DIP Episode 429 - ICU Series Part 2-Crystalloid Solutions

All right, welcome. My name is Devine. This is episode 429 of the Devine Intervention Podcasts. And into this podcast I'll be continuing the ICU series. I believe we studied in one of the early episodes 400s where I said I'll be making a nice use series for medical students and residents. Hopefully try to make it pretty comprehensive and pretty helpful for people. So really into this podcast I'm going to be talking about crystaloids. I'm going to be talking about crystaloids. Crystaloids are kind of fluid. They're kind of fluid. And you know, they, I guess maybe if I won't jump into all of this, I'm going to throw the disclaimer. Very strong disclaimer. Please, please, please remember, this podcast are not supposed to guide their purely for educational purposes. Let's just get this out there. These podcasts are purely for educational purposes. Again, you should consult with your supervisors or whatever in making clinical decisions. Okay, let's get that out of the way. Okay, so this is just for education. That's the only purpose literally of this podcast. So the thing is we're going to be talking about crystaloids. I'm going to be talking about it from different angles. And then I'll just talk about some classic scenarios and some situations where some considerations you should keep in mind when a person's making decisions like in an exam or just thinking about crystaloids really.

But I think before I jump into crystaloids, it'll be probably helpful to just talk about why we give people fluids in the first place, right? Because really there is a lot of there's many different kinds of fluids you can give a patient. Where do fluids, the purpose, the goal of giving fluids is really to raise a person's cardiac output and increase tissue perfusion. That's ultimately what they're trying to accomplish when you give fluids. Right, but the thing that's kind of lost on many people is whenever you give people fluids, you need to remember that the fluid is a medication. There will be some effect to that fluid that you're given, right? Because the thing is fluids they do so much in the body. So it's something you always have to think about, right? Like, oh, this thing affects the cardiovascular system, can affect the GI system, can affect the lungs, can affect the kidneys, can affect immune system even, right? So you need to know like, okay, these things have indications, how do they affect these systems? And the thing is whenever you give fluids, it's always helpful to consider four things, right? Like, what does this fluid contain? That's usually one good consideration. Like, what in the world is in this thing? And given, and the thing you should also consider is, who are you giving it to? Like, what kind of patient are you giving these fluids to? Are you giving it to a person that's normal and healthy?

Are you giving it to a person that has like CHF and their AF is like 30%. You need to also ask yourself, what is your goal in giving that fluid? Like, literally, what are you trying to achieve? And then like, are you trying to like raise the upload volume or try to raise the CVP? Because sometimes if you want to achieve certain goals, certain fluids are better ideas than others. And then you also need to ask yourself, how you're going to assess responsiveness to set fluid? Like, oh, this fluid you've given this person, gee, how am I going to find out how they responded to it? Right? So again, it's just kind of important before you start giving people fluids. It's always helpful to think about these four factors. And it will just kind of cause you to take a step back and make sure you're not walking in the wrong direction. Right? So, like I said, today we're going to focus on crystalloids. Right? The thing I will just say, just as bare bones to start, is that crystalloids are generally the right thing to do in most circumstances. They are generally the right thing. If you're like, man, I don't know what to do. Just give a pressing crystalloid. It's probably the smart play in most circumstances. So when you see the term crystalloid, well, what exactly does that mean? Crystaloid just generally means like an ionic solution.

In general, when you see the word crystalloid in clinical medicine, we typically are talking about the good old normal saline, lactated ringers, sometimes they call lactated ringers, ringers, lactate, and then plasma light. Those are really the three things that fall under the purview of crystalloid. Again, there's probably others, but again, so those are pretty, pretty low yield. Right? So normal saline, LR and plasma light, normal saline, LR and plasma light. And again, I'm going to be doing some comparisons between these three fluids as we go along. I will spend most of my time on normal saline, but then I'll bring in some integrations for LR for lactated ringers and plasma light. So let's maybe talk about our normal saline. Normal saline or 0.9% saline, you know, literally is about 9 grams of sodium chloride in a liter of water. Remember, a liter of water, you know, if you're thinking about the metric system, a liter of water weighs about a thousand grams. So if you're giving 9 grams of something in a thousand grams of water, literally if you think about it, 10 grams is exactly, if you do your division, 10% of a thousand is a hundred. One percent of a hundred is like, okay, let me put it this way. 10% of a thousand is a hundred. One percent of a thousand is 10. So if you're giving something that is 9 grams in a thousand grams of fluid, that 9 grams is just under 1%. That's why it's called 0.9% saline in the first place.

