Use of intravenous fluids/solutions: a narrative review

Crystalloid Solutions in Hospital: A Review of Existing Literature

Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.

Pancreatic Stone Protein as a Biomarker for Sepsis at the Emergency Department of a Large Tertiary Hospital

Early recognition of sepsis is essential for improving outcomes and preventing complications such as organ failure, depression, and neurocognitive impairment. The emergency department (ED) plays a key role in the early identification of sepsis, but clinicians lack diagnostic tools. Potentially, biomarkers could be helpful in assisting clinicians in the ED, but no marker has yet been successfully implemented in daily practice with good clinical performance. Pancreatic stone protein (PSP) is a promising biomarker in the context of sepsis, but little is known about the diagnostic performance of PSP in the ED. We prospectively investigated the diagnostic value of PSP in such a population for patients suspected of infection. PSP was compared with currently used biomarkers, including white blood cell count (WBC) and C-reactive protein (CRP). Of the 156 patients included in this study, 74 (47.4%) were diagnosed with uncomplicated infection and 26 (16.7%) patients with sepsis, while 56 (35.9%) eventually had no infection. PSP was significantly higher for sepsis patients compared to patients with no sepsis. In multivariate regression, PSP was a significant predictor for sepsis, with an area under the curve (AUC) of 0.69. Positive and negative predictive values for this model were 100% and 84.4%, respectively. Altogether, these findings show that PSP, measured at the ED of a tertiary hospital, is associated with sepsis but lacks the diagnostic performance to be used as single marker.

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.

Immune response in fluid therapy with crystalloids of different ratios or colloid for rats in haemorrhagic shock

This study investigated the association between different ratios of balanced salt based-crystalloid (PLASMA SOLUTION-A [CJ HealthCare, Seoul, Korea]) (the ratios of crystalloid for blood loss, 1:1, 1:2 and 1:3) or balanced salt-based colloid (VOLULYTE 6% [Fresenius Kabi, Germany]) (the ratio of colloid for blood loss, 1:1) to restore blood loss and immune response in rats with haemorrhagic shock. About 50% of total estimated blood volume was removed after anaesthesia. The fluid was administered for resuscitation after exsanguination, according to the type of fluid and the ratios of exsanguinated volume and fluid volume for resuscitation. After sacrifice, expression of immune cells in blood and tissues was evaluated. Histological analyses and syndecan-1 immunohistochemistry assays were performed on tissues. Endothelial damage according to syndecan-1 and cytokine levels in blood was also assessed. Fluid resuscitation with same, two-fold, or three-fold volumes of crystalloid, or same volume of colloid, to treat haemorrhagic shock in rats resulted in a similar increase in blood pressure. The expression of neutrophils in blood decreased significantly after colloid administration, compared to before exsanguination. Syndecan-1 expression increased after exsanguination and fluid resuscitation in all groups, without any significant difference. In conclusion, same volume of balanced salt-based crystalloid for blood loss was enough to restore BP at the choice of fluid for the management of haemorrhagic shock in the rats, compared with different ratios of crystalloid or same volume of colloid, on the aspect of immune response.

Changes in colloid solution sales in Nordic countries

BACKGROUND

Administration of resuscitation fluid is a common intervention in the treatment of critically ill patients, but the right choice of fluid is still a matter of debate. Changes in medical practice are based on new evidence and guidelines as well as traditions and personal preferences. Official warnings against the use of hydroxyl-ethyl-starch (HES) solutions have been issued. Nordic guidelines have issued several strong recommendations favouring crystalloids over colloids in all patient groups. Our objective was to describe the patterns of colloid use in Nordic countries from 2012 to 2016.

METHODS

The data were obtained from companies that provide pharmaceutical statistics in different countries. The data are sales figures from pharmaceutical companies to pharmacies and health institutions.

RESULTS

We found a 56% reduction in the total sales of all colloids in Nordic countries over a 5-year period. These findings were mainly related to a 92% reduction in the sales of HES solutions. A reduction in sales of other synthetic colloids has also occurred. During the same period, we found a 46% increase in albumin sales, but these numbers varied between Nordic countries.

CONCLUSION

The general reduction in colloid sales likely reflects the recommendation that colloids should be used only in special circumstances. The dramatic reduction in the sales of HES solutions was expected given evidence of harm and the official warnings. The steady increase in albumin sales and the notable differences between the five Nordic countries cannot be explained.

Hyponatremia in the elderly: challenges and solutions

Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome. The aim of this review is to present certain challenges in the evaluation and treatment of hyponatremia in the elderly population and provide practical solutions. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multifactorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. The treatment of hyponatremia depends on the type of hyponatremia. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. In conclusion, both the evaluation and the treatment of hyponatremia pose many challenges in the elderly population.