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Rev Esp Anestesiol Reanim. 2017;xxx(xx):xxx---xxx

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

ORIGINAL ARTICLE

Maintenance fluid therapy in a tertiary hospital: A

prevalence study夽
R. Uña Orejón a,∗ , L. Gisbert de la Cuadra b , D. Garríguez Pérez b , J. Díez Sebastián c ,
M.P. Ureta Tolsada a

a
Sección de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
b
Sección de Anestesiología y Reanimación, Universidad Autónoma de Madrid, Madrid, Spain
c
Servicio de Medicina Preventiva, Hospital Universitario La Paz, Madrid, Spain

Received 15 July 2016; accepted 19 December 2016

KEYWORDS Abstract
Intravenous fluids; Objective: To assess the types of maintenance fluids used in our hospital, comparing their
Crystalloids; volume and composition to the standards recommended by the guidelines.
Hyperchloraemia Material and methods: Observational, cross-sectional study. Volume and type of fluid therapy
administered during 24 h to patients admitted to various hospital departments were recorded.
Patients receiving fluid therapy because of water-electrolyte imbalance were excluded.
Results: Out of 198 patients registered, 74 (37.4%) were excluded because they did not meet the
criteria for inclusion. Mean administered volume was 2500 cc/day. Mean daily glucose dose was
36 g per 24 h (SD: 31.4). The most frequent combination included normal saline solution (NSS)
and glucose 5% (64.4%). Mean daily dose of sodium and chlorine was, respectively, 173 mEq (SD:
74.8) and 168 mEq (SD: 75), representing a surplus daily dose of +87.4 mEq and +85 mEq. Potas-
sium, magnesium and calcium daily deficit was, respectively, −50 mEq, −22 mEq and −21 mEq
per day. Buffer administration was exceptional, bicarbonate (2.29%), acetate (1.29%), lactate
(1.15%) and gluconate (1.10%) being the buffering agents most frequently used.
Conclusion: NNS is the most frequently used solution. In contrast to excess doses of sodium and
chlorine, there is a great deficit of other ions, buffering agents and caloric intake in the fluid
therapy regimens that are usually prescribed.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

夽 Please cite this article as: Uña Orejón R, Gisbert de la Cuadra L, Garríguez Pérez D, Díez Sebastián J, Ureta Tolsada MP.

Fluidoterapia de mantenimiento administrada en un hospital terciario: estudio de prevalencia. Rev Esp Anestesiol Reanim. 2017.
http://dx.doi.org/10.1016/j.redar.2016.12.006
∗ Corresponding author.

E-mail addresses: runa.hulp@salud.madrid.org, Gorote90@gmail.com (R. Uña Orejón).

2341-1929/© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.

REDARE-776; No. of Pages 7

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PALABRAS CLAVE Fluidoterapia de mantenimiento administrada en un hospital terciario: estudio

Fluidoterapia; de prevalencia
Cristaloides;
Resumen
Hipercloremia
Objetivos: Evaluar el tipo de «fluidos/sueros» de mantenimiento administrados en nuestro hos-
pital, y comparar como se ajustan a las recomendaciones actuales, tanto en volumen como en
composición.
Material y métodos: Estudio observacional y transversal. Se registró el volumen y tipo de
fluidoterapia de mantenimiento que se pautaba durante 24 h a pacientes ingresados en difer-
entes servicios del hospital. Se excluyeron aquellos en los que la administración de líquidos
estuviese condicionada por un exceso o déficit de líquidos y electrólitos.
Resultados: Se recogieron los datos de 198 pacientes, de los cuales 74 (37,4%) fueron excluidos
por no cumplir los criterios de inclusión. El volumen medio administrado fue de 2.500 cc/día. La
dosis media de glucosa fue de 36 g cada 24 h (DE: 31,4). La combinación más frecuente incluyó
suero salino fisiológico (SSF) con glucosado 5% (64,4% de los casos). La cantidad media de sodio
administrada en 24 h fue de 173 mEq (DE: 74,8) y la de cloro de 168 mEq (DE: 75), lo que supone
superávit de +87,4 mEq y +85 mEq, respectivamente. En relación con el potasio, magnesio y
calcio, el déficit fue de −50 mEq, −22 mEq y −21 mEq día, respectivamente. La administración
de sustancias buffer fue excepcional, siendo las más frecuentemente utilizadas el bicarbonato
(2,29%), acetato (1,29%), lactato (1,15%) y gluconato (1,10%).
Conclusión: El SSF es la solución más frecuentemente utilizada. En contraste con el exceso
de sodio y cloro habitualmente pautado, la cantidad de otros iones, como potasio, magnesio,
sustancias buffer y aporte calórico, es muy deficitaria.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction presence of another structure above the endothelial cell

