There has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.
This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.
PV Card: IV Fluid Formations
Adapted from  Go to ALiEM (PV) Cards for more resources.
After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.
— David Y.T. Chen (@dytcmd) January 4, 2013
Has this JAMA study changed your approach to ED intravenous fluid management?
It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.
- Yunos N, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572. [PubMed]