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• W1993674429 abstract "The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury. The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury. Any rational approach to fluid and electrolyte therapy and volume resuscitation must take into account the evolved mammalian responses to stress, starvation, injury, or infection. These responses preserve the blood supply to essential organs, allowing time for the individual to recover, and activate the host defense and repair pathways. In simple terms, the major evolved responses relevant to fluid management are as follows:•Maintenance of perfusion of the heart, brain, and lungs at the expense of the cutaneous, splanchnic, and renal circulations.•Fluid shifts from the intracellular and interstitial compartments to replenish the depleted vascular compartment.•An increase in systemic vascular permeability allowing proteins such as immunoglobulins and albumin, with their attendant fluid, to move from the vascular space into the interstitial compartment.•Intense sodium and water retention by the kidneys to augment the reduced circulating blood volume. In addition to the evolutionary response to conserve salt and water, the patient’s ability to excrete administered salt and water is also limited by renal compromise and reduced ability to concentrate urine. As a consequence, it requires 2–4 times the normal volume of urine to excrete the sodium and chloride load administered, which competes with excretion of nitrogen resultant from catabolic stress during critical illness, resulting in interstitial edema. Although Evans1Evans G.H. The abuse of normal salt solution.JAMA. 1911; 57: 2126-2127Crossref Scopus (21) Google Scholar commented on the dangers of the reckless way in which salt solutions were prescribed as early as 1911, the clinical effects of salt and water excess have largely been ignored till relatively recently, with continued inappropriate and excessive use of chloride-rich crystalloid infusions, such as 0.9% saline, both within the settings of resuscitation and maintenance. The development of balanced crystalloids highlights the need to reappraise the continued use of 0.9% saline, especially considering the detrimental effects the latter has on renal function. In this debate we argue against the use of this unphysiological crystalloid, more appropriately termed ‘abnormal saline’,2Wakim K.G. ‘‘Normal’’ 0.9 per cent salt solution is neither ‘‘normal’’ nor physiological.JAMA. 1970; 214: 1710Crossref PubMed Scopus (35) Google Scholar,3Reid F. Lobo D.N. Williams R.N. et al.(Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study.Clin Sci (Lond). 2003; 104: 17-24Crossref PubMed Scopus (264) Google Scholar and appraise both historical and recent data that support the argument. From the renal perspective, the aim of fluid resuscitation of the hypovolemic patient is to improve renal blood flow, increase glomerular filtration rate (GFR), and reduce the incidence of acute kidney injury (Figure 1). However, the ability of fluid therapy to achieve this aim is dependent on a number of other factors including the type of fluid used and the effects of acute illness, chronic disease, and drugs that may alter determinants of fluid responsiveness. The latter include systemic vascular resistance, myocardial compliance and contractility, regional blood flow distribution, venous capacitance, and capillary permeability.4Prowle J.R. Bellomo R. Fluid administration and the kidney.Curr Opin Crit Care. 2010; 16: 332-336Crossref PubMed Scopus (41) Google Scholar Teleologically, the kidney is better adapted to conservation of salt and water than to excreting an excess of either.5Lobo D.N. Sir David Cuthbertson medal lecture. Fluid, electrolytes and nutrition: physiological and clinical aspects.Proc Nutr Soc. 2004; 63: 453-466Crossref PubMed Scopus (81) Google Scholar In addition, factors such as hypotension, pain, and injury activate the sympathetic nervous system and the renin–angiotensin–aldosterone system. Subsequent release of the antidiuretic hormone overrides normal homeostatic mechanisms and leads to further sodium and water retention. Even in the absence of renal impairment, the relationship between fluid input and natriuresis is weak, and the administration of intravenous fluid may lead to salt and water accumulation rather than a diuresis,3Reid F. Lobo D.N. Williams R.N. et al.(Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study.Clin Sci (Lond). 2003; 104: 17-24Crossref PubMed Scopus (264) Google Scholar,6Chowdhury A.H. Cox E.F. Francis S.T. et al.A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.Ann Surg. 2012; 256: 18-24Crossref PubMed Scopus (527) Google Scholar,7Lobo D.N. Stanga Z. Aloysius M.M. 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: 464-470Crossref PubMed Scopus (151) Google Scholar effects that are exaggerated with 0.9% saline when compared with balanced crystalloids, which bear a closer resemblance to the constituents of plasma (Table 1).Table 1Composition of 0.9% saline and some commonly used balanced crystalloidsHuman plasma0.9% Sodium chlorideHartmann’sRinger’s lactateRinger’s acetatePlasma-Lyte 148Plasma-Lyte A pH 7.4Sterofundin/RingerfundinOsmolarity (mOsm/l)275–295308278273276295295309pH7.35–7.454.5–7.05.0–7.06.0–7.56.0–8.04.0–8.07.45.1–5.9Sodium (mmol/l)135–145154131130130140140145Chloride (mmol/l)94–1111541111091129898127Potassium (mmol/l)3.5–5.30545554Calcium (mmol/l)2.2–2.6021.41002.5Magnesium (mmol/l)0.8–1.000011.51.51Bicarbonate (mmol/l)24–32Acetate (mmol/l)100027272724Lactate (mmol/l)1–2029280000Gluconate (mmol/l)0000023230Maleate (mmol/l)000005Na:Cl ratio1.21:1 to 1.54:11:11.18:11.19:11.16:11.43:11.43:11.14:1 Open table in a new tab Although traditionally believed to have originated during the European cholera pandemic in 1831, none of the intravenous saline solutions described between 1832 and 1895 bore any resemblance to 0.9% saline.8Awad S. Allison S.P. Lobo D.N. The history of 0.9% saline.Clin Nutr. 2008; 27: 179-188Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar The first reference to a solution bearing similarity to 0.9% saline appeared in an 1896 article by Lazarus-Barlow, where Hamburger, a Dutch physiological chemist, was cited as the main authority for suggesting that a concentration of 0.92% saline was ‘normal’ for mammalian blood.9Lazarus-Barlow W.S. On the initial rate of osmosis of blood-serum with reference to the composition of ‘‘physiological saline solution’’ in mammals.J Physiol. 1896; 20: 145-157Crossref PubMed Scopus (12) Google Scholar Hamburger performed experiments on the effects of varying the concentration of salt solutions on erythrocyte fragility.10Hamburger H.J. Koninkl Akad. Wetensch V. te Amsterdam 29/12/1883. 1883Google Scholar He found that ‘for every salt a concentration could be obtained in which the least resistant blood corpuscles lost their coloring matter’ and speculated that ‘the salt solutions used caused a swelling which a number of the blood corpuscles could not withstand without losing their coloring matter’. It was accepted that the freezing point of human serum was -0.52°C. On the basis of his experiments on erythrocyte fragility and freezing points of mammalian serum, Hamburger concluded that ‘the blood of the majority of warm-blooded animals, including man, was isotonic with a NaCl solution of 0.9 per cent., and not of 0.6 per cent., as was generally thought...and which had always been called the physiological NaCl solution’.11Hamburger H.J. A discourse on permeability in physiology and pathology.Lancet. 1921; 198: 1039-1045Abstract Scopus (15) Google Scholar The scientific evidence supporting the use of 0.9% saline in clinical practice seems to have originated solely on these in vitro studies, and, given the evidence presented below, it is unlikely that 0.9% saline would had progressed beyond a phase I clinical trial had it been developed in recent times. As early as 1948, a fall in arterial pH from 7.55 to 7.21 was demonstrated in dogs after an infusion of 1.5liter of 0.9% saline (300ml/h), but not after that of a ‘balanced salt solution’ containing NaHCO3.12Shires G.T. Holman J. Dilution acidosis.Ann Intern Med. 1948; 28: 557-559Crossref PubMed Scopus (78) Google Scholar In a canine model of Escherichia coli endotoxin–induced septic shock, mean saline requirement to maintain mean arterial pressure >80mmHg was 1833ml over 3h.13Kellum J.A. Bellomo R. Kramer D.J. et al.Etiology of metabolic acidosis during saline resuscitation in endotoxemia.Shock. 