Thursday July 24, 2008


Q: 48 year old obese male with renal failure with baseline creatinine of 3.8 mg/dl but not yet on dialysis, presented with infection and needs IV fluid resuscitation. Patient ABG showed acidosis with PH of 7.24. Which of the following IV fluids will be relatively contraindicated in patient ?

A. Lactate Ringer
B. Hydroxyethyl starch (hextand)
C. THAM
D. Normal Saline with potassium mix
E. All of the above



Answer: All of the above

Objective of this question is to establish that choice of IV fluid is an immensely important factor in treatment of any patient and should be choose with caution.

Lactated Ringer's Solution contains 4 mEq/L of potassium and may not be a good choice in patients with renal failure.

There is substanial amount of literature available showing deleterious effect of Hydroxyethyl starch (like Hextand) on kidney particularly with already decreased function 1,2.

THAM is excreted by the kidneys and is contraindicated in renal failure.

Simply, normal saline is a good choice in hypovolumia but addition of potassium should be avoided in renal failure.

Related: Plasma expanders (Excellent presentation from Dr. Wayne Riback - pdf)


References:

1. Hydroxyethyl starch and renal dysfunction Transfusion Alternatives in Transfusion Medicine, Volume 9, Number 3, September 2007 , pp. 182-188(7)
2. Hydroxyethyl starch and change in renal function in patients undergoing coronary artery bypass graft surgery - Kidney International (2003) 64, 1046–1049