pH guided resuscitation: Normal Saline, Ringer Lactate, Isotonic Bicarbonate.

Read:

https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation/

http://www.medsci.org/v10p0747.htm

In simple word:

  1. There are many factors affecting the acidity of the solution (in vitro and in vivo). Simple measurement of pH solution in vitro doesn’t reflect the affect of solution toward body acidity in vivo.
  2. Normal saline : not exposed to atmosphere pH 7, once exposed pH 5.5.
  3. Ringer Lactate: pH 5
  4. Fluid is a drug, correct amount and type is important.
  5. Fluid of choice is important when:
  • large volume of fluid use in resuscitation.
  • There is an acid-base imbalance (this is opportunity for correction with fluid).
  • To correct acid base imbalance to prevent/bought time for dialysis or intubation.

6. Large volume of normal saline will cause dilution acidemia in vivo (with CO2/HCO3 buffer system) due to consumption of HCO3 and leaving constant CO2.

7. While Ringer lactate contain lactate which will metabolised and generate HCO3.

In my opinion:

8. With this new information, pH guided resuscitation is a good approach.

9. Need to bring Isotonic bicarbonate solution into the practice.

10. But require VBG/ABG (limited availability).

11. What kind of patient will get VBG and ABG? :

  • Renal failure
  • Dengue in shock
  • Respiratory distress

12. Who won’t get ABG/VBG?

  • Septic shock with dehydration
  • Hypovolemia patient

13. Who should get at least VBG to use pH guided resuscitation?

  • Any patient with hypotension and IVC show volume depleted (hypovolemic shock). At least IVC <0.5cm. <cost>

14. When to repeat blood gases?

  • After 20cc/kg fluid
  • Or after complete replacement of isotonic bicarbonate.

15. Challenge

  • Interdepartment and intradepartment knowledge gap.
  • early adaptation confusion/fright.

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