowdhury et al. [48 ] studied
the effects of intravenous infusion of 0.9% normal
saline and a balanced solution (Plasma-Lyte 148) on
renal hemodynamics in healthy humans. Following
the initial infusion of 2 l of normal saline, there was a
progressive decrease in RBF velocity, which was sig-
nificantly lower than in the same individuals treated
with Plasma-Lyte 148. Similarly, the renal cortical
tissue perfusion was significantly lower when treated
with 0.9% normal saline. In a retrospective analysis of
&&
patients following open abdominal surgery [43 ],
there was no significant difference in AKI rates when
treated with either 0.9% normal saline or balanced
crystalloid solution, but the need for dialysis was
significantly higher in the normal saline group
(1 vs. 4.8%, P < 0.001). The patients treated with
normal saline had higher mortality compared with
those treated with balanced fluid (5.6 vs. 2.9%,
P < 0.001). In the propensity-matched patient
groups, treatment with balanced fluid was associated
with lower incidence of postoperative infection,
AKI needing dialysis, blood transfusion, electrolyte
disturbances and acidosis investigation. Yunos et al.
&&
[49 ] reported a prospective sequential study in crit-
ically ill patients, in which balanced fluids replaced
chloride-rich fluids during the intervention period.
Chloride administration decreased from 694 mmol/l
during the control period to 496 mmol/l during the
intervention. During the intervention period, there
was a significantly lower increase in creatinine during
the ICU stay (0.17 vs. 2.6 mg/dl, P ¼ 0.007). The inci-
dence of ‘Injury’ class of AKI defined by RIFLE criteria
was lower during the intervention period (6.35 vs.
3%, P ¼ 0.002), but there was no significant difference
in the incidence of risk and failure classes. There was a
significant decrease in the use of dialysis during the
intervention period (6.3 vs. 10%, P ¼ 0.005). Fluid
resuscitation with balanced fluid has a shorter time to
micturition from the start of infusion [50] and higher
postinfusion urine volumes compared with normal
&& &&
saline [48 ]. Shaw et al. [43 ] observed that patients
treated with Plasma-Lyte required lower volumes of
fluid when compared with normal saline. Normal
saline infusion causes a significantly higher extra-
cellular volume increase when compared with
&&
Plasma-Lyte [48 ], potentially leading to compli-
cations associated with volume overload.
Another major difference between normal
saline and balanced fluid is the changes in acid–
base balance following resuscitation. Metabolic
acidosis is one of the complications of septic shock,
and this is attributable to lactic acidosis occurring
secondary to tissue hypoperfusion. Infusion of
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 Renal system
normal saline is associated with a drop in serum
bicarbonate concentration and a decrease in blood
&&
pH [48 ,51,52]. In many cases, the concentration
of lactate cannot explain the degree of acidosis,
and the acidosis occurs secondary to decreased
strong ion difference [53,54]. The clinical import-
ance of iatrogenic hyperchloremic acidosis is
unclear, but in a large observation trial, there was
no significant difference in mortality associated
with hyperchloremic acidosis [54]. In cell culture
experiments, the presence of hyperchloremic
acidosis is pro-inflammatory as compared to lactic
acid, which is anti-inflammatory [55]. In the every-
day clinical setting, it is not easy to differentiate
between hyperchloremic metabolic acidosis associ-
ated with normal saline resuscitation from lactic
acidosis in patients with severe sepsis. Frequently,
acidosis in severe sepsis is attributed to tissue hypo-
perfusion, which is treated with aggressive volume
resuscitation leading to complications of volume
overload such as pulmonary edema and intra-
abdominal hypertension [56], and these compli-
cations could potentially explain the higher rate
of RRT observed in patients treated with normal
&&
saline [43 ].
There is no strong evidence showing differences
in the outcomes of using balanced or unbalanced
crystalloids during initial or maintenance phase of
resuscitation. During the initial management of
septic shock, aggressive volume restitution is the
most important step and the type of crystalloids
may not influence the clinical outcome. The
toxicity associated with unbalanced crystalloids
appears to be dose related [57]. The differences in
adverse outcomes become apparent at high cumu-
lative dose, and benefit of using balanced solutions
may be more apparent during the maintenance
phase of resuscitation. Balanced fluids could thus
play an important role in volume resuscitation in
septic patients. It is important to understand the
physiology and electrolyte abnormalities associated
with chloride-rich fluids. Mislabeling all acidosis in
septic patients as lactic acidosis should be avoided if
volume overload in critically ill patients is to
be avoided.
CONCLUSION
Volume resuscitation plays an important role in the
management of sepsis and septic shock, improving
mortality and renal outcomes in these patients. As
recommended by the recent International Guide-
lines for the Management of Severe Sepsis, crystal-
loids should be used as the initial fluid of choice in
resuscitation [58]. The choice of intravenous fluid
should be based on the underlying pathophysiology,
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and should not be a ‘one size fits all’ approach. In
critically ill patients with hypoalbuminemia and
abdominal sepsis, intravenous albumin should be
considered in addition to crystalloids. Given the
presently available data, we recommend avoiding
HES in septic patients. Balanced fluids should be
considered in patients who have persistent hyper-
chloremic acidosis after receiving chloride-rich
fluids.
Acknowledgements
None.
Conflicts of interest
A.D.S. is a consultant for Baxter Inc, manufacturers of
Plasma-Lyte 148.
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