February 1, 2019
Normal saline versus balanced fluids for volume resuscitation: A long-standing controversy has been the relative benefits of 0.9% normal saline versus balanced intravenous crystalloids (lactated Ringer's and Plasma-Lyte A). Accumulating observational data increasingly suggests that the hyperchloremic metabolic acidosis associated with the administration of large volumes of saline leads to increased rates of acute kidney injury and need for dialysis. Two recent, large, randomized trials (SMART and SALT-ED) have attempted to answer this question in both critically ill and in non-critically ill patient populations. Although the question is not yet definitively resolved, these studies further suggest that major adverse kidney events are more frequently seen in patients resuscitated with normal saline.
Upon completion of the chapter, the reader will be able to:
Estimate the volumes of various body fluid compartments.
Calculate the daily maintenance fluid requirement for patients given their weight and gender.
Differentiate among currently available fluids for volume resuscitation.
Identify the electrolytes primarily found in the extracellular and intracellular fluid compartments.
Describe the unique relationship between serum sodium concentration and total body water (TBW).
Review the etiology, clinical presentation, and management for disorders of sodium, potassium, calcium, phosphorus, and magnesium.
A thorough understanding of the fundamentals of fluid and electrolyte homeostasis is essential, given the frequency with which clinical disturbances are seen and the profound effects these disturbances can have on various aspects of patient care. However, the interplay of body fluids, serum electrolytes, and clinical monitoring is complex, and a thorough command of these issues is a challenging task even for advanced practitioners.1 Practitioners must be familiar with the key concepts of body compartment volumes, calculation of daily fluid requirements, and the various types of fluid available for replacement. The management of disorders of sodium, potassium, calcium, phosphorus, and magnesium integrates these concepts with issues of dose recognition and patient safety.
The most fundamental concept to grasp is an assessment of total body water (TBW), which is directly related to body weight. TBW constitutes approximately 50% of lean body weight in healthy females and 60% of lean body weight in males. For clinical purposes, most clinicians generalize that TBW accounts for 60% of lean body weight in adults, regardless of gender. The percentage of TBW decreases as body fat increases and/or with age (75%–85% of body weight is water for newborns). Unless the patient is obese (body weight > 120% of ideal body weight [IBW]), clinicians typically use a patient’s actual body weight when calculating TBW.2 In obese patients, it is customary to estimate TBW using lean body weight or IBW as calculated by the Devine–Devine method: males’ lean body weight = 50 kg + (2.3 kg/in × [height in inches − 60]) and females’ lean body weight = 45.5 kg + (2.3 kg/in × [height in inches − 60]).3–5 Note that ...