PL Detail-Document #290212

This PL Detail-Document gives subscribers

additional insight related to the Recommendations published in
PHARMACISTS LETTER / PRESCRIBERS LETTER
February 2013

Comparison of IV Fluids
The need for fluid resuscitation, or replacing blood volume with IV fluids to maintain adequate organ perfusion, is not uncommon in the hospital
setting. Options include colloids such as albumin or hydroxyethyl starch (HES) and crystalloids such as normal saline (NS) or lactated Ringers (LR)
solution. New studies such as SAFE (Saline versus Albumin Fluid Evaluation) and updated meta-analyses continue to shed light on the best choices.
One often cited advantage of using colloids over crystalloids is that less volume is needed to produce the desired effect. For example, guidelines have
given a 1:4 volume ratio. However, data have not consistently supported this number, with ratios often being closer to 1:1 or 1:2.1-4 Safety and cost
are two major arguments against the use of colloids, along with the lack of evidence for benefit over crystalloids in many patient populations. Studies
comparing IV fluids for fluid resuscitation that are underway include Albumin in Severe Sepsis (ALBIOS), Lactated Ringer Versus Albumin in Early
Sepsis Therapy (RASP), and Efficacy and Safety of Colloids Versus Crystalloids for Fluid Resuscitation in Critically Ill Patients (CRISTAL). The
following chart lists colloid and crystalloid products, alone with advantages, disadvantages, and evidence for use.
Fluid Advantages Disadvantages Comments
Albumin Low risk for Potential for allergic reactions6 Natural colloid6
5%, 25% adverse reactions5 Potential for transmission of Duration of action 12 to 24 hours5
May modulate infection5 25% albumin is hyperoncotic; 5% albumin is iso-oncotic5,7
inflammation5,6 Hyperoncotic albumin may No mortality benefit over NS for fluid resuscitation in hypovolemia
Colloids may cause kidney damage5,7 (SAFE)5,6,8
provide greater More expensive than HES or A slight but nonstatistically significant benefit for albumin shown in
intravascular volume crystalloids patients with sepsis (SAFE).5 Recommended in severe sepsis and
expansion than equal septic shock for patients who require large amounts of crystalloid.8
volumes of May be beneficial in patients with low albumin5
crystalloids5 Iso-oncotic albumin may improve mortality in cardiac surgery
patients2,5
Avoid in brain trauma. May increase mortality compared with NS
(SAFE).5
Dextran 40 (LMD) Colloids may High risk for adverse reactions5 Artificial colloid
10% in D5W or NS provide greater Potential for allergic or Duration of action one to two hours (dextran 40)5
Gentran-40 intravascular volume anaphylactoid reactions5,7 Use for fluid resuscitation has fallen out of favor due to high risk of
Dextran 70 expansion than equal Impairs hemostasis (sometimes adverse reactions4
6% in D5W or NS volumes of used as anticoagulant)4,5,7 LMD = low-molecular-weight dextran
Gentran-70 crystalloids5 May cause kidney damage7

More. . .
Copyright 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
 (PL Detail-Document #290212: Page 2 of 4)

Fluid Advantages Disadvantages Comments

5% Dextrose NA Pediatric deaths reported from Crystalloid
(D5W) hyponatremia resulting from Hypotonic. Isotonic in the bag, but dextrose gets metabolized almost
infusion of excess volume of immediately in the lining of the blood vessels, leaving free water.10
D5W9 Hypotonic solutions such as D5W are useful for patients with
dehydration and adequate circulatory volume7,11

Hydroxyethyl starch May modulate Potential for anaphylactoid Synthetic colloid

(HES) inflammation5,6 reactions5 Duration of action eight to 36 hours5
6% HES 200/0.5 in NS Colloids may May accumulate in tissue and 6% HES is hyperoncotic5
Hespan (U.S.), provide greater cause prolonged itching4-7 Larger molecular weight than albumin2
intravascular volume May impair platelet function6 Adverse effects are dose-related12
6% HES 200/0.5 in expansion than equal May cause kidney damage5-7 Hespan and Hextend are hetastarches. Voluven is a tetrastarch with a
lactated electrolyte volumes of May cause increases in serum lower molecular weight. This is thought to reduce the risk for adverse
solution crystalloids5 amylase7 effects; however, it has not been proven.3,4,6,12,13
Hextend, More expensive than May increase mortality, need for dialysis, and bleeding compared
6% HES 130/0.4 in NS crystalloids with LR and other fluids in patients with severe sepsis (6S, etc).4,13 Not
Voluven recommended for fluid resuscitation in severe sepsis and septic shock.8
No benefit shown in critically ill patients (e.g., burns, post-op,
trauma) compared with crystalloids1