1998; 9: 364-368Crossref PubMed Scopus (149) Google Scholar The pH decreased from 7.32 to 7.11 (P<0.01) and serum chloride increased (from 128 to 137mmol/l, P=0.016), without changes in pCO2, serum lactate, and sodium. In a study on anesthetized dogs that had one kidney auto-transplanted to the neck, thereby denervating it, infusion of chloride-containing solutions resulted in hyperchloremia that produced progressive concentration-dependent renal vasoconstriction and a decrease in GFR independent of renal innervation.14Wilcox C.S. Regulation of renal blood flow by plasma chloride.J Clin Invest. 1983; 71: 726-735Crossref PubMed Scopus (462) Google Scholar Three swine studies have compared the effects of resuscitation using 0.9% saline and Ringer’s lactate (RL) after 30min of uncontrolled hemorrhage.15Kiraly L.N. Differding J.A. Enomoto T.M. et al.Resuscitation with normal saline (NS) vs. lactated Ringers (LR) modulates hypercoagulability and leads to increased blood loss in an uncontrolled hemorrhagic shock swine model.J Trauma. 2006; 61: 57-64Crossref PubMed Scopus (107) Google Scholar, 16Phillips C.R. Vinecore K. Hagg D.S. et al.Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics.Crit Care. 2009; 13: R30Crossref PubMed Scopus (55) Google Scholar, 17Todd S.R. Malinoski D. Muller P.J. et al.Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock.J Trauma. 2007; 62: 636-639Crossref PubMed Scopus (106) Google ScholarCompared with RL, resuscitation with 0.9% saline required significantly greater volumes (256±145ml/kg saline vs. 126±67ml/kg RL, P=0.04) to attain pre-injury mean arterial pressure.17Todd S.R. Malinoski D. Muller P.J. et al.Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock.J Trauma. 2007; 62: 636-639Crossref PubMed Scopus (106) Google Scholar Hyperchloremic acidosis and dilutional coagulopathy were noted with saline.17Todd S.R. Malinoski D. Muller P.J. et al.Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock.J Trauma. 2007; 62: 636-639Crossref PubMed Scopus (106) Google Scholar Hypercoagulability and low blood loss were noted with RL.15Kiraly L.N. Differding J.A. Enomoto T.M. et al.Resuscitation with normal saline (NS) vs. lactated Ringers (LR) modulates hypercoagulability and leads to increased blood loss in an uncontrolled hemorrhagic shock swine model.J Trauma. 2006; 61: 57-64Crossref PubMed Scopus (107) Google Scholar Extravascular lung water index increased with both fluids, but this occurred earlier and to a greater degree after saline.16Phillips C.R. Vinecore K. Hagg D.S. et al.Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics.Crit Care. 2009; 13: R30Crossref PubMed Scopus (55) Google Scholar Another study examined the effects of resuscitation using four crystalloids (0.9% saline, RL, Plasmalyte-A (Pl-A), and Plasmalyte-R (Pl-R)) in a model of rapid hemorrhage in 116 unanesthetized pigs.18Traverso L.W. Lee W.P. Langford M.J. Fluid resuscitation after an otherwise fatal hemorrhage: I. Crystalloid solutions.J Trauma. 1986; 26: 168-175Crossref PubMed Scopus (87) Google Scholar Aortic blood (54ml/kg) was removed over a period of 15min, and the replaced volume was 14% in 5min with saline, 100% in 20min with saline, and 300% in 30min with saline, RL, Pl-A, or Pl-R. In animals that had 300% replacement of shed blood in 30min, RL provided the best survival rate of 67% (e.g., 50% for saline, 40% for Pl-R, and 30% for Pl-A). The investigators hypothesized that the lower survival rates in animals that were resuscitated with Pl-R and Pl-A may have resulted from the acetate constituent, which may have had differential regional vasodilatory and vasoconstrictive effects in these animals.18Traverso L.W. Lee W.P. Langford M.J. Fluid resuscitation after an otherwise fatal hemorrhage: I. Crystalloid solutions.J Trauma. 1986; 26: 168-175Crossref PubMed Scopus (87) Google Scholar After removal of 40% of total blood volume in three equal aliquots at 30-min intervals, pigs received saline (mean volume infused: 2865ml), RL (2774ml), or Plasma-Lyte (2681ml), in a blinded manner over 15min, at a volume that was three times that of the blood removed.19Noritomi D.T. Pereira A.J. Bugano D.D. et al.Impact of Plasma-Lyte pH 7.4 on acid-base status and hemodynamics in a model of controlled hemorrhagic shock.Clinics (Sao Paulo). 