This page is a work in progress as a IV Fluid guide and will continue to grow throughout the years. Last updated on 3/3/22. This page is quite the mess right now if I am being honest. I will get it together at some point. Just many projects running simultaneously.

Table of Contents for the IV Fluid Guide

• The contents of IV Fluids
• Fluid Extravasation
• 0.9% NaCl
  • The history of NaCl
  • The problem with too much sodium
  • The problem with too much chloride
• Lactated Ringers
  • Is hyperkalemia something we should really worry about?
  • Is the lactate in LR bad?
• Plasma-lyte
• The major recent clinical trials: SMART, SALT-ED, BASICS, PLUS
• Putting it all together
• Albumin
  • 10 myths of albumin
• Which fluid to use in DKA?

Article shared on Instagram on 3/3/22
Balanced Crystalloids versus Saline in Critically Ill Adults — A Systematic Review with Meta-Analysis
Naomi E. Hammond, Ph.D., Fernando G. Zampieri, Ph.D., Gian Luca Di Tanna, Ph.D., Tessa Garside, Ph.D., Derick Adigbli, Ph.D., Alexandre B. Cavalcanti, M.D. Ph.D., Flavia R. Machado, M.D., Ph.D., Sharon Micallef, B.N., John Myburgh, Ph.D., Mahesh Ramanan, M.Med., Todd W. Rice, M.D., Matthew W. Semler, M.D., Paul J. Young, Ph.D., Balasubramanian Venkatesh, M.D., Simon Finfer, M.D., and Anthony Delaney, Ph.D.
Link to Article
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Article shared on Instagram on 6/6/21
Curran JD, Major P, Tang K, Bagshaw SM, Dionne JC, Menon K, Rochwerg B. Comparison of Balanced Crystalloid Solutions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor. 2021 May 14;3(5):e0398. doi: 10.1097/CCE.0000000000000398. PMID: 34036269; PMCID: PMC8133105.
Link to Article AND FULL FREE PDF

Article shared on Instagram on 5/28/21
Van Regenmortel N, Moers L, Langer T, Roelant E, De Weerdt T, Caironi P, Malbrain MLNG, Elbers P, Van den Wyngaert T, Jorens PG. Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults. Ann Intensive Care. 2021 May 17;11(1):79. doi: 10.1186/s13613-021-00851-3. PMID: 33999276.
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Article shared on Instagram on 10/5/21
Yagi K, Fujii T. Management of acute metabolic acidosis in the ICU: sodium bicarbonate and renal replacement therapy. Crit Care. 2021 Aug 31;25(1):314. doi: 10.1186/s13054-021-03677-4. PMID: 34461963; PMCID: PMC8406840.
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The majority of residents do not know the contents of the regularly used IV Fluids

More than 50% of residents do not know how much sodium is in 0.9% NaCl per Lobo et al. I know you do, though… it’s 154mmol/L. Far more than our “normal” of 140mmol/L.

Why do I nag so much with intravenous fluids and what’s in them? Truth be told, I did not know my fluid composition as well as I should have even as an intern. I had an ICU attending, a mentor, now someone I’m fortunate to call a colleague, who would pimp the house staff on IV fluids and make us feel ashamed if we didn’t know the answer. He was right. My embarrassment was deserved.

After all, these are substances that we are mindlessly pouring into our patients. The vast majority of clinicians, I’m not even talking about nurses, I AM REFERRING TO US DOCTORS, do not know what’s in these bags that are so easy to click in the EMR and order. We mindlessly just do it. I was embarrassed. I do not want you to feel the same way. I have been teaching fluids now for 4 years. It’s one of my passions. I have a talk that is complete and can present at any time of the day. I know it well. But I am always reading and adding to it.

I ran into this study from 2001 which asked preregistration house officers and senior house officers (I guess that means interns and residents) about the composition of fluids amongst other things. I won’t go over the methodology but the training needs to start in medical school. Overall, 11.5% said their training in the matter was poor, 22% stated it was unsatisfactory. I have to agree with this 100%. I received ZERO training in med school regarding IVF. Since it’s something so ubiquitous in our daily practice of medicine, it’s something we need to do better. A lot better. If you are in medical school or residency, have you been trained in the composition of IV Fluids? Well you have this page as a resource to help you learn.