Intravenous fluid therapy is one of the most important and
common therapeutic measures used by anaesthesiologists,
intensivists, surgeons, etc. Its objective is the replacement
of body water and the correction of electrolyte alterations
and the acid---base balance, which are often required in sur-
gical patients.1
In the body, water and electrolytes are distributed in
different compartments and maintain a constant balance.
The largest volume is found in the intracellular fluid (ICF),
which accounts for 60% of total body water (TBW), while
extracellular fluid volume (EFV) accounts for the remaining
40%. Around 32% of EFV is made up of interstitial fluid, and
only 8% represents blood volume (BV), with plasma volume
estimated at around 35---40 mL/kg.2
The movement of fluid between the different compart-
ments is determined by the Starling equation,3 which deter-
mines the filtration force: (Filtration force: Kf [Pc − Pi ] − 
[c − g ]); where Kf = filtration coefficient derived from
hydraulic conductance, Pc = capillary hydrostatic pressure,
Pi = interstitial hydrostatic pressure,  = reflection coeffi-
cient derived from osmotic conductance, c = interstitial
oncotic pressure, and g = interstitial pressure. In short, it
represents the difference between the forces tending to
draw water from the vascular compartment into the inter-
stitial space versus those that try to retain it inside the
vessel.
However, this traditional approach has varied since the
introduction of electron microscopy, which revealed the
wall4 : the ‘‘glycocalyx’’. The glycocalyx5 is a gel composed
of glycoproteins and proteoglycans located on the endolumi-
nal aspect of endothelial cells. It repels negatively charged
molecules, macromolecules >70 kDa, sodium, erythrocytes
and platelets. Overlying endothelial cells and the glycocalyx
form the double membrane.
The type of solution to be used will depend on the com-
partment to be replenished. Isotonic crystalloids should be
used to correct hydration and replace electrolytes in inter-
stitial fluid6---8 ; the volume administered will depend on
insensible losses due to surgical exposure (0.5---1 mL/kg/h)9
and urine output.7 Preoperative fasting does not need
replacement, and the third space is a myth.10
On a practical level, the Holliday---Segar formula, also
known as the 4-2-1 rule, is widely used. According to this
formula, blood volume replacement is performed as follows:
• Weight less than 10 kg: 40 mL/kg/h.
• Weight >10---20 kg: 40 mL/h for the first 10 kg body weight,
plus 2 mL/kg/h for each kg over 10 kg.
• Weight >20 kg to 80 kg: 60 mL/h for the first 20 kg body
weight, plus 1 mL/kg/h for each kg over 20 kg, up to a
maximum of 2400 mL per day.
Table 1 shows some of the different solutions on the mar-
ket.
In patients with decreased effective circulating volume,
i.e. intravascular losses, hypovolaemia and hypoperfusion,
vascular replacement is performed with fluid to increase
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Table 1 Composition of different ideal crystalloid solutions.