2011; 66: 1969-1974Crossref PubMed Scopus (26) Google Scholar All three solutions attenuated hemorrhage-induced low cardiac output and anuria equally, but saline induced negative base excess and a significant hyperchloremia.19Noritomi D.T. Pereira A.J. Bugano D.D. et al.Impact of Plasma-Lyte pH 7.4 on acid-base status and hemodynamics in a model of controlled hemorrhagic shock.Clinics (Sao Paulo). 2011; 66: 1969-1974Crossref PubMed Scopus (26) Google Scholar A rat study compared the effects of resuscitation with saline and RL following moderate (mean 36% estimated blood volume) and massive hemorrhage (mean 218% estimated blood volume).20Healey M.A. Davis R.E. Liu F.C. et al.Lactated Ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation.J Trauma. 1998; 45: 894-899Crossref PubMed Scopus (99) Google Scholar The animals with moderate hemorrhage were bled to a MAP of 60mm Hg for 2h, then resuscitated with the appropriate crystalloid for 1h. In these animals, resuscitation with saline and RL was equivalent. The final hematocrit, pH, and base excess were not different, and all animals survived. In the massive hemorrhage group, animals resuscitated with saline+blood were significantly more acidotic than animals resuscitated with equal volumes of RL+blood (pH 7.14 vs. 7.39, P<0.01) and had significantly worse survival (50 vs. 100%, P<0.05).20Healey M.A. Davis R.E. Liu F.C. et al.Lactated Ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation.J Trauma. 1998; 45: 894-899Crossref PubMed Scopus (99) Google Scholar Furthermore, some saline+blood-resuscitated animals developed profound acidosis associated with cardiorespiratory arrest in some cases and early death in others. Hyperchloremic acidosis also resulted in increased concentrations of circulating inflammatory mediators in an experimental model of severe sepsis in rats, with a dose-dependent increase in circulating interleukin-6, tumor necrosis factor-α, and interleukin-10 concentrations with increasing acidosis.21Kellum J.A. Song M. Almasri E. Hyperchloremic acidosis increases circulating inflammatory molecules in experimental sepsis.Chest. 2006; 130: 962-967Crossref PubMed Scopus (155) Google Scholar In a sheep model of septic shock (intravenous administration of live E. coli), resuscitation with saline (20ml/kg over 15min), versus observation, resulted in transient reversal of the hemodynamic effects of septic shock but had no effect on renal blood flow.22Wan L. Bellomo R. May C.N. The effect of normal saline resuscitation on vital organ blood flow in septic sheep.Intensive Care Med. 2006; 32: 1238-1242Crossref PubMed Scopus (37) Google Scholar Interestingly, infusion of 25ml/kg saline over 20min in normovolemic conscious and anesthetized sheep altered fluid kinetics in the anesthetized group by reducing urinary excretion and resulting in interstitial fluid accumulation.23Brauer K.I. Svensen C. Hahn R.G. et al.Volume kinetic analysis of the distribution of 0.9% saline in conscious versus isoflurane-anesthetized sheep.Anesthesiology. 2002; 96: 442-449Crossref PubMed Scopus (58) Google Scholar A porcine model24Wauters J. Claus P. Brosens N. et al.Pathophysiology of renal hemodynamics and renal cortical microcirculation in a porcine model of elevated intra-abdominal pressure.J Trauma. 2009; 66: 713-719Crossref PubMed Scopus (61) Google Scholar of elevated intra-abdominal pressure demonstrated a progressive decrease in renal venous and arterial blood flow with increasing intra-abdominal pressure. Development of renal interstitial edema has been hypothesized to contribute, at least in part, to development of a ‘renal compartment-syndrome’–type effect due to kidney parenchymal swelling within the tough unyielding capsule, contributing to onset of anuria/oliguria in acute tubular necrosis. In a study on the effects of renal decapsulation in 12 rhesus monkeys subjected to cross-clamping of the supra-renal aorta for periods of 15–55min followed by declamping, split ureteral