Not every cc/ml of fluid you provide your patients is retained! Most of it is extravasated.

A Contextual Introduction of IV Fluids

0.9% Sodium Chloride aka Normal Saline

The history of 0.9% NaCl

Click here for a full post on this matter with a citation by Awad et al.

I credit Awad et al. for doing much of this heavy lifting, by the way. I can’t actually get this paper to you but I’m going to do my best to briefly summarize.

1888: Hamburger. This Dutch physiologic chemist performed in vitro studies (not in vivo, take a second to let that process) where he found that there was less hemolysis with 0.92% saline than other concentrations.

1888: Dr Churton. “he was ordered transfusion of ‘normal saline’ solution in order to replace the fluid thus lost”. That fluid was nothing like the saline we know and are still trying to understand to this day. That particular fluid had 150meq/L of Na and 128meq/L of chloride. It also had some bicarb in it.

1892: Dr Spencer used the term “normal salt solution” but the composition of the fluid was not defined.

There are plenty more goodies in the article which I recommend you try to get your hands on. The article is going to definitely be included in my lecture regarding intravenous fluids that I will be giving to the anesthesia department in my shop next month and on various lectures I have scheduled nationally next year. It’s that important. A great job by the authors!

All in all, can we really stop saying “normal saline”? I think it’s too embedded in our vernacular and it’ll be too challenging to fix. I am always trying to make a conscious effort to stop but it’s challenging because I have been hearing it for over a decade now. I’m getting old.

The hyperchloremia caused by 0.9% NaCl causes harm

This article by Chowdhury et al. from 2012 shows a study that was performed on 12 healthy volunteers. It was a randomized, double blind, cross over study. I bet they were either college students or medical students; the mean age was 22. This was not disclosed in the article, of course. The participants received either 2L of 0.9% NaCl or plasma-lyte over an hour on separate occasions 7 to 10 days apart. If you still don’t know what Plasma-lyte is, you must be new here. They did some bloodwork as well as MRI’s. They must have had some good funding here. 

Amongst the results, they found a significant difference in the serum chloride, as expected (p < 0.0001) and a much lower strong ion difference (p = 0.025) in the saline group. All the other electrolytes were unremarkable. From the MRI results, they found lower mean renal artery flow velocity (p = 0.045) and lower renal cortical tissue perfusion (p = 0.008) in the saline group. This proves that hyperchloremic metabolic acidosis is not benign. For the full post, click here.

Lactated Ringers/Ringer’s Lactate

Does lactated ringer’s cause hyperkalemia?

Does Plasma-Lyte Cause Hyperkalemia relative to 0.9% NaCl

Weinberg L, Harris L, Bellomo R, Ierino FL, Story D, Eastwood G, Collins M, Churilov L, Mount PF. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial. Br J Anaesth. 2017 Oct 1;119(4):606-615. doi: 10.1093/bja/aex163. PMID: 29121282.
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Plasma-lyte/Plasmalyte/Normosol

Which IV Fluids to Choose in Resuscitation

Hyperkalemia with Balanced Salt Solutions?

0.9% saline is 154mmol/L of sodium and 154mmol/L of chloride. That’s it. There’s no potassium, calcium, magnesium, nor buffering agent in there. Ringer’s lactate, however, has 130mmol/L of sodium, 109mmol/L of chloride, 4mmol/L of potassium, 28mmol/L of lactate, and 3mmol/L of calcium. One would expect that the solution containing potassium would cause a greater increase in potassium than the one without potassium, right? Well, not so fast. Large volumes of sodium chloride, produce a hyperchloremic metabolic acidosis. What happens during acidosis? Well, there’s a shift of potassium from the intracellular space to the extra cellular space. Much of this has to do with the strong ion difference which I will be breaking down in the near future. In this study by Khajavi et al., 52 patients patients received either LR or NS during their renal transplants.

