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Full Review
A critical appraisal of intravenous uids: from the
physiological basis to clinical evidence
David Severs1, Ewout J. Hoorn1 and Maarten B. Rookmaaker2
Department of Internal Medicine Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands and 2Department of
A B S T R AC T
INTRODUCTION
In 1832, Dr Thomas Latta rst reported on an attempt to intravenously replace uids and salts lost in cholera sufferers. He
made up a solution containing two to three drachms of
muriate of soda and two scruples of the subcarbonate of soda
in six pints of water. Faced with failure of earlier attempts at
oral rehydration, and with no precedent to direct him, he
proceeded to throw the uid immediately into the circulation
[1]. This highly successful intervention led to a number of
important experimentsin 1834, Dr John Mackintosh rst
used intravenous albumin [2], Ringers solution was introduced in 1876 by Dr Sydney Ringer and a modication was
made by Dr Alexis Hartmann in 1932 to include lactate [3].
Given impetus by a better understanding of the principles
of membrane permeability, uid tonicity and osmosis at the
time, it appears that the in vitro studies of the Dutch physiologist Hartog Jakob Hamburger in the 1890s led to the acceptance of NaCl 0.9% as isotonic to human blood. Noting that
erythrocytes were least likely to lyse in this solution, he called
it indifferent saline [4, 5]. While the use of intravenous
gelatin in animals was reported as early as 1894 [6], and a rst
study in humans was performed in 1915 [7], interest in gelatins
as well as other larger molecules to expand the intravascular
volume was renewed only in the Second World War [8]. Asanguineous infusion uids are most commonly classied as crystalloids (small electrolytes in water) or colloids (larger
molecules that are meant to remain in circulation for a longer
time). Crystalloids include 0.9% NaCl (normal saline) as well
as buffered and more balanced solutions such as lactated
Ringers solution.
Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
REVIEW CRITERIA
We performed a search for original full-text English language
papers in Medline, EMBASE and the Cochrane library, using
Table 1. Summary of haemodynamic effects,
disadvantages of commonly used infusion uids
advantages
and
Colloids
Normal saline
Balanced
crystalloids
Intravascular
persistence
Advantages
Long
Short
Short
Larger
haemodynamic
effects
Extensive
experience
Disadvantages
Nephrotoxicity,
greater mortality
High
Hyperchloraemic
acidosis
Low
Most closely
resemble ionic
composition of
blood
Slightly
hypotonic
Low
Costs
D. Severs et al.
FULL REVIEW
I N F U S I O N F L U I D C H A R AC T E R I S T I C S
A N D P H Y S I O LO G Y
The ionic composition of infusion uids is important because
it directly affects biological processes like signal transduction
and coagulation. The choice of infusate can be guided by the
intention to maintain or deliberately change the composition
of body uids. It is of note that clinical laboratories generally
report the electrolyte concentrations in serum. Concentrations
in the aqueous fraction of plasma are 7% higher due to the
presence of proteins and lipids. It follows that if the electrolyte
contents of an infused uid are to be proportionate to the corresponding aqueous fraction of blood plasma and effects on
acidity are to be minimal, it should contain 153 mmol/L Na+,
111 mmol/L Cl, 4.8 mmol/L K+, 2.7 mmol/L Ca2+ and 1.35
mmol/L Mg2+, and be able to maintain a plasma pH of 7.35
7.45 [12]. Surprisingly, however, no such uid is available
(Table 2). A change in plasma Ca2+ concentration, for
example, will change cellular (de)polarization, whereas
changes in acidity directly inuence processes like coagulation
[1317]. This is in line with the profound impairment in
factor VIIa (FVIIa), FVIIa/tissue factor and FXa/FVa activity
with decreases in pH [16]. In vitro and animal models also
suggest increased extracellular acidity may alter the immune
response in multiple ways, ranging from a change in production of proinammatory mediators to impaired leucocyte
chemotaxis and lymphocyte cytotoxicity [18, 19].