® ® ®
Electrolyte (mEq/L) Glucose 5% NaCl 0.9% Ringer’s lactate Isofundin Plasmalyte Normaion
Sodium 0 154 130 145 140 137
Potassium 0 4 4 5 10
Calcium 0 4 5 0 5
Magnesium 0 2 2 3 3
Chlorine 0 154 112 127 98 102
Bicarbonate 0
Lactate 0 28
Gluconate 0 23
Acetate 0 24 27 47
Malate 0 5
Glucose (g/L) 50 50
Citrate 5.9
Osmolarity (T) 278 308 276 309 295 579
Osmolarity (M) 286 256 271
SID 0 28 29 50
Osmolarity (M): measured osmolarity; Osmolarity (T): theoretical osmolarity; SID: strong ion difference.

preload. Colloids may be indicated in these cases,6,7 but
current dosage limitations due to the risk of nephrotoxicity
associated with semisynthetic colloids should be taken into
consideration.9,11
Although maintenance fluids should be considered drugs
due to their effect on normal bodily functions, electrolyte
and blood volume replacement is often performed routinely,
based on local customs,12 with no clear justification, and
without properly assessing the patient’s needs based on their
metabolic status.
Some of the solutions currently used were first introduced
in the 19th century (normal saline solution [NSS], Ringer’s
solution, Ringer’s lactate [RL]) without undergoing the type
of trials that such drugs or solutions would currently require.
It was not until 2013, following the controversy sparked by
studies that reported higher mortality rates with colloidal
solutions in septic patients,13 that researchers took a real
interest in different fluid management strategies.
The primary objective of this observational study was
to evaluate the maintenance fluids or sera administered in
our hospital by different departments, and to compare how
these comply, both in volume and composition, with cur-
rent recommendations derived from various studies. In this
way, we have been able to perform a ‘‘self-appraisal’’ of our
routine practice and introduce improvement measure where
needed.
Materials and methods
Patients receiving parenteral or enteral nutrition were
excluded, even if they received an ‘‘extra’’ liquid sup-
plement, since the aim of the study was only to evaluate
maintenance fluid therapy. Patients receiving fluid ther-
apy due to an excess or deficit of fluid and electrolytes
(acute pulmonary oedema, kidney or liver failure, exces-
sive drainage losses, diabetes insipidus, etc.) were also
excluded.
Data was collected from the computerized physician
order entry for each patient, using the pharmacy manage-
®
ment software FarmaTools . Data regarding the type and
volume of each solution administered, the regimen pre-
scribed and duration of treatment were collected.
A database of the solutions available in the hospital and
their composition was developed in order to calculate the
volume of electrolytes (sodium, chlorine, potassium and
buffers), glucose, and the total volume administered in each
case. Collected data were verified and entered in a Microsoft
®
Excel table.
The results obtained were compared with general
recommendations1,6,9 to meet daily electrolyte and caloric
requirements, and the adequacy of the volume administered
was evaluated taking the Holliday---Segar formula as a refer-
ence.
The study was observational, and no attempt was made
to modify the treatment prescribed.
All statistical analyses were performed by the hospital’s
computer service, using the STATA statistical analysis pro-
gramme (version 12).

This is an observational, cross-sectional prevalence study in

fluid management practices. All information relating to the
characteristics of the fluid maintenance therapy adminis-
tered in a 24-h period to patients admitted to each hospital
unit during the study period was collected. Participating
units were: post-anaesthesia care unit (PACU), medical crit-
ical care, general surgery, vascular surgery, maxillofacial
surgery, urology, internal medicine, neurosurgery and oto-
laryngology. As this was a purely observational study, at no
time was the treatment prescribed by the attending doctor
altered or modified.
Results
Data from 198 patients were collected, of whom 45 (22.7%)
were receiving parenteral nutrition, 5 (2.5%) were receiving
an enteral diet, and 24 (12.2%) were not prescribed any type
of solution, according to their treatment orders, and were
therefore excluded. The final sample size was 73 patients.
Median age was 64.5 years, with 68.5% men and 31.5%
women. The participating departments were general surgery
(29.2%), internal medicine (25.8%), vascular surgery (9.6%),
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4 R. Uña Orejón et al.

