Medscape is available in 5 Language Editions – Choose your Edition here.


Volume Resuscitation Technique

  • Author: Jeromy T Boucher, DO; Chief Editor: Erik D Schraga, MD  more...
Updated: Jul 07, 2016

Approach Considerations

Several types of fluids are available for resuscitation. They are generally divided into isotonic crystalloid solutions (most commonly used), colloids, hypertonic solutions, oxygen therapeutic agents and blood products (see the image below). Clinicians should adopt an individualized fluid approach based on the clinical scenario and best available evidence.[14]

empty para to satisfy content model empty para to satisfy content model

Blood Transfusion

The American Society of Anesthesiologist set the lower threshold for blood transfusion at hemoglobin less than 6 g/dL or hematocrit less than 18% in a healthy individual. Transfusing a patient with a hemoglobin greater than 10 g/dL or a hematocrit over 30 is not recommended.[15, 16] This leaves a relatively wide range for practitioners to choose when blood transfusion is necessary based on the etiology of hypovolemia, comorbidities, and disease processes, in addition to the stability of the patient and their laboratory abnormalities.

The Transfusion Requirements in Critical Care (TRICC) trial showed that patients on a restrictive transfusion strategy where red cells were transfused for Hgb less than 7 g/dL and maintained at 7-9 g/dL showed a lower in-hospital mortality rate than a liberal strategy, although 30-day mortality was similar.[17] Also, literature exists that supports maintaining a hematocrit above 30 for patients with a history of coronary artery disease.

When time is available, typed and cross-matched blood is preferred. Unstable patients may be transfused with low-titer O-negative blood (see the image below). In the setting of hemorrhage, 4 classes exist for which specific clinical responses are demonstrated requiring different levels of fluid resuscitation.

Table 4: Classes of Hemorrhage Table 4: Classes of Hemorrhage

Massive Transfusion

Massive transfusion is defined as a transfusion of more than 10 units PBRC at one given time. In the setting of massive hemorrhage, when large volumes of crystalloid and blood have been given, FFP and platelet transfusion may be required to address the effects of dilutional coagulopathy. Some debate exists in the literature, but it is generally suggested that when initiating a massive transfusion protocol, patients should be transfused PRBC, FFP, and platelets in a ratio close to 1:1:1 if multiple units of blood will be necessary.

Whole blood should be considered only when dealing with a patient with an acute hemorrhage and then only after the patient has received approximately 5-7 units of red cells plus crystalloids.[18] Reinfusion of autologous red cells is a good approach for patients for who have large quantities of blood collected from chest tubes or aspirated from peritoneal cavities reducing the need for an allogenic transfusion. Proper collecting devices are necessary for this type of transfusion but should be considered in patients who present with massive hemorrhage or patients such as Jehovah’s Witnesses who do not accept any donor products.


Crystalloids versus Colloids

Colloids have larger molecular-weight particles that give them oncotic plasma pressures similar to natural plasma proteins. This theoretically allows for better volume resuscitation by remaining in the intravascular space and supporting circulating volume as compared to crystalloids, which may have extravascular shift causing pulmonary and interstitial edema. However, in patients with increased vascular permeability as seen in sepsis and late hemorrhagic shock, leakage of these larger colloid molecules also exists. Physiologically balanced crystalloids may be the default fluid for critically ill patients, whereas the role for colloids remains unclear.

Several studies have compared the use of crystalloid and several different types of colloids as resuscitation fluids and have found no difference in mortality.[19, 20] Furthermore, most evidence shows there is no clear evidence that one colloid solution is more effective or safer than any other.[21] Newer studies have shown that differences in chloride load and strong ion difference appear to be clinically important. Quantitative toxicity can be mitigated when dosing is based on dynamic parameters that measure volume responsiveness. Qualitative toxicity for colloids and isotonic saline remain a legitimate concern.[22] Given the cost associated with colloids, no clear benefit exists to using these agents over the more affordable and generally available crystalloids.


Hypertonic Fluids

Hypertonic saline has been proposed as a crystalloid alternative that may have some benefit in head injury and trauma patients by limiting tissue edema effects associated with volume resuscitation. Recent studies have shown that hypertonic saline plus dextran does not reduce mortality or the risk of acute respiratory distress syndrome (ARDS) compared to resuscitation with lactated Ringer solution in trauma patients.[23] Evidence from the SAFE trial demonstrated that albumin and saline have similar outcomes for fluid resuscitation in patients receiving volume resuscitation in intensive care units.[24]


Oxygen-Carrying Fluids

Two classes of agents are under development in hopes of replicating the oxygen-carrying capacity of native RBC that may be lost during hemorrhage.[25, 26, 27] Hemoglobin-based oxygen carriers are not currently approved for human use in the United States and fluorocarbon-based oxygen carriers have yet to show any effectiveness in large-volume resuscitation.


Tranexamic Acid

Tranexamic acid (TXA) has been demonstrated to reduce bleeding in patients undergoing elective surgery. The CRASH-2 trial aimed to determine the effect of early administration of TXA on death and transfusion requirement in bleeding trauma patients. Early administration of TXA safely reduced the risk of death in bleeding trauma patients and may be cost-effective. However, treatment beyond 3 hours of injury is unlikely to be effective.[28]

Contributor Information and Disclosures

Jeromy T Boucher, DO Resident Physician, Department of Emergency Medicine, George Washington University Hospital

Jeromy T Boucher, DO is a member of the following medical societies: American Osteopathic Association, Association of Military Osteopathic Physicians and Surgeons, Florida Osteopathic Medical Association, Student Osteopathic Medical Association, Texas Osteopathic Medical Association

Disclosure: Nothing to disclose.


