Harms and pitfalls of intravenous fluid therapy in the hospital

Introduction -The administration of intravenous fluid therapy is common in hospitalized patients but involves different risks. Particularly, the impact of both high sodium and chloride burdens is still unclear. Methods -Two retrospective “big data” analyses. A cross-over study in healthy volunteers. A randomized controlled trial in the perioperative setting. A narrative review integrating additional results from the latter two studies. -The focus of this PhD thesis lies on the impact of isotonic compared to hypotonic maintenance fluids on fluid retention in health and the clinical setting. Physiological mechanisms are discussed. Results -We found a significant and consistent association between severe hyperchloremia (>110 mmol/L) and mortality. On the other hand, a low strong ion difference did not seem to be associated with deleterious effects. -We demonstrated that maintenance and replacement fluids accounted for a much larger part of the mean daily total fluid volume than resuscitation fluids and that they formed the most important source of sodium and chloride. We drew attention to the enormous part of daily fluid administration in the form of oral and intravenous medication and termed this large unintentional volume fluid creep. -Regarding maintenace fluid therapy, maintenance fluid therapy containing 154 mmol/L of sodium lead to lower urine output than hypotonic solutions containing 54 mmol/L of sodium in healthy volunteers. In a surgical population, we were able to demonstrate that maintenance fluids containing 154 mmol/L of sodium cause an importantly more positive cumulative fluid balance and substantial hyperchloremia than fluids with 54 mmol/L of sodium, revealing them as an independent cause of potentially detrimental fluid, sodium and chloride overload. Hyponatremia was encountered more frequently under the hypotonic solution but it was mostly mild and asymptomatic. -Even healthy kidneys deal inefficiently with the large sodium burdens that are typically administered to many hospitalized patients. Conclusion -Hyperchloremia is associated with mortality, but the absence of an association between a low strong ion difference and mortality warrants a careful interpretation when judging the value of balanced solutions based on findings on electrolyte disorders. -Based on our sodium studies, we advise to reduce unintentional sodium administration in the hospital and recommend hypotonic over isotonic maintenance fluid therapy (while avoiding any maintenance fluids when sufficient alternative fluid sources are being administered). Yet, patients at risk for developing hyponatremia deserve specific attention.

Publication year:2021

Keywords:Doctoral thesis

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