180
Table 2 Commonly used fluid management regimens.
NSS + S with 5% glucose solution 64.4% 160
NSS 24.7%
140
10% glucose solution + RL 4.1%
5% Glucose solution 4.1%
® 120
Plasmalyte 1.4%
RL 1.4% 100
®
Normaion 0
Low sodium glucose solution 0 80

NSS: normal saline solution; RL: Ringer’s lactate.

60

heart surgery (6.1%), maxillofacial surgery (6.1%), ENT 40

(5.6%), urology (5.6%), trauma (3.5%) and neurosurgery
(3.5%). 20
The most commonly used regimens are shown in Table 2,
0
the most frequent combination being NSS with 5% glu- Na Cl K Ca Mg
cose solution (64.4% of cases). NSS was the only solution
administered in 24.7% of cases, therefore, 89% of solution mEq administered/day mEq ideal to manage/day
administered fluids in the hospital include NSS.
The most commonly used maintenance volume was Figure 1 Difference between theoretical and real volume of
2000 cc every 24 h (SD: 666), and the median volume of fluids ions administered.
used to deliver medication was 500 cc, so the total volume of
fluid administered was on average 2500 cc in 35.6% of cases, Table 4 Type of solutions used in different departments.
followed by 1500 cc in 28.8% and 2000 cc in 13.7%.
The mean electrolytes dose administered and its ability 10% glucose NSS NSS + 5% GS
to meet theoretical needs are shown in Table 3. solution + RL
A mean volume of 173 mEq (SD: 74.8) sodium and Internal 0% 100% 0%
168 mEq (SD: 75) chlorine were administered over the 24-h medicine
period. Interestingly, potassium replacement was not given Surgery 0% 13.7% 86.3%
in 83.6% of cases. The remaining cases received on aver- suite
age 4.24 mEq (SD: 12) potassium over the 24 h period. Critical care 4.1% 24.7% 64%
Calcium and magnesium replacement was not adminis- GS: glucose solution; NSS: normal saline solution; RL: Ringer’s
tered in 95% of patients. The remaining cases received lactate.
the minimum dose of 0.11 mEq (SD: 0.5) calcium and
0.11 (SD: 0.7) magnesium. A comparison between the the-
oretical volume of sodium and chlorine (2 mEq/kg/day) in internal medicine and surgery (+117 mEq and +114 mEq,
and the dose actually administered showed that the lat- respectively), and was closer to theoretical in medical crit-
ter exceeded theoretical requirements by +87.4 mEq and ical care and the PACU (+46 mEq and +13 mEq; p < 0.001),
+85 mEq, respectively. However, the differences between respectively. Potassium deficit also showed statistically sig-
theoretical and real potassium (1 mEq/kg/day), magnesium nificant differences (p < 0.002) between the medical and
(0.3 mEq/kg/day) and calcium (0.3 mEq/kg/day) adminis- surgical departments (−48.6 mEq and −50 mEq) and criti-
tered showed a deficit of −50 mEq, −22 mEq and −21 mEq cal care (−29.6 mEq). There were no differences between
per day, respectively (Fig. 1). Correlation tests to identify services in respect of calcium and magnesium replacement,
factors associated with these deficits only found a correla- which was considerably below theoretical in all cases.
tion between volume deficits and age (Pearson correlation In terms of caloric intake, the mean dose of glucose was
coefficient R = −0.33; p = 0.015). 36 g per 24 h (SD: 31.4).
Comparing departments (Table 4) showed that sodium The volume of buffer solution used to ensure the
and chlorine administration far exceeded theoretical values acid---base balance was very low. The most commonly used
buffers were bicarbonate (2.29%), followed by acetate
Table 3 Volume of ions administered and difference with (1.29%), lactate (1.15%) and gluconate (1.10%), and these
respect to theoretical needs. solutions were only administered in medical and surgical
critical care units.
Volume of ions Difference with respect to Comparing the volume actually administered with the
(mEq) theoretical needs (mEq) theoretical dose calculated according to Holliday---Segar for-
Na+ 173 +87 mula showed an average difference of −200 cc, although
Cl2 − 168 +85 the volume was close to theoretical in surgical (−21 cc) and