Now 0.9% saline, normal saline literally contains sodium chloride. Right. In general, it does not contain potassium, but as you'll see, in all saline can relate to potassium pretty heavily. But basically, it contains 154 million equivalents of sodium and 154 million equivalents of chloride. So the total of smallalities about 300 and 8, you can already begin to see that that's not exactly perfect compared to the human body, because blood usually has the sodium chloride or smallality in the blood. It's about 285, if you kind of take both together. But if you start seeing it, you're like, man, no, sitting is 308. That's a fairly big spread. If you even look at just the chloride angle, because that's probably the more important angle to be honest with you. Well, the chloride angle, think about it. You literally have 154 million equivalents per liter of chloride in normal saline. It may be like, oh, the vine, that's almost physiologic. No, it's not. It's really not. Because if you look at the body, the chloride concentration, you can even if you're a US Emily ticker, you can literally look at those US Emily tables. Right. Chlorite normally is between like 96 to like 107 million equivalents per liter. So if you really think about it, when you're giving a person normal saline, you're giving them a pretty heavy, pretty hefty chloride load. And that heavy chloride load is not without its problems. Right. Because if you think about it, I mean, let's just go back to reno physiology.

When you give a person a ton of chloride, well, we know that the kidneys handle about 20% of your cardiac output at any given time, right around there. Well, if your kidneys are seen all that chloride, how do you think they're going to behave? Well, let's raise it through this. When chloride comes through your off-renaterial, your GG cells see it, your Jocke Stadglomerular cells, which are part of the off-renaterial. But in addition to that, there is a group of cells that are from the distal convoluted tubule, they're called the macular densa. The macular densa. They are also like osmotic sensors. You see that? Gee, this is a very high chloride load that is coming through. So what do you think happens in those circumstances? Well, the thing that happens in those circumstances is you pretty much dial down the reno and your tensin out those urine system. Right. You dial it down and you also make less in the way of prostaglandins. So if you dial down the reno and your tensin out those urine system because you're like, man, I have too much salt. I cannot be activated in a system that makes me make a ton of salt. And you're making less prostaglandins. Well, think about if you have less prostaglandins, we know that prostaglandins are visual dilators. If you have less of them, you're going to have visual constriction. You're going to have constriction of the off-renaterial. That already begins to introduce you to one of the problems with normal sealing.

Normal sealing can cause constriction of the off-renaterial. Again, what's the mechanism? Increase salt delivery to the off-renaterial causes the GG cells to freak out and also causes the macular densa to freak out and say, oh gee, this is too much chloride. This is way too much chloride. So you're going to release less prostaglandins. That can cause you to have a constriction of the off-renaterial. Well, if you think about it, if you constrict the off-renaterial, I can be profusing the kidneys particularly well, probably not. And if you don't profuse the kidneys particularly well, you're almost creating like a pre-renew physiology. So acute kidney injury, believe it or not, is a well-described side effect that may be found when you give people pre-heavy amounts of normal sealing. But then let's maybe consume this chloride business. I said that this chloride, heavy chloride load we see with normal sealing is not particularly good. Well, let's explain. The thing is, that heavy chloride load in addition to indirectly leading to a constriction of the off-renaterial, which can cause an acute kidney injury, can also cause you to have metabolic acid doses. It can also cause you to have metabolic acid doses. Because think about it. Two of the major anions in the body are chloride and bicarb. Two of the major anions in the body are chloride and bicarb. So whenever you finish the body with a ton of chloride, what is going to be like? I mean, we have too many negative ions.

We got a let go of some. So your body is going to try to let go of some bicarb. But the thing is, bicarb is kind of important because it's a very important buffer in your bloodstream, in your plasma. So if bicarb is being lost, then you're not going to be able to buffer the acid, the ions that you have. And that can cause you to have a metabolic acid doses. That can cause you to have a hyperchlorimic metabolic acid dose. It can cause you to have a hyperchlorimic metabolic acid doses. And the thing is, if you think about it, if you start losing bicarb, that's actually going to keep worsening the acid doses. Again, think about it this way. Carbon dioxide that seals to dissolve in water, it forms carbonic acid. That's H2 CO3. That carbonic acid is going to split off to form hydrogen ions and bicarb. Okay. So think about it. Think about Loshatli principle. I know some people will be like, oh gee, Loshatli principle is coming back. I know. All right. There's a reason why you kept emphasizing in college. It's not for fun. But think about it. If you go by Loshatli principle, if you're losing bicarb, then you're going to keep driving that equation that leads to hydrogen ion plus bicarb formation. I'm going to keep driving that equation forward. So you're going to keep generating a ton of hydrogen ions.

