How useful is balanced fluid?
Canterbury, UK
E-mail: martin.mayall{at}ekht.nhs.uk
Editor—I was interested to read Dr J. Boldt's editorial1 advocating the use of total balanced volume replacement. I agree that intuitively it seems a very sensible approach. I also agree that ‘although the clinical relevance of hyperchloraemic acidosis is not fully elucidated’, it would seem logical to avoid it if possible. However, I feel obliged to question his argument that ‘Avoidance of acid–base alterations by the choice of volume replacement regime is important as base excess may serve as an important marker to identify patients with under-perfused tissues’. I suspect he is aware that this problem can be resolved by calculating the anion gap. A hyperchloraemic acidosis will produce a normal anion gap whereas hypo-perfusion will result in an abnormally large one. The position can be further clarified by simply measuring the serum lactate. A normal serum lactate indicates that a metabolic acidosis is not due to under-perfusion.
Many blood gas analysers already give values for serum chloride and lactate so no additional expense should be incurred if this information is used. However, it will be interesting to note how the cost of balanced colloid compares with the cost of the fluids we use at present.
Ludwigshafen, Germany
E-mail: boldtj{at}gmx.net
Editor—I thank Dr Mayall for his valuable comments regarding my editorial on balanced volume replacement strategies. As long as everybody possesses blood gas analysers providing lactate concentrations, this should be used to rule out microperfusion deficits. However, increased lactate concentration does not rule out perfusion deficits. Concerning costs, it is hard to imagine that balancing fluids will increase costs for a plasma substitute considerably. Thus, cost does not appear to argue against using a balanced, plasma-adapted volume replacement strategy.
Reference
1 Boldt J. The balanced concept of fluid resuscitation. Br J Anaesth (2007) 99:312–5.
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