The distribution of infused uids between the intracellular
and extracellular compartments is dictated by the osmotic
pressure in the different compartments. The osmotic pressure
is determined by the amount of solutes and their osmotic coefcients, which describe the deviation of the osmotic behaviour
of solutes from their theoretical osmotic behaviour. When
considering the tonicity of an infused uid, it is important to
appreciate the differences between theoretical osmolarity (obtained by addition of all osmotically active molecules to 1 L of
solution) and actual osmolality (mOsmol/kg solvent),
especially in vivo. As sodium and chloride, when dissolved,
only partially dissociate, and as such are only partially osmotically active (osmotic coefcient 0.926), the actual osmolality of
a uid in which they are dissolved is lower than their added
molarities. The osmolality of a uid is derived from the ideal
osmolarity, the osmotic coefcient and the solvent content
(93% water for plasma) and may be directly measured via
freezing point depression. Surprisingly, the measured osmolality of plasma (288 mOsmol/kg H2O) is practically identical to
the calculated osmolarity (291 mOsmol/L) [12, 20]. This is in
stark contrast to the difference between the theoretical osmolarity of NaCl 0.9% (308 mOsmol/L) and its actual osmolality
of 286 mOsmol/kg H2O. It is of note that changes in the osmolality and volume of the blood plasma lead to more limited,
Na (mmol/L)
Cl (mmol/L)
K+ (mmol/L)
Ca2+ (mmol/L)
Mg2+ (mmol/L)
Bufferb (mmol/L)
Colloid (g/L)
Oncotic pressure (mmHg)
Osmolarity (mOsmol/L)
Osmolality (mOsmol/kg)
142
103
4.5
2.5
1.25
24
3545
25
291
288
Crystalloids
Colloids
0.9% NaCl
Lactated Ringers
Plasma-Lyte
Sterofundin
Gelofusinea
Dextran 40
154
154
0
0
0
0
0
0
308
286
130
109
4
2.7
0
28
0
0
273
254
140
98
5
0
1.5
50
0
0
295
N/K
140
127
4
2.5
1
29
0
0
304
290
154
154
0
0
0
0
60
36
308
N/A
154
120
0
0
0
0
40
2629
274
N/A
154
154
0
0
0
0
100
168191
308
N/A
FULL REVIEW
C O L LO I D S
D. Severs et al.
FULL REVIEW
Normal saline
Normal saline (NS, 0.9% or 154 mM NaCl) is the most
frequently prescribed crystalloid in clinical practice [75], yet
remarkably few studies address the time scale and extent of its
effects in normal subjects on haemodynamic parameters,
blood dilution and excretion. After infusion, normal saline is
rapidly distributed between the compartments of the extracellular space but remains in the body for a long time.
In normovolaemic subjects, expansion of the intravascular
volume persists for as long as 6 h after infusion of normal
saline, even though most of the infused volume is found in the
interstitial compartment. A study in 28 healthy volunteers
found that 30 min after completion of a 20-min infusion of
1030 mL/kg, 64% of the infused volume had diffused into the
interstitial compartment [76]. Studies in pre-surgical patients
and healthy volunteers receiving a 2-L normal saline infusion
over the course of 1 or 2 h reported intravascular retention of
the infused uid of 1824% (calculations based on haematocrit values) [7779]. After 6 h, 60% of the uid volume still remained in the body, an estimated 13% in the intravascular
space [78, 79]. Finally, it is of note that during anaesthesia and
surgery, distribution and elimination of infused crystalloids
are delayed when compared with healthy volunteers [80].
