Despite physiological rationale, common sense, and a JAMA article now almost 2 years old, I still sadly see most of my internal medicine colleagues still routinely reaching for (ab)normal saline.
I genuinely feel bad recommending other fluids in consultations, or in the room of a crashing patient asking the nurse to stop the bolus of NS and change it at least to RL, because it is such a ‘basic’ intervention. Prior to the JAMA article, I mostly gave people the benefit of the doubt. Resuscitation isn’t everyone’s field of interest, nor is physiology, so I didn’t feel that necessarily everyone HAD to know this and ascribe to it. I do understand the 10 year time of knowledge translation, but that’s why #FOAMed exists, to try to cut that down.
So please, unless your goal is specifically chloride repletion, take a deep breath and release your grasp on habit and tradition, and embrace physiology (at least to some degree) and stop using NS as a volume expander whether in bolus or in infusion. RL or plasmalyte – although not physiological, at least not as biochemically disturbing as is 0.9% NaCl.
Having said that, let’s keep in mind that human fluid is colloid, whether it includes a cellular suspension (blood, lymph) or not (interstitial fluid), made of a varying mix of proteins, electrolytes, hormones and everything else we know – and some we don’t – floating around. There is no compartment that contains a crystalloid solution.
I’m quite aware that no meta-analysis has shown that colloids are superior, but it likely is just a matter of the right colloid. Resuscitating with crystalloids is kinda like throwing a bucketful of water at an empty bucket across the room. 70-80% spill, if you’re lucky. And the cleanup may be more costly than a few sweeps of the mop. This is evidence based (SOAP, VASST, etc..).
So a plea to all, spread the word. Its a simple switch. Boycott hyperchloremic acidosis at least.
For more details, here’s a link to my earlier post on NS: http://wp.me/p1avUV-5x
Amen. Tell our critical care docs as well. Sean. BTW, I want to do Aug 4, 5, 6th. Let me know so I can make my reservations. Thanks. Look forward to learning from you. Sean
Thanks again Philippe, you know already how much I agree with you on this topic. In Italy we say “you’re breaking through an open door”.
I also think that the increased incidence of AKI, which led to restrictions on the use of colloids by the European authorities, were due to chloride more than the colloid itself.
In any case, I’m spreading the word among my colleagues and your post is very helpful to the cause!