And another thing is, whenever you have a lot of chloride ions in your bloodstream, one thing that happens is that that chloride, again, when you populace your bloodstream so much, what it would be like, wow, there are way too many negative charges in the bloodstream in the plasma. I need to maintain like electron neutrality. So the thing that's going to happen is you're going to be dumping a lot of bicarb into cells. You're literally going to be putting them in the cell. In the cell, bicarb is not particularly helpful to you in the plasma because it's in the plasma that you need to. Yes, don't get me wrong. You need to buffer yourself. Fine. But that bicarb that's supposed to be in the bloodstream is now inside your cells because chloride is eating its Losh. I kind of think of chloride is like, okay, there are 100 bicarb seeds in the bloodstream. And when you give a normal amount of chloride, not a big deal, but when you give huge amounts of chloride, chloride needs some chairs to sit down. So it's going to take some of those bicarb seeds. So bicarb will have to stand in a holding pattern in the intracellular space inside your cells. And again, if bicarb is not in your bloodstream and using your cells, it's not helping you buffer your acidity. So you develop a metabolic acidosis. You develop a metabolic acidosis. Again, very, very important to kind of keep that in mind. So I think, and you know, there's some other stuff with chloride and the strong ion difference.

I've kind of explained some antecedents of that. That strong ion difference is not something I'm going to go into a lot of detail on. That's something if you're going to pump critical care or whatever, I'm sure you're going to get bashed on pretty heavily when you get into fellowship. But that's like, we can't be on the scope of what I think should be discussed here. Maybe I'll discuss it in the future in a hyper-specialized podcast, but it's just not really appropriate to discuss here. So the thing I guess I will then now say is, okay, so divine like, you'll set all these things with chloride, chloride, chloride, chloride. Is this a big deal? Again, like I've said, it's a big deal. There's actually a lot of studies that have shown in general that normal saline compared to the other kinds of crystalloid. Because again, like I said, the other kinds of crystalloid, there's lactated ringers, there's plasma light. Compared to other kinds of crystalloid, normal saline just has more problems, right? There are many studies that have shown this. We're pretty large studies actually that have shown that in comparing crystalloid, I mean, in comparing normal saline to LR plasma light in ICU patients, right? There's been more like a higher risk of death, higher risk of death. In people that take normal saline, there's been more acute kidney injury in people that take normal saline, right?

Just higher mortality in general, more kidney related events in people that are taking normal saline, right? And again, all these problems, all these problems arise again from that super physiologic sodium and chloride load, right? That's super physiologic, sodium and chloride load. I mean, if you want to look up some of these trials, there's one called like the salt ed trial, there's like a smart med trial and things like that that kind of talked about many of these things. So you can maybe dig deep into those if you have access to those papers, right? But this chloride load, I mean, like the kidney problems it causes is an issue, the metabolic acid dose it causes an issue, but it can also cause hyperchylemia, right? And you may be like, okay, divine, what's the mechanism behind that hyperchylemia? Well, the mechanism behind that hyperchylemia is the metabolic acid dose is you're getting from that heavy chloride load. Because again, if you think about it, your body tries to maintain an electron when you develop an acid dose is your body's going to be like, hmm, well, I need to, I don't want to be as idotic because if your body is as idotic, right? In those very low peach environments, there's 13 enzymes in your body that are not going to work very well. There are certain proteins that are going to be nature. Your body is no willing to accept that. So your body is going to try to switch some of those hydrogen ions for potassium ions, right?

So the thing that can happen is you can say, okay, hmm, let me put some hydrogen ions into the cell and bring some potassium ions out of the cell to maintain electron neutrality, but kind of deal with this metabolic acid dose is problem that I have this excess hydrogen ion problem that I have. So you can get hyperchylemia as a result of that. So even if normal saline does not in itself contain potassium, it can cause your body to redistribute potassium and give you a hyperchylemia. Because that's one of the big concerns, one of the big quibbles, many people are like, oh, divine, you know, lactated ringers actually contains potassium, but normal saline does not. Oh, divine plasma life actually contains potassium, but normal saline does not. Well, the thing is, yes, those things contain potassium, but when you're giving them, the potassium rise you'll have in your bloodstream is generally not as fast as the potassium rise you'll have with giving normal saline, right? So normal saline, even if it does not actually contain potassium, will cause a potassium redistribution in your body that can lead to problems, okay? That can lead to problems. So again, the other kinds of crystal oil like LR and plasma light, those things, they're more physiologic, they are pretty close to what obtains in the body. I mean, plasma light is pretty amazing. The pitch of plasma light is almost identical to what you're finding in the bloodstream in plasma. So it's pretty good.