K+ 4.2 −50 intensive care (−355 cc) units, and far below theoretical
Ca++ 0 −22 in internal medicine (−1320 cc), suggesting that it was not
Mg++ 0 −21 really used for the purpose of maintaining basal needs, but
for the sole purpose of maintaining vascular patency.
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The distribution of solutions by the different departments
studied is shown in Table 4. Internal medicine departments
used NSS in 100% of cases studied, while in surgical suites
a combination of NSS + 5% glucose was used in 83% of cases,
with the remaining 13.7% receiving NSS alone. Finally, in
intensive care and the PACU, regimens were much more
variable, and the following formulas were administered in
equal proportions (27.3%): NSS + 5% glucose; 10% glucose
solution + RL, or 5% glucose solution supplemented with KCI
and NaCl. In the remaining patients (18.2%), a balanced solu-
®
tion (Plasmalyte 9.1% or 9.1% RL) was used. NSS alone was
not administered in any patients.
Discussion
Intravenous solutions were first used 180 years ago and are
routinely prescribed by different specialists. They are the
cornerstone of multimodal resuscitation and maintenance
strategies in hospitalized patients. A wide range of solu-
tions are available to clinicians (Table 1). However, concerns
have been raised about the safety of some preparations.
Our intention was to assess the composition of the most
commonly used solutions and the extent to which they are
administered according to the recommended theoretical
dose.
In our hospital, the solution most commonly used
over the study period was NSS 0.9%, also called, for
unknown reasons, physiological saline. Perhaps the pop-
ularity of this solution is due to its misleading name,
although its composition (154 mEq sodium and chlo-
rine) differs widely to that of plasma (plasma Na+ :
135---145 mEq/l). Furthermore, NSS is an unbalanced solu-
tion, with a strong ion difference (SID) of zero. Strong
ions are those that are fully dissociated in plasma.
According to Stewart’s14 acid---base imbalance formula (SID
a = [Na+ + K+ + Mg+ + Ca+ ] − [Cl− + Lactate− ] = 38---42), NSS can
cause hyperchloraemic acidosis. In our study, the average
excess sodium and chlorine administered was +87 mEq and
+85 mEq, respectively (plasma Cl2 95---105 mEq/L), which
can be extremely harmful. Indeed, in 1994, McFarlane and
Lee15 found that patients undergoing hepatobiliary surgery
developed hyperchloraemic acidosis when NSS was adminis-
tered instead of a balanced solution.
Subsequently, a study comparing the administration of
RL to NSS in healthy volunteers found that the RL group pre-
sented higher urine output and less abdominal discomfort,
and were less likely to suffer subjective mental changes,
such as difficulty performing mental calculations, difficulty
reading, and drowsiness.16
Young et al.17 (2013) studied the effect of initial resus-
citation with NSS vs a calcium-free balanced solution
®
(Plasmalyte ) in polytrauma patients, and observed greater
acid---base balance alteration in the group receiving NSS.
In a randomized, controlled, double-blind study con-
ducted in 2012 in healthy volunteers, Chowdhury et al.8
compared the effect of administering 2000 cc of a balanced
solution vs NSS. The study confirmed that the administration
of saline led to greater weight gain by increasing extravas-
cular fluid volume (oedema), with increased chloride and
sodium levels. More importantly, the Doppler ultrasound
scan showed a reduced flow rate in the renal artery with
5
decreased cortical perfusion. This could support the ear-
lier findings of Hadimioglu et al.,18 who observed that NSS
caused hyperchloraemic acidosis in transplant patients. This
in turn can cause splanchnic hypoperfusion with secondary
decreased glomerular filtration, which is presumed to be
secondary to renal artery vasoconstriction due to inhibition
of intrarenal renin and angiotensin II release. Weight gain
due to fluid retention in postsurgical patients is associated
