title: Choice of fluid in acute illness: what should be given? An international consensus.
abstract: Fluid management during critical illness is a dynamic process that may be conceptualized as occurring in four phases: rescue, optimization, stabilization, and de-escalation (mobilization). The selection and administration of resuscitation fluids is one component of this complex physiological sequence directed at restoring depleted intravascular volume. Presently, the selection of i.v. fluid is usually dictated more by local practice patterns than by evidence. The debate on fluid choice has primarily focused on evaluating outcome differences between 'crystalloids vs colloids'. More recently, however, there is interest in examining outcome differences based on the chloride content of crystalloid solutions. New insights into the conventional Starling model of microvascular fluid exchange may explain that the efficacy of colloids in restoring and maintaining depleted intravascular volume is only moderately better than crystalloids. A number of investigator-initiated, high-quality, randomized controlled trials have demonstrated that modest improvements in short-term physiological endpoints with colloids have not translated into better patient-centred outcomes. In addition, there is substantial evidence that certain types of fluids may independently worsen patient-centred outcomes. These include hydroxyethyl starch and albumin solutions in selected patient populations. There is no evidence to support the use of other colloids. The use of balanced salt solutions in preference to 0.9% saline is supported by the absence of harm in large observational studies. However, there is no compelling randomized trial-based evidence demonstrating improved clinical outcomes with the use of balanced salt solutions compared with 0.9% saline at this time.
authors.affiliation: Duke University Medical Center, Division of Veterans Affairs, Durham, NC 27710, USA.
authors.forename: K
authors.initials: K
authors.lastname: Raghunathan
authors.affiliation: School of Medicine and Medical Science, University College Dublin, Dublin, Ireland patrick.murray@ucd.ie lisa.crowe@ucd.ie.
authors.forename: P T
authors.initials: PT
authors.lastname: Murray
authors.affiliation: Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
authors.forename: W S
authors.initials: WS
authors.lastname: Beattie
authors.affiliation: Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham NG7 2UH, UK.
authors.forename: D N
authors.initials: DN
authors.lastname: Lobo
authors.affiliation: Department of Intensive Care Medicine, St George Hospital, The George Institute for Global Health, Sydney, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Myburgh
authors.affiliation: Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA.
authors.forename: R
authors.initials: R
authors.lastname: Sladen
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Kellum
authors.affiliation: Department of Anaesthesia, University College London, London, UK.
authors.forename: M G
authors.initials: MG
authors.lastname: Mythen
authors.affiliation: Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: A D
authors.initials: AD
authors.lastname: Shaw
mesh_terms: D000208:Acute Disease / Q000628:therapy*; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000628:therapy; D003956:Dialysis; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans
keywords: balanced salt solutions; colloids; crystalloids; fluid choice; isotonic saline