The only problem is plasma light is quite expensive. In fact, if you compare the cost of plasma light and LR and normal saline, obviously normal saline is going to be the cheapest that would mix on intuitive cents. LR is just a little bit more expensive than normal saline. And then plasma light is certainly way more expensive than LR, certainly more expensive than normal saline, right? So in terms of cost, cheapest is normal saline, at least in most settings. And then plasma light is the most expensive. And then LR is kind of a middle grounder, although it's a lot more closer to normal saline in cost than it used to plasma lighting cost. Again, I'm just trying to give you these different considerations so you can make more informed decisions when you're dealing with these things. Now, the thing is, so in general, what are some situations where normal saline makes sense? Well, I mean, if a person has hyponitrine, normal saline is probably helpful because those superficial logic amounts of sodium that you have in the fluid can help shore up that person's sodium. And then another thing that normal saline is also pretty useful for is if you're doing like fluid resuscitation in a person that has like a traumatic brain injury when a person that has increased infocretion pressure or something like that, normal saline is pretty helpful. In fact, I think maybe like a good dovetail here is talking about hyperatonic saline.

It's like a normal saline derivative, but it's a very souped up normal saline derivative. Instead of being 0.9% saline, it's like 3% saline. Although believe it or not, hyperatonic saline has a pretty wide range. There's like some 7% hyperatonic salines. I'm just going to say this to you. If you're ever prescribing hyperatonic saline, you better know what you're doing. That thing can go from, oh, I'm just giving fluid to, oh, GM, it's a nightmare very quickly. So you just gotta be careful. Just gotta be careful. But again, hyperatonic saline is something that's classically used, you know, present that has increased ICP, so increasing infocretion pressure, present that has severe hyponitrine. Especially put a half-hyponitrine with your season, because if you think about it, how would it help? Well, the thing is since it's hyperatonic solution, if you expose your cells to it, well, especially your brain cells, for example, it's going to draw water out of those cells, and that's going to cause those cells to shrink. It's going to cause your brain cells to shrink. So if your brain cells shrink, you're reducing intracranial pressures. These things can lower intracranial pressures. But you gotta be careful, though, about correcting a person's hyponitrine a little too fast. If you correct the person's hyponitrine a little too quickly, that can cause again some significant problems, because there's this whole thing called idugenic osmos in the brain. Let me explain.

The thing is your brain adjusts to it's surrounded. So if, for example, your brain is around hypotonic solution, your brain will try to, your brain cells on the intracellular level will be like, okay, let's try to reduce the amount of inocetol, the amount of glutamine that we have in tracelolally. Let's try to lower the osmolality so that we don't have these crazy fluid shifts between the extracellular environment and the intracellular environment. So if, for example, a person is, if the brain cells are hypotonic solution, your brain will generate, right? Because if you're in hypotonic solution, the problem is, since you're hypotonic relative to the solution around you, you'll send fluid in that direction out of the cell. Your brain is like, I don't want to deal with that. So your brain will generate those idugenic, idio, g-e-n-i-c. Your brain will generate those idugenic osmos, like again, like glutamine, like anocetol, like betaine, stuff like that. And that's gonna cause you to gonna maintain an osmotic balance, right? But again, that process takes time. You cannot just generate glutamine for the fun of it immediately. No. So process that takes time. So if, for example, a person is hypoting-trimic and you're like, oh, oh, gee, I need to repair your hypoting-trimic right now. I got to fix it right now. Well, the thing that's gonna happen is if you give a ton of hypotonic ceiling, that's gonna raise your serenmost malarity significantly very quickly.