Here are the findings:
“Patients in the NS group had a lower mean PH level during the transplantation compared with those who received LR (p < 0. 001).
Mean serum potassium levels in the NS and LR groups were 4.88 ± 0.7 and 4.03 ± 0.8 meq/L, respectively (p < 0.001).
Mean changes of the serum potassium were +0.5 ± 0.6 meq/L in the NS group and –0.5 ± 0.9 meq/L in the LR group (p < 0.001).
Mean changes of PH were −0.06 ± 0.05 in the NS group and –0.005 ± 0.07 in the LR group (p < 0.001)”

If next time someone tells you that LR causes hyperkalemia, you can be armed with data. I have other articles with similar results that I plan on sharing in the upcoming days. I don’t know what to make of that thrombosis phenomenon they found. Must keep an eye out for more data regarding that. Other post with these data is HERE.

Click here for my analysis of the Modi article.
Modi et al. published an article discussing Ringer’s Lactate versus 0.9% saline solution in renal transplant patients. They also acknowledged the consensus to provide NS rather than LR to avoid hyperkalemia in patients but they weren’t happy with that, especially understanding and running into the data suggesting that NS creates the non-anion gap metabolic acidosis from hyperchloremia which can result in hyperkalemia due to the extra-cellular shift of potassium. That’s the reason why they decided to proceed with a prospective double blind clinical trial on patients undergoing kidney transplants.

They had 37 patients in each group. Each group of patients, the LR and the NS groups, received a little more than 5L each. Patients who received NS had a pH drop from 7.43 to 7.33. The LR group had no change in pH. The table in the article breaks down the serum electrolytes during the study as they checked it four times throughout the course of the surgery. The authors concluded that RL may not only be safe, but also superior to NS in these patients. The article cites another study where that team had to to treat more patients for hyperkalemia in the NS arm compared to the LR arm. Cool stuff, right? A 🎩 tip to the authors!

0.9% Saline vs. Balanced Crystalloids

Saline versus Plasma-lyte in Trauma?

Click here to learn which is better in this scenario.

IV Fluid Guide: Balanced Salt Solutions vs. 0.9% NaCl in DKA

Can we start looking at our diabetic ketoacidosis protocols and changing them? Chau et al. published a study in 2012 that is admittedly small, retrospective, and leaves a lot to be desired. But their findings are significant in my opinion. Usually studies need large sample sizes to prove their endpoints. Here, the endpoints were proved (within their methodology) with this small sample size. The article is not free and I bet that more people would benefit from the knowledge one could gain from it if it wasn’t hidden behind the paywall. Grrrrrrr. Here are the benefits of using plasmalyte over saline.
1. the mean arterial pressure was improved in the PL group p less than 0.05
2. there was improved urine output in the PL group in the first 4-6 hours p less than 0.05
3. the patients who received NS had higher potassium levels than the PL group between the 6-12 hour mark. Remember, PL has 5meq/L of K while NS has ZERO. Can we drop this hyperkalemia with LR and PL nonsense already?
They disclose the COST of plasma-lyte in Australia to be $1.94/L vs. $1.17/L of NS. It’s not $30 a liter like I’ve heard in the past. This was in 2012.

There was another article published in 2011 that supports the same that you can read my take on it HERE.

Adding the SMART and SALT-ED Trials to the IV Fluid Guide

In March of 2018 two landmark trials were published looking at balanced salt solutions (Ringer’s lactate or Plasma-lyte) versus 0.9% sodium chloride in different clinical scenarios. Those were the SALT-ED and the SMART trials. I won’t get into the nuance of these studies as I have covered them before but long story short, they kicked “normal saline” in the face.

Taking a deeper look into the large group of patients enrolled in the study, the authors, they were able to conduct a subgroup analysis of the patients who had DKA. They were able to come up with 126 patients. They postulated that since plasma-lyte and lactated ringer’s have more physiologic chloride levels, 98meq/L and 109meq/L respectively, there would be less metabolic acidosis than what is seen when we provide patients with 0.9% sodium chloride which has 154meq/L of chloride.

