The History & Practice of IV Fluid Therapy have we advanced in 185 years?

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1 The History & Practice of IV Fluid Therapy have we advanced in 185 years? Liam Plant Clinical Professor of Renal Medicine University College Cork Consultant Renal Physician Cork University Hospital National Clinical Director HSE National Renal Office

2 The Chimes at Midnight.

3 Halite

4 Salt & Water Living on Land Scarcity & Plenty Biological response to variation in water intake is rapid Biological response to sodium depletion is rapid Too little Too much?!!!!!

5 William Brooke O Shaughnessy iv Fluid Therapy University of Edinburgh Blue Cholera Thomas Latta Leith Hospital 1832 Lancet

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7 Classic References SALINE VENOUS INJECTION IN CASES OF MALIGNANT CHOLERA, PERFORMED WHILE IN THE VAPOUR-BATH. Thomas Latta Lancet 1832; 19(480):

8 Some Physiological Fluids Ringer s Solution 1880 s Lactated Ringer s Solution (LRS) 1930 s Hartmann s Solution (CSL) 1930 s

9 Sydney Ringer Alexis Hartmann

10 Hartog Jacob Hamburger Utrecht % Saline

11 Fluid & Electrolyte requirements Resuscitation Routine Maintenance Replacement Redistribution Reassess

12 Disturbing Case(s). 67 yr old female CKD3, no proteinuria, hypertension Elective laparascopic cholecystectomy 5 days later EWS 8; oedema; pulmonary oedema AKIN2; hypernatraemia; hypokalaemia BXS -6mmol/l; Lactate 1.1mmol/l; Why?

13 Thesis Disorders of Volume & Tonicity occur as a consequence of Fluid management choices in the ill/injured/post-surgical patient These, in turn lead to AKI and electrolyte disorders

14 Who s in charge?

15 BMJ 2011; 342: d prospective fluid prescriptions over 24h 40% - no fluid status assessment documented 17% - no fluid balance chart 100% - no weight mentioned in prescription 60% - prescription differed from output >1000ml 96% - excessive daily sodium prescription 80% - insufficient daily potassium prescription

16 Soc Critical Care Anaes 2012; 114: GD, fluid-restrictive, fluid-liberal GD: FR: reduced compared with non-gd renal complications, pneumonia, time to 1 st bowel movement, resumption of normal diet, LOS reduced compared with FL pulmonary oedema, pneumonia, time to 1 st bowel movement, LOS GD & FL: increased crystalloid intake; different outcomes

17 Into the Darkness Necessary Tetrad Dumbed-down Duo Water Sodium How much fluid? Chloride How much potassium? Potassium

18 Response to Injury Sodium retention phase Sodium diuresis phase Avoid pre-operative/perioperative/postoperative hypovolaemia BUT NOT AT COST OF POST-OPERATIVE SODIUM, CHLORIDE AND WATER OVERLOAD

19 Dramatis Personae Effective renal plasma flow Glomerular filtration rate Catecholamines RAAS ANP AVP (if Renal Function is normal..)

20 What reduces ability to excrete: Sodium Water Stress Response catecholamines/raas/avp Hyperchloraemia renal vasoconstriction decreased GFR Catabolism competition with urea decreased urine concentration Potassium depletion Stress Response catecholamines/raas/avp Catabolism competition with urea decreased urine concentration Urine concentration/dilution AKI/CKD AKI/CKD

21 G.I.F.T.A.Su.P. March The British Association for Parenteral and Enteral Nutrition (BAPEN), the Association for Clinical Biochemistry, the Association of Surgeons of Great Britain and Ireland and Society of Academic and Research Surgery, the Renal Association and the Intensive Care Society.

22 NICE Guideline CG174 December Algorithms 1. Assessment 2. Fluid Resuscitation 3. Routine Maintenance 4. Replacement & Redistribution