Lactated Ringers Low risk for Crystalloids freely distribute Crystalloid

(LR) adverse reactions5 across the vascular barrier6
Risk for respiratory acidosis
due to accumulated CO214
Risk for hyperkalemia (has
4 mEq/L potassium)5,7
Impaired metabolism of lactate
to bicarbonate in patients with
severe liver disease10
Duration of action one to four hours5
Slightly hypotonic5
Considered equally effective as normal saline11
May be preferred for hemorrhagic shock because large volumes will
not cause hyperchloremic metabolic acidosis, as with NS7,11
Because of slight hypotonicity, might increase risk of brain swelling
in brain trauma13,15

More. . .
Copyright 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
 (PL Detail-Document #290212: Page 3 of 4)

Fluid Advantages Disadvantages Comments

0.9% NaCl Low risk for Crystalloids freely distribute Crystalloid
Normal saline (NS) adverse reactions5 across the vascular barrier6 Duration of action one to four hours5
Risk of hypernatremia and Isotonic
hyperchloremic metabolic No mortality benefit of 4% albumin over NS for fluid replacement in
acidosis7,14 hypovolemia (SAFE)5,6,8
Considered equally effective as LR. Preferred over LR for patients
with brain trauma.11
No evidence that hypertonic saline (e.g., 3%) is better than NS for
fluid resuscitation7,11
Hypotonic solutions such as D5W/ 1/2 NS are useful for patients with
dehydration and adequate circulatory volume7,11

Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making
clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and internet links in this article were current as of the date of publication.

More. . .
Copyright 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
 (PL Detail-Document #290212: Page 4 of 4)

Project Leader in preparation of this PL Detail- http://survivingsepsis.org/Guidelines/Pages/default.a

Document: Stacy A. Hester, R.Ph., BCPS,
Assistant Editor
References
1. Perel P, Roberts I. Colloids versus crystalloids for
fluid resuscitation in critically ill patients. Cochrane
Database Syst Rev 2012;(6):CD000567.
2. Han J, Martin GS. Rational or rationalized choices in
fluid resuscitation? Crit Care 2010;14:1006.
3. Hartog CS, Kohl M, Reinhart K. A systematic review
of third-generation hydroxyethyl starch (HES
130/0.4) in resuscitation: safety not adequately
addressed. Anesth Analg 2011;112:635-45.
4. Perner A, Haase N, Guttormsen AB, et al.
Hydroxyethyl starch 130/0.42 versus Ringers
acetate in severe sepsis. N Engl J Med
2012;367:124-34.
5. Kruer RM, Ensor CR. Colloids in the intensive care
unit. Am J Health Syst Pharm 2012;69:1635-42.
6. Strunden MS, Heckel K, Goetz AE, Reuter DA.
Perioperative fluid and volume management:
physiological basis, tools and strategies. Ann
Intensive Care 2011;1:2.
7. Talbert RL, DiPiro JT, Matzke GR, et al.
Hypovolemic shock. In: Talbert RL, DiPiro JT,
Matzke GR, et al, Eds. Pharmacotherapy: A
Pathophysiologic Approach. 8th ed. New York:
McGraw-Hill;2011.
8. Surviving Sepsis Campaign. Hemodynamic support
and adjunctive therapy.
spx. (Accessed January 15, 2013).
9. Plain D5W or hypotonic saline solution post-op could
result in acute hyponatremia and death in healthy
children. ISMP Medication Safety Alert! August 13,
2009.
http://www.ismp.org/newsletters/acutecare/articles/2
0090813.asp. (Accessed January 15, 2013).
10. Rosenthal K. Tonicity and IV fluids. Resource
Nurse.
http://www.resourcenurse.com/feature_tonicity_fluids
.html. (Accessed January 15, 2013).
11. Intravenous fluid resuscitation. The Merck Manual.
July 2012. http://www.merckmanuals.com/profes
sional/critical_care_medicine/shock_and_fluid_resus
citation/intravenous_fluid_resuscitation.html.
(Accessed January 15, 2013).
12. Traynor K. Trauma experts urge cautious use of i.v.
fluids. Am J Health Syst Pharm 2012;69:1846,1848.
13. Vincent JL, Gottin L. Type of fluid in severe sepsis
and septic shock. Minerva Anestesiol 2011;77:1190-
6.
14. The great fluid debate revisited. Medscape Critical
Care (2008). http://www.medscape.org/viewarticle
/572584. (Accessed January 15, 2013).
15. Ropper AH. Hyperosmolar therapy for raised
intracranial pressure. N Engl J Med 2012;367:746-
52.

Cite this document as follows: PL Detail-Document, Comparison of IV Fluids. Pharmacists Letter/Prescribers

Letter. February 2013.

Evidence and Recommendations You Can Trust

3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249
Copyright 2013 by Therapeutic Research Center

Subscribers to the Letter can get PL Detail-Documents, like this one,

on any topic covered in any issue by going to www.PharmacistsLetter.com,
www.PrescribersLetter.com, or www.PharmacyTechniciansLetter.com