Well, the thing is your brain is gonna be like, I don't have enough time to generate idugenic osmos. And you've just put this sharply hypotonic fluid around me. So you're gonna literally draw a lot of water out of the person's brain cells. And if you draw a lot of water out of the person's brain cells very quickly, that can cause like significant dysfunction. That can cause problems with your with myelin, right? That can cause problems with myelin. In fact, that's something we know as central point in myelin. So usually it will be a person, they had hypotonic trimia. You give them hypotonic ceiling to correct it pretty quickly. And they notice that they develop this acute like diffuse paralysis. They have dysphagia, they have dysaphria, they have other neurological symptoms. It's just their eye muscles that really take stroke long eye muscles that are working. That's obviously not a good thing, right? So again, just be careful, right? But that that's what we use normal ceiling. And again, traumatic brain injuries and hypotonic trimia, but again be careful when you're doing those things, right? Again, many times you use normal ceiling as a volume expander in many situations, as I've kind of described already. You can use them to flush wounds as well. You can use them to flush skin abrasions. If people have a allergic rhinitis, actually normal ceiling is also pretty helpful in those people. Just those ceiling washes of the nose.

Believe it or not, actually pretty helpful for breaking up mucus. And if you use them long term, they're actually pretty helpful. They're losing of the mucus. They're pretty helpful. I guess one tip bit I'm just going to throw in here is be very wary of using straight up tap water to flush your person's nose. This is a classic USM any question, right? Or it could be a classic USM any question, right? But it feels like straight up tap water and it's not clean, right? Let's say it contains something bad like I don't know like neglect area of fallurite, right? It's a kind of amoeba that can be very fatal, right? Because you're basically shooting up in pure water for persons nose. My gluer of fallurite can take refuge in a person's brain. A person's probably not going to survive. They're probably going to die actually. So it's just something I want to be careful about. I mean, it's very rare, but it's something that can absolutely happen. It's very, very rare, but it's something that can absolutely happen. Now, I guess since I've talked about hypertonic ceiling, I've talked about normal ceiling, probably makes sense to talk about hypertonic ceiling, right? Like 0.45% ceiling. 0.45% ceiling, you know, it's pretty good, right? We use it in select circumstances, right? Usually when a person has like hypolimic hypermetremia, right? Usually we'll give those people normal ceiling first, but after that we're going to give them like half normal ceiling.

But the thing is maybe times when we give people half normal ceiling, we don't just give them straight up half normal ceiling. We give them half normal ceiling with dextrose. Like you've probably heard of the term D5 half normal ceiling, D5 half normal ceiling. So you may be like, define why do we give dextrose with half normal ceiling? I mean, half normal ceiling is hypertonic. Like why we adding dextrose to it or whatever. Well, let me explain. Let me explain. Again, yes, so people give straight up half normal ceiling, but many times it's pretty common to give D5 half normal ceiling, right? So what's the point of that? Well, think about it. You give a person straight up half normal ceiling. That's hypertonic solution. How do you think your red blood cells will fare when you put them in hypotonic solution? Probably not very well. I mean, the thing that would probably happen is when you put your red blood cells in hypotonic solution, you'll be like, wow, this hypotonic solution is very hypotonic, right? And to balance out your smallality by your smallces, water in that hypotonic solution will flow into your red blood cells and your red blood cells will expand and then they will pop. And when they pop, you're being very big trouble. You have a lot of intravascular himalosis. So that's obviously not a good thing, right? So what do we do? Many times when we give half normal ceiling, we add dextrose to give an extra oomph, that extra oomph, right?

Just to keep the smallality reasonable so that your red blood cells don't stop popping and you don't start having all this intravascular himalosis. And by the way, before I wrap up, there's a few last things I want to say here. If, for example, you're taking the USML exams, if you're taking like step two, step three, I do have a few classes coming up that will help you. I have a biostatistics bootcamp. Actually, for step one, two, step three, I have a few classes coming up. I have a biostatistics bootcamp on the 15th of this month. That's literally last week, Thursday. It's a four hour class. If you're really trouble biostats, and you're like, wait, I actually want to understand certain things. Because many questions these days on USM Ls, they are not like, oh, just plug and chuck the formula. Yes, they are some, but they're very few and far between the very sparsities these. Most times on the exams, it's actually the understanding that will take you and help you answer the question. In fact, sometimes people don't even know what's been tested because they don't know that it's biostatistics. They don't know the concept. They don't realize it because the question is like a word problem. If you want to become like a biostatistics expert, that course is for you. In the MBME Testicking Strategies class, I'm going to begin to advertise that something that's going to be helpful for people taking step one to step three.