function tests demonstrated that renal decapsulation resulted in better preservation (threefold higher) of creatinine, urea, and free water clearance.25Stone H.H. Fulenwider J.T. Renal decapsulation in the prevention of post-ischemic oliguria.Ann Surg. 1977; 186: 343-355Crossref PubMed Scopus (74) Google Scholar Pathological examination revealed that kidneys with an intact capsule were either smaller than their decapsulated partners or obviously atrophic.25Stone H.H. Fulenwider J.T. Renal decapsulation in the prevention of post-ischemic oliguria.Ann Surg. 1977; 186: 343-355Crossref PubMed Scopus (74) Google Scholar Edema-related subcapsular pressure elevation was examined in a murine model of renal ischemia reperfusion.26Herrler T. Tischer A. Meyer A. et al.The intrinsic renal compartment syndrome: new perspectives in kidney transplantation.Transplantation. 2010; 89: 40-46Crossref PubMed Scopus (75) Google Scholar After 24h of elevated subcapsular pressures, significant reductions were noted in tubular excretion rates and renal perfusion, coupled with severe tissue damage on histological examination. Surgical capsulotomy effectively prevented these functional and structural alterations.26Herrler T. Tischer A. Meyer A. et al.The intrinsic renal compartment syndrome: new perspectives in kidney transplantation.Transplantation. 2010; 89: 40-46Crossref PubMed Scopus (75) Google Scholar Large volume infusions (50ml/kg over 1h) of 0.9% saline in healthy volunteers have been shown to be associated with a persistent acidosis and delayed micturition, and to produce abdominal discomfort and pain, nausea, drowsiness, and decreased mental capacity to perform complex tasks, but these changes were not noted after infusion of identical volumes of Hartmann’s solution.27Williams E.L. Hildebrand K.L. McCormick S.A. et al.The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers.Anesth Analg. 1999; 88: 999-1003PubMed Google Scholar Slow excretion of saline after a 2-liter intravenous load, with only 29% having been excreted after 195min, has also been reported.28Singer D.R.J. Shore A.C. Markandu N.D. et al.Dissociation between plasma atrial-natriuretic-peptide levels and urinary sodium-excretion after intravenous saline infusion in normal man.Clin Sci (Lond). 1987; 73: 285-289Crossref PubMed Scopus (36) Google Scholar A further comparison of the effects of 2-liter infusions of 0.9% saline and Hartmann’s solution over 1h in healthy volunteers has confirmed the sluggish urinary response after saline infusion, which occurs at the expense of the production of a significant and sustained hyperchloremia.3Reid F. Lobo D.N. Williams R.N. et al.(Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study.Clin Sci (Lond). 2003; 104: 17-24Crossref PubMed Scopus (264) Google Scholar At 6h, 56% of the infused saline was retained, in contrast to only 30% of the Hartmann’s solution. Time to first micturition was quicker, and urine volumes and sodium excretion were greater after infusion with Hartmann’s solution than after saline. Similar changes were also noted when 2-liter infusions of saline were compared with those of Plasma-Lyte 148.6Chowdhury A.H. Cox E.F. Francis S.T. et al.A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.Ann Surg. 2012; 256: 18-24Crossref PubMed Scopus (527) Google Scholar In addition, although calculated blood volume expansion was similar after the two infusions, interstitial fluid accumulation was significantly greater after saline than after Plasma-Lyte.6Chowdhury A.H. Cox E.F. Francis S.T. et al.A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.Ann Surg. 2012; 256: 18-24Crossref PubMed Scopus (527) Google Scholar The hyperchloremic acidosis caused by infusion of moderate-to-large quantities of 0.9% saline can last for several hours after the end of the infusion even in healthy volunteers3Reid F. Lobo D.N. Williams R.N. et al.(Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study.Clin Sci (Lond). 2003; 104: 17-24Crossref PubMed Scopus (264) Google Scholar,6Chowdhury A.H. Cox E.F. Francis S.T. et al.A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.Ann Surg. 2012; 256: 18-24Crossref PubMed Scopus (527) Google Scholar,7Lobo D.N. Stanga Z. Aloysius M.M. 