It makes sense, right? DKA is a process where you have a metabolic acidosis. To that metabolic acidosis which fluid should be better? The one with more chloride which is known to cause an acidosis or the fluids without that much chloride? This is why it’s completely absurd to me that this is even a discussion. It’s absurd to me that the fluid of choice at most institutions for their patients with DKA is normal saline. Old habits don’t die, I guess. When you’re trying to get the patient out of a metabolic acidosis, use the fluid that does not cause a metabolic acidosis.

“Oh but Eddy, what about the potassium in plasma-lyte or Ringer’s lactate? That should make the patients hyperkalemic!” That’s definitely not what the study proved to us. As a matter of fact, and before I go off on this I have to state that these are NOT statistically significant (p=0.19), but there was more new hyperkalemia after ED presentation in the normal saline group than the balanced salt solutions group. 23% in the saline group vs. 12% in the balanced crystalloids. Again, this was not powered to show statistical significance here. Don’t forget physiology, team. In acidosis there’s a shift of potassium from the intracellular space to the extracellular space. If a patient has an acidosis when hitting the door of the ED from the DKA, then giving acidic normal saline is not going to fix the acidosis.

So what did they find when they looked at these 126 patients? 94 being in the balanced crystalloid group and 78 being in the saline group for further clarification. Turns out that the balanced crystalloid group got out of DKA faster than the saline group. A median of 13 hours versus 16.9 hours respectively (p=0.004). In addition, the insulin drip was discontinued earlier (median 9.8 vs 13.4h, p=0.03). There was less hypokalemia (not surprising) in the balanced salt solution group (p=0.03).

All in all, the authors did a great job of crunching numbers with the data they had collected from the SALT-ED and SMART trials to provide us with better insight as to how we should provide our patients who are in DKA with fluids.

Balanced Crystalloids in Sepsis: IV Fluid Guide

Brown et al. performed a secondary analysis of the SMART trial which I covered HERE.

Sometimes we need to make minor adjustments in what we do in the ICU to see a difference. I have been going off for several years now on my instagram account as well as YouTube channel regarding the importance of utilizing balanced crystalloids such as lactated ringers or plasma-lyte and I keep on hearing “there’s no mortality benefit”. Well, now there’s data showing that there is. I knew it was just a matter of time. It just makes sense. This analysis is a piggyback on the SMART trial performed by the good people over at Vanderbilt published last year in the NEJM. In that study and therefore this study, they looked at using saline solution versus either lactated ringers or plasma-lyte. You may be asking yourself “but I thought that study didn’t show any mortality benefit”. You are correct, it didn’t, but that finding was regarding all critically ill patients.

This study looked at 30 day mortality in patients in the MICU who were septic. All in all, they looked at 1641 patients with the diagnosis of sepsis. Note: not necessarily septic shock. 34.1% of patients were on vasopressors and 40% were on the vent.

Here are the outcomes:
30 day mortality: 26.3% in the balanced crystalloids group vs. 31.2% in the saline group (p=0.01)

Patients who received balanced crystalloids had more days free of vasopressors, free of dialysis days, lower plasma lactate concentrations after ICU admission.

PLUS Trial

The PLUS trial was completed by the ANZICS group and I cover it thoroughly HERE.

Albumin (Updated 04.29.22)

Joannidis M, Wiedermann CJ, Ostermann M. Ten myths about albumin. Intensive Care Med. 2022 May;48(5):602-605. doi: 10.1007/s00134-022-06655-8. Erratum in: Intensive Care Med. 2022 Mar 18;: PMID: 35247060.
Link to Article
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Citations for the IV Fluid Guide

Self WH, Evans CS, Jenkins CA, Brown RM, Casey JD, Collins SP, Coston TD, Felbinger M, Flemmons LN, Hellervik SM, Lindsell CJ, Liu D, McCoin NS, Niswender KD, Slovis CM, Stollings JL, Wang L, Rice TW, Semler MW; Pragmatic Critical Care Research Group. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open. 2020 Nov 2;3(11):e2024596. doi: 10.1001/jamanetworkopen.2020.24596. PMID: 33196806.
Link to Article and FULL FREE PDF

Lobo DN, Stanga Z, Aloysius MM, et al. Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers. Crit Care Med. 2010;38(2):464–470. doi:10.1097/CCM.0b013e3181bc80f1

Ragaller MJ, Theilen H, Koch T. Volume replacement in critically ill patients with acute renal failure. J Am Soc Nephrol. 2001;12 Suppl 17:S33–S39.