with increased risk of mortality, reaching 100% when weight
gain exceeds 20%.6
However, the evaluation of the impact of NSS on renal
function and weight gain is beyond the scope of this study.
A very recent study by Young et al.19 raises doubts as to
the true negative impact of NSS-derived hyperchloraemic
acidosis. This study (SPLIT Trial), however, has some design
limitations, such as the small volume of fluid administered in
such critically ill patients (less than 2000 cc)and the short
length of stay in the ICU. The authors do not the specify
chlorine levels in either groups, which makes it impossible
to deduce whether the differences were great enough to
reach the conclusions described. In addition, kidney injury
is defined on the basis of creatinine levels; however, in a
kidney with sufficient reserve, creatinine may take time to
increase, even when renal perfusion is impaired. It would
have been preferable, therefore, to use other forms of
assessment, such as biomarkers or imaging tests such as
Doppler ultrasound.20 Finally, it should be noted that in
this study, mortality was discretely, though not significantly,
higher in the NSS group than in the balanced solution group,
both in the ICU (6.6% vs 7.2%) and on the ward (7.6% vs 8.6%).
The SPLIT research programme that includes 6 studies is cur-
rently under way, and aims to determine the real effect of
hyperchloraemic acidosis on the kidney.
The second most commonly used solution in our hospital
was 5% glucose. The glucose in this solution is transported
into the cells by insulin, ultimately leaving free water
which is distributed as follows: 60% passes into cells, 32% is
retained in the interstitial space, and only 8% remains inside
the vessel, thus limiting the volume expansion effect of
the solution.6,9 Administration of this solution dilutes elec-
trolytes and proteins by lowering the osmotic pressure of
the extracellular compartment. The imbalance between the
osmotic pressure of the extracellular and intracellular com-
partments is compensated by the passage of water into the
cell. Under normal conditions, osmoreceptors sensitive to
decreases in osmotic pressure inhibit antidiuretic hormone
secretion, and fluid overload is compensated by increased
urine output.6,9
The main indications for 5% glucose solution are rehy-
dration in cases of hypertonic dehydration and as an energy
source.21 However, the amount administered in our study
was just 36 g, which is well below recommended caloric
requirements, and can place patients at risk of malnutrition.
Despite the large volume of NSS administered and the
resulting risk of acidosis, balanced solutions and buffer
agents to maintain the acid---base balance were rarely used,
®
and only in critical units (RL, 27.3% and Plasmalyte 9.7%).
In 1880, Sydney Ringer demonstrated the benefit for car-
diac contractility of adding calcium and other ions to a
sodium chloride solution. Later, Alexis Hartmann modified
the original solution by adding lactate in order to bal-
ance the solution and combat acidosis. RL contains far less
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6 R. Uña Orejón et al.
chlorine and sodium than NSS, making it slightly hypotonic.
This makes it unsuitable in neurosurgery and in patients
with brain injuries.22,23 The solution has a nearly ideal SID
of 29 mEq/L.24 Currently all lactate is provided in the form
of isomer l-lactate, so the risk of accumulation is very low.
As lactate is a precursor of gluconeogenesis, large amounts
can increase blood sugar; it also has a buffer effect, since
it is first converted into pyruvate and then into bicarbonate
during metabolism as part of the Cori cycle, and is there-
fore contraindicated in liver failure.25,26 Administration of
a large volume of RL limits the predictive value of plasma
lactate as a biomarker of hypoperfusion. Due to its calcium
content (2 mmol/L), the perfusion system must be changed
after blood transfusion due to the risk of precipitate. For this
