Too Much IV Fluid? Part 2: Albumin, LR vs. Normal Saline, and Fluid Creep in the ICU

In this episode

- Crystalloid vs. colloid vs. hypertonic. Isotonic crystalloids spread through the extracellular space and redistribute within about an hour. Colloids and hypertonic fluids hold volume in the vessels.
- Albumin, explained. 5% vs. 25% albumin, and how concentrated albumin pulls interstitial fluid back into the vascular space.
- The SAFE trial. What it found in septic shock and neuro patients, and Michael’s take on why the 4% albumin used may have shaped the results.
- Albumin for oncotic pressure, not resuscitation. When the Surviving Sepsis guidelines suggest considering albumin during large-volume resuscitation.
- Hypertonic bicarb in septic shock. How Michael uses a 4.2% bicarb solution in acidotic patients, plus the BICAR-ICU trials.
- Normal saline’s chloride problem. Why high-chloride fluid drives a non-anion gap metabolic acidosis and is linked to kidney injury.
- The LR “lactic” myth. Lactated Ringer’s gives a lactate salt, not lactic acid. Its slightly hypotonic sodium is the bigger concern.
- Why Plasma-Lyte/Normosol. Balanced, closer to isotonic, and slightly alkaline to offset acidic diluents like normal saline and D5W.
- Maintenance fluids. Michael’s literature deep dive and the one population where continuous fluids had support: immediately post kidney transplant.
- The ROSE model. Resuscitation, Optimization, Stabilization, Evacuation. Also why kidney edema inside Gerota’s fascia leads to AKI.
- Fluid creep. Antibiotics, electrolyte riders, and drip diluents can add up to several liters a day, often more than the “one liter bolus” that was ordered.
- Know what it’s mixed in. Using diluent choices (D5W vs. saline) to help with glucose and sodium problems.
- Treat fluid like a prescription. Know the goal, the side effects, and go back to the bedside to check the response.


Chapters
00:59 Crystalloids vs. colloids vs. hypertonic fluids
02:27 Albumin and blood as colloids
03:19 Hypertonic saline and hypertonic bicarb
06:55 The SAFE trial and albumin in neuro patients
08:46 Albumin for oncotic pressure and Surviving Sepsis guidelines
10:36 Normal saline, LR, and Plasma-Lyte/Normosol
12:19 The “LR causes lactic” myth
16:32 The maintenance fluid deep dive
19:33 The ROSE concept and deresuscitation
22:02 Fluid creep
24:46 Knowing what your drips are mixed in
26:47 Nurses and the bedside view
28:46 Treat fluids like a prescription