Owing to the non-physiological ion content and the lack of
buffering capacity, normal saline infusion can be complicated
by metabolic acidosis. The determination of saline-induced
acidosis is subject to vivid debate [81]. The most commonly
used method for interpreting acid-base disturbances is the
HendersonHasselbalch equation, in which the dependent
variable pH is calculated from the variables PaCO2 and plasma
FULL REVIEW
C R Y S TA L LO I D S
bicarbonate. The acidosis resulting from normal saline infusion is often interpreted as dilutional, i.e. the result of decreased bicarbonate concentrations relative to stable PaCO2
[81]. The model assumes changes in the volume of distribution of bicarbonate with changes in pH [82, 83]. Advocates
of the alternative Stewart approach, introduced in 1983 [84],
argue that the essential change is not dilution of bicarbonate
(HCO
3 ) but infusion of the strong ion Cl . This explanation
is based on the concept that independent variablesPaCO2,
the strong ion difference and the total concentration of nonvolatile weak acidsinuence the dependent variables pH and
bicarbonate concentration [85]. Indirect effects of chloride
loading might also be responsible for the acidosis. Intraluminal chloride is needed for pendrin-mediated bicarbonate
excretion [8688]. We therefore speculate that excessive chloride loading might be involved in disproportionate urinary
bicarbonate loss. However, it should be noted that in animal
models, pendrin protein expression is rapidly downregulated
in response to induction of acidosis [89]. In addition, the presence of chloride ions in an infusion uid is instrumental in
this uids capacity to suppress renin release, and subsequently
its capacity to suppress aldosterone availability and bicarbonate retention [90]. The latter was demonstrated in experiments
in healthy, sodium-restricted volunteers, in whom no suppression of PRA was found after infusion of 750 mL 1.4%
NaHCO3, whereas infusion of 500 mL 0.9% NaCl led to a 50%
decrease in PRA [91]. Regardless of the explanatory model,
reductions in blood pH on infusion of saline, not in the more
balanced Ringers solution, were demonstrated in healthy
human volunteers who received 50 mL/kg over 1 h (average
pH reduction 0.04 0.04) [92], and, as described later in this
review, in patients undergoing gynaecological surgery (average
pH reduction 0.13) [93] and pancreatico-hepatobiliary surgery
[94].
As normal saline contains a supraphysiological concentration of chloride [12], its infusion increases plasma chloride
concentrations [93], which is associated with renal vasoconstriction and decreased glomerular ltration rate (GFR). In an
animal model, intrarenal infusion of chloride-rich solutions to
denervated kidneys resulted in decreases in renal blood ow
(RBF) and GFR compared with low-chloride solutions of
equal tonicity [95, 96]. Two studies with healthy human volunteers consistently showed a longer time to rst micturition
after infusion of normal saline compared with a low-chloride
solution [79, 92]. Changes in plasma osmolality must be taken
into account in these studies, where the low-chloride solution
had a lower osmolality than normal saline, with a potential
effect on the release of antidiuretic hormone. Strengthening
the hypothesis of renal vasoconstriction by chloride infusion,
however, a study in healthy volunteers showed signicant
reductions in renal artery ow velocity and renal cortical tissue
perfusion during and after infusion of normal saline, but not
with a low-chloride solution (Plasma-Lyte 148) [97]. Such increases in renal cortical tissue perfusion were also seen when
healthy volunteers received 1-L infusions of 6% HES suspended in a low-chloride solution compared with 6% HES
suspended in normal saline [98]. The effect may be due to
luminal chloride concentrations in the cortical thick ascending
Balanced crystalloids
Some of the above effects can be prevented by using a
solution that more closely mimics the ionic make-up of
the aqueous fraction of plasma. Acidosis can be avoided by
inclusion of bicarbonate or metabolizable anions, such as
acetate, lactate, malate and citrate. Examples of more balanced
crystalloid solutions are lactated Ringers solution, Hartmanns
solution, featuring slightly different ionic concentrations,
Plasma-Lyte and Sterofundin. Their characteristics are summarized in Table 2. As described above, the use of infusates
with metabolizable anions instead of chloride has been shown
not to increase plasma acidity [92, 93]. In addition, balanced
salt solutions did not reduce renal artery ow and renal cortical
perfusion seen after infusion of normal saline (see above) [97].