23 Bodily Fluids

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25 Composition of commonly used crystalloids Content Plasma Sodium chloride 0.9%* Na + (mmol/l) Sodium chloride 0.18%/ 4% glucose a 0.45% NaCl/ 4% glucose a 5% Hartmann s Lactated glucose a Ringer s (USP) Ringer s acetate Alternative balanced solutions for resuscitation** Cl (mmol/l) [Na + ]:[Cl ] ratio :1 1:1 1:1 1:1-1.18:1 1.19:1 1.16:1 1.43:1 1:1 K + (mmol/l) * * * * HCO 3 / Bicarbonate Ca 2 + (mmol/l) Mg 2 + (mmol/l) Glucose (mmol/ l) (lactate) 28 (lactate) 27 (acetate) 27 (acetate) 23 (gluconate) (40 g) 222 (40 g) 278 (50 g) Alternative balanced solutions for maintenance** 16 (acetate) ph Osmolarity (mosm/l) * These solutions are available with differing quantities of potassium already added, and the potassium-containing versions are usually more appropriate for meeting maintenance needs. ** Alternative balanced solutions are available commercially under different brand names and composition may vary by preparation. a The term dextrose refers to the dextro-rotatory isomer of glucose that can be metabolised and is the only form used in IV fluids. However IV fluid bags are often labelled as glucose so only this term should be used. Traditionally hospitals bought a small range of fluids combining saline ( %) with glucose but several recent NICE/NPSA documents have recommended specific combinations, which are now purchased to enable guidelines to be followed. Glucose saline combinations now come in 5 different concentrations, and the addition of variable potassium content expands the pre-mixed range to 13 different products. Prescribers must therefore specify the concentration of each component; the term dextrose-saline (or abbreviation D/S) is meaningless without these details. What is specified also impacts significantly on the cost of the product. Source: This table was drafted based on the consensus decision of the members of the Guideline Development Group. Intravenous fluid therapy in adults in hospital, NICE clinical guideline 174 (December 2013)

26 Commonly prescribed fluids Fluid [Sodium] mmol/l [Chloride] mmol/l [Potassium] mmol/l Osmolarity mosm/l 5% Dextrose % Dextrose/0.18 % Saline % Saline Plasma Ringer s Lactate Hartmann s % Gelatine % Albumin % Saline

27 2 important studies Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg 2012; 255: Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308:

28 Differences Chloride Liberal 2,211 litres 0.9% Saline 469 litres Hartmann s 65 litres Plasma-Lyte Chloride Restricted 52 litres 0.9% Saline 3,205 litres Hartmann s 160 litres Plasma-Lyte 50% reduction in AKI 40% reduction in RRT BXS< -5mmol/l: 9% BXS> 5mmol/l: 25% BXS< -5mmol/l: 3% BXS> 5mmol/l: 34%

29 Zhang et al. BMC Nephrology :235 doi: / Non-AKI AKIN-1 AKIN-2 AKIN-3 Cl 0 (mmol/l) ± ± ± ± 10.8 Cl max (mmol/l) ± ± ± ± 11.0 Cl min (mmol/l) 98.3 ± ± ± ± 8.4 Cl mean (mmol/l) ± ± ± ± 7.8

30 JAMA October ; 314 CARING FOR THE CRITICALLY ILL PATIENT Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial Paul Young, FCICM1,2; Michael Bailey, PhD3; Richard Beasley, DSc1; Seton Henderson, FCICM1,4; Diane Mackle, MN1; Colin McArthur, FCICM1,3,5; Shay McGuinness, FANZCA1,3,6; Jan Mehrtens, RN4; John Myburgh, PhD7,8; Alex Psirides, FCICM2; Sumeet Reddy, MBChB1; Rinaldo Bellomo, FCICM3,9 ; for the SPLIT Investigators and the ANZICS CTG Assessing Toxicity of Intravenous Crystalloids in Critically Ill Patients John A. Kellum; Andrew D. Shaw.

31 Recommendation 1 Because of the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions e.g. Ringer s lactate/acetate or Hartmann s solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or gastric drainage. Evidence level 1b

32 Recommendation 3 To meet maintenance requirements, adult patients should receive sodium mmol/day, potassium mmol/day in litres of water by the oral, enteral or parenteral route (or a combination of routes). Additional amounts should only be given to correct deficit or continuing losses. Careful monitoring should be undertaken using clinical examination, fluid balance charts, and regular weighing when possible. Evidence level 5

33 NICE Guideline CG174 December Algorithms 1. Assessment 2. Fluid Resuscitation 3. Routine Maintenance 4. Replacement & Redistribution

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35 Principles and protocols for intravenous " uid therapy

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39 Commonly prescribed fluids Fluid [Sodium] mmol/l [Chloride] mmol/l [Potassium] mmol/l Osmolarity mosm/l 5% Dextrose % Dextrose/0.18 % Saline % Saline Plasma Ringer s Lactate Hartmann s % Gelatine % Albumin % Saline

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41 Thank You