same reason, RL should never be mixed with ceftriaxone, as
it can produce insoluble salts.27
The balanced solution most widely used in our hospi-
®
tal is Plasmalyte , a calcium-free solution buffered with
acetate or gluconate, which has a SID of 50 mEq/L, 271
osmolarity, and a pH of between 4 and 8. Acetate has tra-
ditionally been used as an alternative to bicarbonate in
haemodialysis,28 since bicarbonate is incompatible with cal-
cium and magnesium salts. In patients undergoing renal
replacement therapy, and therefore receiving large vol-
® revealed by ruthenium red. Fed Proc. 1966;25:1773---83.
umes of Plasmalyte (35 mmol/L), it has been associated
with haemodynamic instability, vasodilation and a nega-
®
tive inotropic effect. Low-dose Plasmalyte is unlikely to
cause these adverse effects. Unlike lactate, acetate has
the advantage of being more widely and rapidly metab-
olized, even in the presence of shock. Furthermore, it
does not affect glucose levels, and can protect against
malnutrition29 by replacing fat as a source of antioxidant
energy without affecting glucose oxidation and without pro-
ducing hyperglycaemia. Gluconate, meanwhile, is almost
entirely (80%) eliminated unchanged in the urine. Its
use is associated with false positives when testing for
galactomannans.30
In conclusion, maintenance solutions should be given the
same consideration as drugs, and therefore the metabolic
status of the patient must be evaluated prior to adminis-
tration. Our study showed NSS to be the most widely used
solution in our setting. It is associated with hyperchloraemic
acidosis, and there is some, albeit inconclusive, evidence to
suggest that it may be associated with splanchnic hypoper-
fusion and kidney damage. Interestingly, while the volume
of sodium and chloride usually administered exceed the-
oretical requirements, other ions such as potassium and
magnesium as well as buffer and caloric agents fall far short
of requirements. In our hospital, fluid maintenance does not
comply with current recommendations, showing that tradi-
tional fluid resuscitation regimens need to be changed to
meet current theoretical requirements. The use of balanced
solutions with a far more plasma-like composition may be
useful, although in our hospital these are only administered
to critically ill patients.
Ethical disclosures
Protection of human and animal subjects. The authors
declare that no experiments were performed on humans or
animals for this study.
Confidentiality of data. The authors declare that they have
followed the protocols implemented in their place of work
regarding the use of patient data in publications.
Right to privacy and informed consent. The authors
declare that no patient data appears in this article.
Conflict of interest
Dr. Rafael Uña Orejón has occasionally received honoraria
from Braum, Fresenius and Baxter for various speaking
engagements. The remaining authors have no conflict of
interest to declare.
References
1. Maxwell MH, Kleeman CR. Clinical disorders of fluids and elec-
trolyte metabolism. New York: McGraw-Hill; 1994. p. 3---20.
2. Guyton AC, Hall JE. Textbook of medical physiology. Elsevier
Science; 2006.
3. Starling E. On the absorption from the connective tissues
spaces. J Physiol. 1986;19:312---26.
4. Luft JH. Fine structures of capillary and endocapillary layer as
5. Saladin KS. Anatomy & physiology: the unity of form and func-
tion. 5th ed. McGraw Hill; 2010. p. 94---5.
6. Chappel D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A
rational approach to perioperative fluid management. Anesthe-
siology. 2008;10:723---40.
7. Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Scher-
mer CR, et al. Major complications, mortality, and resource
utilization after open abdominal surgery: 0.9% saline compared
to Plasma-Lyte. Ann Surg. 2012;255:821---9.
8. Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized,
controlled, double-blind crossover study on the effects of 2-
L infusion of 0.9% saline and Plasma-Lyte(R) 148 on renal blood
