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Fluid Management Learning Zone


Read time: 20 mins
Last updated:13th Mar 2020
This overview is intended as a learning tool for healthcare professionals involved in fluid management. You can navigate via the tabs to access information on a variety of relevant topics, including sepsis and septic shock and the use of albumin for fluid management in cardiac surgery.


Despite several decades of research indicating the potential benefits of fluid therapy, our understanding of these therapies is continuing to grow, and controversies still remain surrounding the choice of resuscitation fluid. Join the debate on fluid choice and keep up to date with all of the latest news in our series of publication digests.

Intravenous Fluids

Key points

  • Fluid choice continues to be mainly determined by clinician and regional preferences


  • The choice of IV fluid affects patient outcome, with urgent need for further research into optimal fluid therapy
  • CIT TAIT (‘sit tight’): Context, Indication, Targets, Timing, Amount of fluid, Infusion strategy, Type of fluid

In this section, we review the evidence and current recommendations for the use of IV fluids. 

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Sepsis and Septic Shock

Key points

  • Hypoalbuminaemia is the most important prognostic factor in severe sepsis and septic shock
  • Human albumin plus crystalloid is efficacious and safe in severe sepsis
  • Recent research indicates that albumin, in addition to crystalloids, reduces mortality in both sepsis-2 and sepsis-3 categories
  • HES is associated with increased mortality and AKI in critically ill patients. The EMA has issued strict new guidance due to the HES being given wrongly to critically ill patients and those with sepsis
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Liver Cirrhosis

Key points


  • Volume replacement after large-volume paracentesis is recommended by clinical guidelines, to prevent post-paracentesis circulatory dysfunction
  • Albumin performs better than other volume expanders or vasoconstrictors
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European Association for the Study of the Liver (EASL) clinical practice guidelines on the management of decompensated cirrhosis, including ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome in cirrhosis are available (European Association for the Study of the Liver, 2018).

Based on these guideline the following 4-minute animation summarises current recommendations regarding the treatment of these conditions, including key information on the role of human albumin.  

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Cardiac Surgery

Key points

  • Both pre- and postoperative hypoalbuminaemia are associated with adverse outcomes, such as increased incidence of AKI in children and an increased mortality
  • Albumin is 5 times more effective than saline as plasma volume
  • Albumin versus HES reduced mortality after CABG
  • Discontinuation of HES in one Canadian institution led to a shorter hospital stay and reduced risk of red blood cell, plasma and platelet transfusion
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Bellmann R, Feistritzer C, Wiedermann CJ. Effect of molecular weight and substitution on tissue uptake of hydroxyethyl starch: a meta-analysis of clinical studies. Clin Pharmacokinet. 2012;51:225–36.

Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology. 2012;55:1172–81.

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Bucsics T, Hoffman S, Grünberger J, Schoder M, Matzek W, Stadlmann A, et al. ePTFE-TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis. Liver Int. 2018;38:1036–44.

Bunn F, Roberts I, Tasker R, Akpa E. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004:CD002045.

Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412–21.

Caraceni P, Angeli P, Prati D, Bernardi M; Italian Association for the Study of the Liver (AISF), Liumbruno GM, et al. AISF-SIMTI position paper: the appropriate use of albumin in patients with liver cirrhosis. Blood Transfus. 2016;14:8–22.

Charpentier J, Mira J-P. Efficacy and tolerance of hyperoncotic albumin administration in septic shock patients: the EARSS study. Intensive Care Med. 2011;37:Suppl 1:S115.

De Crescenzo C, Gorouhi F, Salcedo ES, Galante JM. Prehospital hypertonic fluid resuscitation for trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2017;82:956–62.

de la Cruz KI, Bakaeen FG, Wang XL, Huh J, LeMaire SA, Coselli JS, et al. Hypoalbuminemia and long-term survival after coronary artery bypass: a propensity score analysis. Ann Thorac Surg. 2011;91:671–5.

Di Pascoli M, Fasolato S, Piano S, Bologesi M, Angeli P. Long-term administration of human albumin improves survival in patients with cirrhosis and refractory ascites. Liver Int. 2018. [Epub ahead of print].

Dingankar AR, Cave DA, Anand V, Sivarajan VB, Nahirniak S, Sheppard C, et al. Albumin 5% Versus Crystalloids for Fluid Resuscitation in Children After Cardiac Surgery. Pediatr Crit Care Med. 2018;19:846–53.

Duan L, Hu GH, Jiang M, Zhang CL, Duan YY. Association of hypoalbuminemia with acute kidney injury in children after cardiac surgery. Zhongguo Dang Dai Er Ke Za Zhi. 2018;20:475–80.

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Ernest D, Belzberg AS, Dodek PM. Distribution of normal saline and 5% albumin infusions in cardiac surgical patients. Crit Care Med. 2001;29:2299–302.

