Choice of fluid therapy

Invasive monitoring is extremely useful for evaluating objectively and scientifically the relative efficacy of alternative therapies in various clinical conditions. In a prospective random-order cross-over designed study, patients in early acute respiratory distress syndrome (defined as within 24 to 48 h after the diagnosis was established) were given 1.0 liters of Ringer's lactate and 100 ml of 25 per cent albumin. Each patient received each agent: half received Ringer's lactate first and then crossed over to albumin, and the other half received albumin first and then Ringer's lactate. Infusion of 1 liter of Ringer's lactate increased blood volume by only 200 ml, whereas infusion of 100 ml of 25 per cent albumin increased blood volume by an average of 450 ml. In essence, albumin did not leak but, rather, pulled 350 ml of interstitial water back into the plasma volume with a concomitant increase in cardiac index, colloid osmotic pressure, and O 2 consumption without worsening the P(A-a)O2 gradient or pulmonary shunt. Albumin also significantly improved both Do2 and Vo2, whereas Ringer's lactate only transiently increased Do2 and actually decreased Vo2.

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