flow velocity and renal cortical tissue perfusion in healthy vol-
unteers. Ann Surg. 2012;256:18---24.
9. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med.
2013;369:1243---51.
10. Kragelund E. Changes of the apparent 3HOH, 82Br, 125I human
albumin and 51Cr red blood cell dilution volumes before,
during and after operation in human subjects. Ann Surg.
1970;172:116---24.
11. Bellomo R, Bion J, Finfer S, Myburgh J, Perner A, Reinhart K.
Open letter to the Executive Director of the European Medicines
Agency concerning the licensing of hydroxyethyl starch solutions
for fluid resuscitation. Br J Anaesth. 2014;112:595---600.
12. Reddy S, Weinberg L, Young P. Crystalloids fluid therapy. Crit
Care. 2016;20:59.
13. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson
G, Åneman AN. Hydroxyethyl starch 130/0.42 versus Ringer’s
acetate in severe sepsis (6S). N Engl J Med. 2012;367:124---34.
14. Kellum J, Elbers P. Stewart’s textbook of acid---base. 2.a ed;
2009. USA.
15. McFarlane C, Lee A. A comparison of Plasmalyte 148 and
0.9% saline for intra-operative fluid replacement. Anaesthesia.
1994;49:779---81.
16. Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. Effect of
intravenous lactated Ringer’s solution versus 0.9% sodium chlo-
ride solution on serum osmolality in human volunteers. Anesth
Analg. 1999;88:999---1003.
17. Young JB, Utter GH, Schermer CR, Galante JM, Phan HH, Yang Y,
et al. Saline versus Plasma-Lyte in initial resuscitation of trauma
patients: a randomized trial. Ann Surg. 2014;259:255---62.
+Model
ARTICLE IN PRESS
Maintenance fluid therapy in a tertiary hospital
18. Hadimioglu N, Saadawy I, Saglqan T, Ertug Z, Dinckhan A. The
effect of different crystalloid solutions on acid---base balance
and early kidney function after kidney transplantation. Anesth
Analg. 2008;107:264---9.
19. Young P, Balley M, Beasley R, Henderson S, Mackle D, McArthur
C. Effect of a buffered crystalloids solutions versus saline on
acute injury among patient in the intensive care unit: the SPLIT
randomized clinical trial. JAMA. 2015;314:1701---10.
20. Kellum JA, Shaw AD. Assessing toxicity of intravenous crystal-
loids in critically ill patients. JAMA. 2015;314:1695---7.
21. Rose BD, Post TW. Trastornos de los electrolitos y del equilibrio
ácido-base. Madrid: Marban; 2002. p. 258---86.
22. Simma B, Burger R, Falk M, Sacher P, Fanconi S. A prospective,
randomized, and controlled study of fluid management in chil-
dren with severe head injury: lactated Ringer’s solution versus
hypertonic saline. Crit Care Med. 1998;26:1265---70.
23. Shackford SR, Bourguignon PR, Wald SL, Rogers FB, Osler TM,
Clark DE. Hypertonic saline resuscitation of patients with head
injury: a prospective, randomized clinical trial. J Trauma.
1998;44:50---8.
24. Kempthorne PM. The European Consensus Statement on intra-
operative fluid therapy in children: a step in the right direction.
Eur J Anaesthesiol. 2011;28:618---9.
7
25. Wagner BK, D’Amelio LF. Pharmacologic and clinical consid-
erations in selecting crystalloid, colloid and oxygen arraying
resuscitation fluid. Clin Pharm. 1993;12:335---46.
26. Garnacho-Montero J, Fernández-Mondéjar E, Ferrer-Rocac R,
Herrera-Gutiérrez ME, Lorentef JA, Ruiz-Santanai S, et al.
Cristaloides y coloides en la reanimación del paciente crítico.
Med Intensiva. 2015;39:303---15.
27. Murney P. To mix or not to mix-compatibilities of parenteral drug
solutions. Aust Prescr. 2008;31:98---101.
28. Schrander-vd Meer AM, teer Wee PM, Kan G, Donker AJ, van
Dorp WT. Improved cardiovascular variables during acetate free
biofiltration. Clin Nephrol. 1999;51:304---9.
29. Akanji AO, Bruce MA, Frayn KN. Effect of acetate infu-
sion on energy expenditure and substrate oxidation rates in
non-diabetic and diabetic subject. Eur J Clin Nutr. 1989;43:
107---15.
30. Quindós G, Eraso E, López Soria L, Ezpeleta G. Enfermedad fúng-
ica invasora: ¿diagnóstico micológico convencional o molecular?
Enfer Infecc Microbiol Clin. 2012;30:560---71.