Griffin L Davis, MD, MPH Chair, Department of Emergency Medicine, Prince George's Hospital Center; Assistant Professor, Department of Emergency Medicine, George Washington University School of Medicine

Griffin L Davis, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, National Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth M Phillips, MD, MA Resident Physician, Department of Emergency Medicine, George Washington University Medical Center

Disclosure: Nothing to disclose.

  1. Hinds CJ, Watson D. ABC of intensive care: circulatory support. BMJ. 1999 Jun 26. 318(7200):1749-52. [Medline]. [Full Text].

  2. Zengin S, Al B, Genc S, et al. Role of inferior vena cava and right ventricular diameter in assessment of volume status: a comparative study: ultrasound and hypovolemia. Am J Emerg Med. 2013 May. 31(5):763-7. [Medline].

  3. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27. 331(17):1105-9. [Medline].

  4. Stern SA. Low-volume fluid resuscitation for presumed hemorrhagic shock: helpful or harmful?. Curr Opin Crit Care. 2001 Dec. 7(6):422-30. [Medline].

  5. Reilly PM, Wilkins KB, Fuh KC, Haglund U, Bulkley GB. The mesenteric hemodynamic response to circulatory shock: an overview. Shock. 2001 May. 15(5):329-43. [Medline].

  6. Maslanka K, Uhrynowska M, Lopacz P, et al. Analysis of leucocyte antibodies, cytokines, lysophospholipids and cell microparticles in blood components implicated in post-transfusion reactions with dyspnoea. Vox Sang. 2014 Aug 18. [Medline].

  7. Peters AL, van Hezel ME, Juffermans NP, Vlaar AP. Pathogenesis of non-antibody mediated transfusion-related acute lung injury from bench to bedside. Blood Rev. 2014 Sep 20. [Medline].

  8. Stack G, Judge JV, Snyder EL. Febrile and non-immune transfusion reactions. Rossi EC, Simon TL, Moss GS, Gould SA. Principles of Transfusion Medicine. Philadelphia: Williams and Wilkins; 1996. p778.

  9. Weiskopf RB. Do we know when to transfuse red cells to treat acute anemia?. Transfusion. 1998 Jun. 38(6):517-21. [Medline].

  10. Sirchia G, Rebulla P, Parravicini A, Carnelli V, Gianotti GA, Bertolini F. Leukocyte depletion of red cell units at the bedside by transfusion through a new filter. Transfusion. 1987 Sep-Oct. 27(5):402-5. [Medline].

  11. Sanchez R, Lee TH, Wen L, Montalvo L, Schechterly C, Colvin C, et al. Absence of transfusion-associated microchimerism in pediatric and adult recipients of leukoreduced and gamma-irradiated blood components. Transfusion. 2011 Oct 7. [Medline].

  12. Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. Guidelines on the management of massive blood loss. Br J Haematol. 2006 Dec. 135(5):634-41. [Medline].

  13. Goldflam K, Saul T, Lewiss R. Focus On: Inferior Vena Cava Ultrasound. ACEP News. June 2011. [Full Text].

  14. van Haren F, Zacharowski K. What's new in volume therapy in the intensive care unit?. Best Pract Res Clin Anaesthesiol. Sept 2014. 28(3):275-83. [Medline].

  15. Goodnough LT. Transfusion triggers. Surgery. 2007 Oct. 142(4 Suppl):S67-70. [Medline].

  16. Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology. 1996 Mar. 84(3):732-47. [Medline].

  17. Informed consent, parental permission, and assent in pediatric practice. Committee on Bioethics, American Academy of Pediatrics. Pediatrics. 1995 Feb. 95(2):314-7. [Medline].

  18. Högman CF, Meryman HT. Red blood cells intended for transfusion: quality criteria revisited. Transfusion. 2006 Jan. 46(1):137-42. [Medline].

  19. Roberts I, Blackhall K, Alderson P, Bunn F, Schierhout G. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2011 Nov 9. 11:CD001208. [Medline].

  20. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2011 Mar 16. CD000567. [Medline].

  21. Bunn F, Trivedi D, Ashraf S. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev. 2008 Jan 23. CD001319. [Medline].

  22. Raghunathan K, Shaw AD, Bagshaw SM. Fluids are drugs: type, dose and toxicity. Curr Opin Crit Care. August 2013. 19(4):290-8. [Medline].

  23. Bulger EM, May S, Kerby JD, Emerson S, Stiell IG, Schreiber MA, et al. Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial. Ann Surg. 2011 Mar. 253(3):431-41. [Medline]. [Full Text].

  24. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27. 350(22):2247-56. [Medline].

  25. Eastman AL, Minei JP. Comparison of Hemoglobin-based oxygen carriers to stored human red blood cells. Crit Care Clin. 2009 Apr. 25(2):303-10, Table of Contents. [Medline].

  26. Jahr JS, Walker V, Manoochehri K. Blood substitutes as pharmacotherapies in clinical practice. Curr Opin Anaesthesiol. 2007 Aug. 20(4):325-30. [Medline].

  27. Cohn CS, Cushing MM. Oxygen therapeutics: perfluorocarbons and blood substitute safety. Crit Care Clin. 2009 Apr. 25(2):399-414, Table of Contents. [Medline].

  28. Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects oftranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. March 2013. 17(10):1-79. [Medline].

empty para to satisfy content model
empty para to satisfy content model
empty para to satisfy content model
empty para to satisfy content model
empty para to satisfy content model
empty para to satisfy content model
Table 1: Body Fluid Spaces
Table 2: Causes of Intravascular Volume Loss
Table 3: Types of Resuscitation Fluids
Table 4: Classes of Hemorrhage
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.