Bark BP, Persson J, Grände PO. Importance of the infusion rate for the plasma expanding effect of 5% albumin, 6% HES 130/0.4, 4% gelatin, and 0.9% NaCl in the septic rat. Crit Care Med. 2013;41(3):857–866. doi:10.1097/CCM.0b013e318274157e

Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr. 2001 Apr;20(2):125-30. doi: 10.1054/clnu.2000.0154. PMID: 11327739.
Link to Article (NOT FREE)

Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008 Apr;27(2):179-88. doi: 10.1016/j.clnu.2008.01.008. Epub 2008 Mar 3. PMID: 18313809.
Link to Article (NOT FREE)

Lewins, Robert. Injection of Saline Solutions into the Veins. (1832). The Boston Medical and Surgical Journal, 6(24), 373–375.

Hartmann AF, Senn MJ. STUDIES IN THE METABOLISM OF SODIUM r-LACTATE. II. RESPONSE OF HUMAN SUBJECTS WITH ACIDOSIS TO THE INTRAVENOUS INJECTION OF SODIUM r-LACTATE. J Clin Invest. 1932;11(2):337–344. doi:10.1172/JCI100415

Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235
Rizoli S. PlasmaLyte. J Trauma. 2011;70(5 Suppl):S17–S18. doi:10.1097/TA.0b013e31821a4d89

Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019;200(12):1487–1495. doi:10.1164/rccm.201903-0557OC

Li H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181–187. doi:10.1631/jzus.B1500201

Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest. 1983;71(3):726–735. doi:10.1172/jci110820

Quilley CP, Lin YS, McGiff JC. Chloride anion concentration as a determinant of renal vascular responsiveness to vasoconstrictor agents. Br J Pharmacol. 1993;108(1):106–110. doi:10.1111/j.1476-5381.1993.tb13447.x

Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012 Jul;256(1):18-24. doi: 10.1097/SLA.0b013e318256be72. Erratum in: Ann Surg. 2013 Dec;258(6):1118. PMID: 22580944.
Link to Article

Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243–1251. doi:10.1056/NEJMra1208627

Noritomi DT, Soriano FG, Kellum JA, et al. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37(10):2733–2739. doi:10.1097/ccm.0b013e3181a59165

Neyra JA, Canepa-Escaro F, Li X, et al. Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients. Crit Care Med. 2015;43(9):1938–1944. doi:10.1097/CCM.0000000000001161

Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315. Published 2016 Oct 6. doi:10.1186/s13054-016-1499-7

Balanced Salt Solutions do not cause Hyperkalemia: Citations

Khajavi MR, Etezadi F, Moharari RS, Imani F, Meysamie AP, Khashayar P, Najafi A. Effects of normal saline vs. lactated ringer’s during renal transplantation. Ren Fail. 2008;30(5):535-9. doi: 10.1080/08860220802064770. PMID: 18569935.
Link to Article
Link to FULL FREE PDF

Modi MP, Vora KS, Parikh GP, Shah VR. A comparative study of impact of infusion of Ringer’s Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7. PMID: 22237237.
Link to Article
Link to FULL FREE PDF

Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am. 2012;92(2):189–vii. doi:10.1016/j.suc.2012.01.004

Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127–1140. doi:10.1016/j.mayocp.2013.06.012Ichai C, Orban JC, Fontaine E. Sodium lactate for fluid resuscitation: the preferred solution for the coming decades?. Crit Care. 2014;18(4):163. Published 2014 Jul 7. doi:10.1186/cc13973

Farkas, Josh. “Three myths about Plasmalyte, Normosol, and LR” https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/\.1/26/15

Nalos M, Leverve XM, Huang SJ, Weisbrodt L, Parkin R, Seppelt IM, Ting I, Mclean AS: Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomized controlled clinical trial. Crit Care 2014, 18:R48.

Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Yartsev, Alex. Metabolic Fate of Lactate, Acetate, Citrate and Gluconate. http://www.derangedphysiology.com/main/core-topics-intensive-care/manipulation-fluids-and-electrolytes/Chapter%204.1.4/metabolic-fate-lactate-acetate-citrate-and-gluconate. Accessed 3.13.2020

Spriet I, Lagrou K, Maertens J, Willems L, Wilmer A, Wauters J. Plasmalyte: No Longer a Culprit in Causing False-Positive Galactomannan Test Results. J Clin Microbiol. 2016;54(3):795–797. doi:10.1128/JCM.02813-15

Stocker RA. “Normal” Saline and Co: What Is Normal?. Crit Care Med. 2016;44(12):2282–2283. doi:10.1097/CCM.0000000000002030

Zampieri FG, Ranzani OT, Azevedo LC, Martins ID, Kellum JA, Libório AB. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016;44(12):2163–2170. doi:10.1097/CCM.0000000000001948Shaw 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(5):821–829. doi:10.1097/SLA.0b013e31825074f5

Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. Crit Care. 2015;19(1):286. Published 2015 Aug 28. doi:10.1186/s13054-015-1011-9

Ince C, Groeneveld AB. The case for 0.9% NaCl: is the undefendable, defensible?. Kidney Int. 2014;86(6):1087–1095. doi:10.1038/ki.2014.193

Hammond NE, Taylor C, Saxena M, et al. Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med. 2015;41(9):1611–1619. doi:10.1007/s00134-015-3878-y

Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011;29(6):670–674. doi:10.1016/j.ajem.2010.02.004

McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia. 1994;49(9):779–781. doi:10.1111/j.1365-2044.1994.tb04450.x

Young JB, Utter GH, Schermer CR, et al. Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial. Ann Surg. 2014;259(2):255–262. doi:10.1097/SLA.0b013e318295feba

Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial [published correction appears in JAMA. 2015 Dec 15;314(23):2570]. JAMA. 2015;314(16):1701–1710. doi:10.1001/jama.2015.12334

Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):819–828. doi:10.1056/NEJMoa1711586

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

Young PJ. Balanced Crystalloids or 0.9% Saline in Sepsis. Beyond Reasonable Doubt?. Am J Respir Crit Care Med. 2019;200(12):1456–1458. doi:10.1164/rccm.201908-1669ED

McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg. 2013;117(2):412–421. doi:10.1213/ANE.0b013e318293d81e

Hammond DA, Lam SW, Rech MA, Smith MN, Westrick J, Trivedi AP, Balk RA. Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis. Ann Pharmacother. 2020 Jan;54(1):5-13. doi: 10.1177/1060028019866420. Epub 2019 Jul 31. PMID: 31364382.
Link to Article
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Van Regenmortel N, Moers L, Langer T, Roelant E, De Weerdt T, Caironi P, Malbrain MLNG, Elbers P, Van den Wyngaert T, Jorens PG. Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults. Ann Intensive Care. 2021 May 17;11(1):79. doi: 10.1186/s13613-021-00851-3. PMID: 33999276.
Link to Article
Link to FULL FREE PDF

Brown RM, Wang L, Coston TD, Krishnan NI, Casey JD, Wanderer JP, Ehrenfeld JM, Byrne DW, Stollings JL, Siew ED, Bernard GR, Self WH, Rice TW, Semler MW. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019 Dec 15;200(12):1487-1495. doi: 10.1164/rccm.201903-0557OC. PMID: 31454263; PMCID: PMC6909845.
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IV Fluids in DKA Citations

Chua HR, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, Kruger P, Bellomo R. Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care. 2012 Apr;27(2):138-45. doi: 10.1016/j.jcrc.2012.01.007. PMID: 22440386.
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Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011 Jul;29(6):670-4. doi: 10.1016/j.ajem.2010.02.004. Epub 2010 May 1. PMID: 20825879.
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Disclaimer for this IV Fluid Guide

Although great care has been taken to ensure that the information in this post is accurate, eddyjoe, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom. These are not medical recommendations. Please read the cited peer-reviewed publications for more legitimate resources.

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