Unfortunately, some of the most commonly used balanced
solutions (like lactated Ringers solution) are neither isotonic
nor precisely balanced. With an osmolarity of 273 mOsmol/L
and a measured osmolality of 254 mOsmol/kg, infused lactated Ringers solution leads to a small decrease in plasma osmolality [79, 92]. Theoretical concerns with slightly hypotonic
infusion uids include a potential increase in brain water
[102] and effects on diuresis. Interestingly, Hartmanns solution (a slightly modied form of Ringers solution) when
compared with normal saline, doubled urine output in the 6 h
after infusion, and subsequently had a shorter persistence in
the body [79]. Such effects may be relevant considering the
goals of infusion therapy. Commercial initiatives, such as
Plasma-Lyte 148 and Sterofundin, have attempted to address
concerns over differences in tonicity and ionic composition
between plasma and the infused uid. Unfortunately, there are
no published studies that address potential differences in kinetics and the effect on plasma osmolality between the more
balanced solutions.
CLINICAL STUDIES
In light of concerns raised around colloids, their use should be
restricted. For (intravascular) volume repletion, crystalloids
deserve consideration as infusates of rst choice. Below, we
compare the use of normal saline with balanced salt solutions
in clinical outcome studies.
Surgery
The risk of hyperchloraemic acidosis in patients receiving
normal saline was demonstrated in surgical patients. Subjects
undergoing intra-abdominal gynaecological surgery were randomly assigned to receive normal saline or lactated Ringers,
with an average volume of 6 L over 2 h. Predictably, hyperchloraemia and metabolic acidosis were more prevalent in the
normal saline group (average pH 7.28 versus 7.41, chloride
115 versus 107 mmol/L) [93]. Such metabolic derangements
D. Severs et al.
FULL REVIEW
limb of the loop of Henle being a rate-limiting step in tubuloglomerular feedback [95, 99101], a mechanism that induces
alterations in the GFR by inuencing afferent arteriolar vasoconstriction. Finally, chloride has been shown to be actively involved in the suppression of renin release, as described above.
Miscellaneous
A small number of studies compared the use of balanced
crystalloids with saline in resuscitation in diabetic ketoacidosis
and choleriform diarrhoea, and found faster resolution of
CONCLUSIONS
We have reviewed the available experimental and clinical data
on colloid and crystalloid infusates. In view of an overall
lack of survival benet with albumin, recent evidence on
adverse safety outcomes associated with semisynthetic colloids, as well as the effects of the retraction of a large body of
work by Dr Joachim Boldt due to integrity concerns, the use
of colloid infusates is to be limited. Therefore, we have focused
on balanced salt solutions and normal saline.
Infusion of normal saline is clearly associated with hyperchloraemia and metabolic acidosis [93, 94], and such derangements can be prevented by using balanced crystalloids [93,
94]. Studies in surgical and ICU patients reported a signicantly lower incidence of renal replacement therapy in groups
receiving balanced crystalloids compared with those receiving
normal saline [105, 114]. Interestingly, one study involving
kidney transplant recipients found that correction of acidosis
was associated with signicantly lower creatinine levels and increased diuresis [110]. One explanation for this phenomenon
is that by inducing renal vasoconstriction, hyperchloraemia
appears to reduce RBF and GFR [9597]. Acidosis leads to a
dysfunction of various cellular and extracellular mechanisms,
most notably coagulation [1317]. This may explain the increased need for blood products in surgical patients receiving
normal saline [104, 105].
A shortcoming in the literature is the absence of a direct
comparison between the various balanced crystalloids and the
relatively small study participant numbers. Furthermore, in
the largest meta-analysis on this subject to date, relatively heterogeneous data on various salt solutions were pooled to
compare balanced with unbalanced crystalloids. Even though
the documented negative safety outcomes pertaining to the
use of normal saline seem relatively persistent across studies,
the heterogeneity of studies leaves questions on the size of the
mentioned effects in clinical scenarios, especially mortality,
unanswered.
In conclusion, there is a growing body of evidence that balanced crystalloids are preferred over normal saline in clinical
practice and that the positive effects of these solutions are not
restricted to one specic application only. In our opinion,
FULL REVIEW
C O N F L I C T O F I N T E R E S T S TAT E M E N T
All authors conrm they have no conicts of interest with
regard to this submission.
D. Severs et al.
FULL REVIEW
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Received for publication: 14.10.2013; Accepted in revised form: 3.1.2014
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