European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53:397–417.

European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69:406–60.

European Medicines Agency (EMA). Hydroxyethyl starch solutions for infusion. October 2013; Available from: (Accessed 15th June 2016).

European Medicines Agency (EMA). Hydroxyethyl starch solutions: CMDh introduces new measures to protect patients. August 2018; Available from: (Accessed 23rd August 2018).

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Food and Drug Administration (FDA). FDA Safety Communication: Boxed Warning on increased mortality and severe renal injury, and additional warning on risk of bleeding, for use of hydroxyethyl starch solutions in some settings. November 2013; Available from: (Accessed 15th June 2016).

Fritz HG, Brandes H, Bredle DL, Bitterlich A, Vollandt R, Specht M, et al. Post-operative hypoalbuminaemia and procalcitonin elevation for prediction of outcome in cardiopulmonary bypass surgery. Acta Anaesthesiol Scand. 2003;47:1276–83.

Garcia-Martinez R, Caraceni P, Bernardi M, Gines P, Arroyo V, Jalan R. Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications. Hepatology. 2013;58:1836‒46.

Gatta A, Verardo A, Bolognesi M. Hypoalbuminemia. Intern Emerg Med. 2012;7 Suppl 3:S193–9.

Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S; et al. Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy. Intensive Care Med. 2013;39:558–68.

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Goto T, Yoshida K, Tsugawa Y, Filbin MR, Camargo CA Jr, Hasegawa K. Mortality trends in U.S. adults with septic shock, 2005-2011: a serial cross-sectional analysis of nationally-representative data. BMC Infect Dis. 2016;16:294.

Groeneveld AB, Navickis RJ, Wilkes MM. Update on the comparative safety of colloids: a systematic review of clinical studies. Ann Surg. 2011;253:470–83.

Haase N, Perner A, Hennings LI, Siegemund M, Lauridsen B, Wetterslev M, et al. Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis. BMJ. 2013;346:f839.

Hammond NE, Taylor C, Finfer S, Machado FR, An Y, Billot L et al. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study. PLoS One 2017;12:e0176292.

Hariri G, Joffre J, Deryckere S, Bigé N, Dumas G, Baudel JL, et al. Albumin infusion improves endothelial function in septic shock patients: a pilot study. Intensive Care Med. 2018;44:669–71.

Hecht-Dolnik M, Barkan H, Taharka A, Loftus J. Hetastarch increases the risk of bleeding complications in patients after off-pump coronary bypass surgery: a randomized clinical trial. J Thorac Cardiovasc Surg. 2009;138:703–11.

Holder AL, Gupta N, Lulaj E, Furgiuele M, Hidalgo I, Jones MP, et al. Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis. Int J Emerg Med. 2016;9:10.

Hong M, Jones PM, Martin J, Kiaii B, Arellano R, Cheng D, et al. Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study. Can J Anaesth. 2018. [Epub ahead of print].

Jacob M, Chappell D, Hofmann-Kiefer K, Helfen T, Schuelke A, Jacob B, et al. The intravascular volume effect of Ringer's lactate is below 20%: a prospective study in humans. Crit Care. 2012;16:R86.

Jacob M, Fellahi JL, Chappell D, Kurz A. The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis. Crit Care. 2014;18:656.

Jiang L, Jiang S, Zhang M, Zheng Z, Ma Y. Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis. PLoS One. 2014;9:e114666.

Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC Surg. 2018;18:93.

Joosten A, Delaporte A, Ickx B, Touihri K, Stany I, Barvais L, Van Obbergh L, et al. Crystalloid versus Colloid for Intraoperative Goal-directed Fluid Therapy Using a Closed-loop System: A Randomized, Double-blinded, Controlled Trial in Major Abdominal Surgery. Anesthesiology. 2018;128:55–66.

Jung DM, Ahn HJ, Yang M, Kim JA, Kim DK, Lee SM, et al. Hydroxyethyl starch is associated with early postoperative delirium in patients undergoing esophagectomy. J Thorac Cardiovasc Surg. 2018;155:1333–43.

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Kingeter AJ, Raghunathan K, Munson SH, Hayashida DK, Zhang X, Iyengar S, et al. Association between albumin administration and survival in cardiac surgery: a retrospective cohort study. Can J Anaesth. 2018. [Epub ahead of print].

Laake J, Møller M. Continued licensing of hydroxyethyl starch despite high‐quality data documenting harm in vulnerable patient populations: A sad day for patient safety. Acta Anaesthesiol Scand. 2018. [Epub ahead of print].

Lee EH, Chin JH, Choi DK, Hwang BY, Choo SJ, Song JG, et al. Postoperative hypoalbuminemia is associated with outcome in patients undergoing off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2011;25:462–8.