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: 464-470Crossref PubMed Scopus (151) Google Scholar,27Williams E.L. Hildebrand K.L. McCormick S.A. et al.The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers.Anesth Analg. 1999; 88: 999-1003PubMed Google Scholar,29Lobo D.N. Stanga Z. Simpson J.A.D. et al.Dilution and redistribution effects of rapid 2-litre infusions of 0.9% (w/v) saline and 5% (w/v) dextrose on haematological parameters and serum biochemistry in normal subjects: a double-blind crossover study.Clin Sci (Lond). 2001; 101: 173-179Crossref PubMed Scopus (114) Google Scholar and may reflect the lower [Na+]:[Cl−] ratio in saline (1:1) than in balanced crystalloids (1.18–1.43:1) or in plasma (1.38:1).30Veech R.L. The toxic impact of parenteral solutions on the metabolism of cells: a hypothesis for physiological parenteral therapy.Am J Clin Nutr. 1986; 44: 519-551Crossref PubMed Scopus (62) Google Scholar Two theories have been proposed to explain this phenomenon: dilutional acidosis31Goodkin D.A. Raja R.M. Saven A. Dilutional acidosis.South Med J. 1990; 83: 354-355Crossref PubMed Scopus (25) Google Scholar,32Prough D.S. Bidani A. Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline.Anesthesiology. 1999; 90: 1247-1249Crossref PubMed Scopus (137) Google Scholar and the Stewart hypothesis.33Stewart P.A. Modern quantitative acid-base chemistry.Can J Physiol Pharmacol. 1983; 61: 1444-1461Crossref PubMed Scopus (1029) Google Scholar It has been proposed that infusion of large volumes of saline causes a decrease in serum bicarbonate concentration due to a dilutional effect, resulting in acidosis.31Goodkin D.A. Raja R.M. Saven A. Dilutional acidosis.South Med J. 1990; 83: 354-355Crossref PubMed Scopus (25) Google Scholar,32Prough D.S. Bidani A. Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline.Anesthesiology. 1999; 90: 1247-1249Crossref PubMed Scopus (137) Google Scholar The effects of randomly allocated 2-h infusions of almost 70ml/kg (i.e., up to 5liters) of 0.9% saline or Hartmann’s solution were studied in patients undergoing elective gynecological operations.34Scheingraber S. Rehm M. Sehmisch C. et al.Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery.Anesthesiology. 1999; 90: 1265-1270Crossref PubMed Scopus (595) Google Scholar There was a significant decrease in pH (7.41–7.28), serum bicarbonate concentration (23.5–18.4mmol/l), and anion gap (16.2–11.2mmol/l), accompanied by an increase in serum chloride concentration (104–115mmol/l) during the first 2h of saline infusion. Although pH, bicarbonate, and chloride concentrations did not change significantly after Hartmann’s solution, the anion gap decreased (15.2–12.1mmol/l). The volume of fluid replacement in this study34Scheingraber S. Rehm M. Sehmisch C. et al.Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery.Anesthesiology. 1999; 90: 1265-1270Crossref PubMed Scopus (595) Google Scholar may be considered excessive, but it confirmed that hyperchloremic acidosis accompanied saline infusions in patients. In a study of 30 patients undergoing major surgery, randomly allocated to receive either 0.9% saline or Plasma-Lyte 148 at 15ml/kg/h, those receiving saline had significantly increased chloride concentrations (Δ[Cl−] +6.9 vs. +0.6mmol/l, P<0.01), decreased bicarbonate concentrations (Δ[HCO3−] -4.0 vs. -0.7mmol/l, P<0.01), and increased base deficit (Δ base excess -5.0 vs. -1.2mmol/l, P<0.01) compared with those receiving Plasma-Lyte 148.35McFarlane C. Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement.Anaesthesia. 1994; 49: 779-781Crossref PubMed Scopus (183) Google Scholar There were no significant changes in plasma sodium, potassium, or lactate concentrations in either group.35McFarlane C. Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement.Anaesthesia. 1994; 49: 779-781Crossref PubMed Scopus (183" @default.
• W1993674429 created "2016-06-24" @default.
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• W1993674429 date "2014-12-01" @default.
• W1993674429 modified "2023-10-12" @default.
• W1993674429 title "Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury?: con" @default.
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