Lee EH, Kim WJ, Kim JY, Chin JH, Choi DK, Sim JY, et al. Effect of exogenous albumin on the incidence of postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass surgery with a preoperative albumin level of less than 4.0 g/dl. Anesthesiology. 2016;124:1001–11.

Lee JH, Jung JY, Park SW, Song IK, Kim EH, Kim HS, et al. Risk factors of acute kidney injury in children after cardiac surgery. Acta Anaesthesiol Scand. 2018. [Epub ahead of print].

Leisman DE, Goldman C, Doerfler ME, Masick KD, Dries S, Hamilton E et al. Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort. Crit Care Med.2017;45:1596–1606.

Lenz K, Buder R, Kapun L, Voglmayr M. Treatment and management of ascites and hepatorenal syndrome: an update. Therap Adv Gastroenterol. 2015;8:83–100.

Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018;8:CD000567.

Liu C, Mao Z, Hu P, Hu X, Kang H, Hu J, et al. Fluid resuscitation in critically ill patients: a systematic review and network meta-analysis. Ther Clin Risk Manag. 2018;14:1701–9.

Long E, Babl FE, Oakley E, Sheridan B, Duke T. Cardiac Index Changes With Fluid Bolus Therapy in Children With Sepsis-An Observational Study. Pediatr Crit Care Med. 2018;19:513–8.

Martin C, Jacob M, Vicaut E, Guidet B, Van Aken H, Kurz A. Effect of waxy maize-derived hydroxyethyl starch 130/0.4 on renal function in surgical patients. Anesthesiology. 2013;118:387–94.

McDermid RC, Raghunathan K, Romanovsky A, Shaw AD, Bagshaw SM. Controversies in fluid therapy: Type, dose and toxicity. World J Crit Care Med. 2014;3:24–33.

Medicines and Healthcare products Regulatory Agency (MHRA). Hydroxyethyl starch intravenous infusions. December 2014; Available from: (Accessed 15th June 2016).

Min JJ, Cho HS, Jeon S, Lee JH, Lee JJ, Lee YT. Effects of 6% hydroxyethyl starch 130/0.4 on postoperative blood loss and kidney injury in off-pump coronary arterial bypass grafting. A retrospective study. Medicine. 2017;96:18.

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Navickis RJ, Haynes GR, Wilkes MM. Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass: a meta-analysis of randomized trials. J Thorac Cardiovasc Surg. 2012;144:223–30.

Navickis RJ, Haynes GR, Wilkes MM. Tetrastarch in cardiac surgery: error, confounding and bias in a meta-analysis of randomized trials. Crit Care. 2015;19:187.

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Niemi TT, Suojaranta-Ylinen RT, Kukkonen SI, Kuitunen AH. Gelatin and hydroxyethyl starch, but not albumin, impair hemostasis after cardiac surgery. Anesth Analg. 2006;102:998–1006.

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Oliver WD, Willis GC, Hines MC, Hayes BD. Comparison of Plasma-Lyte A and Sodium Chloride 0.9% for Fluid Resuscitation of Patients With Diabetic Ketoacidosis[SS1] . Hosp Pharm. 2018;53:326–330.

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Spoelstra-de Man AME, Smorenberg A, Groeneveld ABJ, et al. Different effects of fluid loading with saline, gelatine, hydroxyethyl starch or albumin solutions on acid-base status in the critically ill. PLoS ONE[SS2] . 2017;12:e0174507.

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Taverna M, Marie AL, Mira JP, Guidet B. Specific antioxidant properties of human serum albumin. Ann Intensive Care. 2013;3:4.

Thomas-Rueddel DO, Vlasakov V, Reinhart K, Jaeschke R, Rueddel H, Hutagalung R, et al. Safety of gelatin for volume resuscitation -a systematic review and meta-analysis. Intensive Care Med. 2012;38:1134–42.

Ünal MN, Reinhart K. Understanding the harms of HES: a review of the evidence to date. Turk J Anaesthesiol Reanim. 2019;47:81–91.

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Van Haren F. Personalised fluid resuscitation in the ICU: still a fluid concept? Critical Care 2017;21(Suppl 3):313.

Vasques F, Duscio E, Romitti F, Pasticci I, Caironi P, Meessen J, et al. Septic shock-3 vs 2: an analysis of the ALBIOS study. Crit Care. 2018;22:237.

Wengenmayer T, Schroth F, Biever PM, Duerschmied D, Benk C, Trummer G, et al. Albumin fluid resuscitation in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy is associated with improved survival. Intensive Care Med. 2018;44:2312–4.

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Wiedermann CJ, Joannidis M. Albumin Replacement in Severe Sepsis or Septic Shock. N Engl J Med. 2014;371:83.

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