Because the thing is the step one exams are becoming extremely clinical. So the MBME Testicking MBME Testicking Strategies class is certainly something that will help a person that's taking step one. Although it's created more for step two, step three, what is going to be tremendously helpful to a person taking step one, a person taking MBME Schof exams. That's going to be on the 16th of this month. Then I have a 20-hour review course for step two and step three specifically. That's going to be taking place from the 19th to the 22nd of this month. Then I have a step one class that's studying on the 5th of January. It's a 25-hour review. It's for step one. It's also a bouticking step two or step three. They have very poor basic science foundations. Because whether you like it or not, a lot of basic science is beginning to migrate to step two and step three. If you have a very poor basis and want to remedy those things, I will strongly encourage you to consider attending that step one class as well. Starting on the 5th of January next year. Again, if you notice, I try to explain things instead of just giving you facts. Because giving you facts is not very helpful. If you want a class or a course that would really help you understand things and present them in scenario form. Many times when I teach classes, I actually don't give lectures, I bring scenarios. Then I use those scenarios to teach the concept. I'm basically killing two birds with one stone.

I'm teaching the concept, but I'm also showing you the classic ways those things present so that you can recognize them in a cue step. Again, if you like the way explained things, then I think you'll find the classes to be extremely helpful. As I wrap up today, maybe let me go ahead and discuss a few last things with ceiling. Some people may be like, you're talking about crystal oil. How about the worst deal with colloid? The thing is colloid, we can talk about in the future. But colloid is basically a kind of fluid that has more protein in it. Maybe like, oh, divine. I can see the intrinsic benefit of this. Since it has more protein, it must be really good for uncoded pressures. It must be very good at maintaining transvascular volume. Because it's very good at maintaining transvascular volume, it must be very good at improving cardiac output, in preventing tissue profusion, in prevent oxygen delivery. To be honest with you, all those things are true. All those things are true. Because if you compare this with normal saline, remember the way the body distributes fluid. Whenever you give a person normal saline, they're either not a big chunk of it goes out of the intravascular space and goes out of it. It goes out of the intravascular space. Because again, your body wants to maintain everything in equilibrium. Because remember, a lot of your fluid is intracellular. Right? About 67% of your fluid is intracellular.

So when you give a person normal saline, about 70 to 75% of it does not remain in the bloodstream. That's why sometimes when a person loses a ton of blood, they say it looks like a liter of blood. If you want to replenish them appropriately, right? You want to give enough fluid that will measure for the amount of blood lost. Typically, you have to give three to four x, three to four times the amount of blood that they lost. Because if you think about it, you feel like, oh, this person will lose the liter of blood. Let me give you a liter of fluid back. Of that liter of fluid, you're giving the person, it's probably like 250 ml that will actually stain the person's bloodstream. Because that's 75% of it roughly will just pretty much depart into the literally extravacid out of the bloodstream and go to the intercellular space, the interstitial space. But if you're like, I want to replace one liter. Well, if you give three or four liters and you lose like 70 to 75% of that three or four liters, well, the stuff that's remaining is going to obviously be good for the intervacid, for the, the stuff that's going to be remaining is going to be good for the intervacid space. Because if you take like 75% of four liters, for example, that leaves you with a liter. And that's actually a pretty, pretty good principle to kind of keep your mind. So, you know, so colloid is good, right? Theoretically, right? If you look at it from a logical perspective, it's pretty amazing, right?

Things like Albion and whatnot. But if there are many studies that I've shown literally no improvement in outcomes when a person gets colloid versus crystaloid, they've not found any mortality benefit from giving colloid versus crystaloid. And the thing is, colloid is a very expensive. Colloid are very, very expensive, right? Colloid are very, very expensive. So it's almost like, it's been a pressing very expensive fluid for no particular clinical benefit. So that's why again, in general, crystaloid is just, it's just better. So what I will just say is, so again, like I'm saying, this is just for educational purposes. But just from analyzing all the information, analyzing all the data out there, looking at the clinical studies, looking at the clinical trials, it just seems that in general, if you're trying to give a pressing crystaloid, giving like T-rated renders is not a bad idea. It almost like offers the best combination of cost is not too expensive and of less in the well of side effects, right? Normal saline is good in general for people that have traumatic brain injuries, people that have hyponitremia. But obviously, again, you will not be super wrong by giving a pressing normal saline and giving point in time. But lactating ringers is just kind of a good fluid in many circumstances where crystaloid is demanded. Plasma light, if you have a ton of money to spend, plasma light is not a bad idea. Okay, and again, who knows?

Maybe the price is decrease over time or decrease over time or whatever. But again, please, like I said, this podcast is just for educational purposes. I'm going to leave it at that. Again, as I wrap up, I do offer one on one tutor for all the USM and the exams. Step one to three, come let's one to three. I just do not tutor all M M. That's one thing I do not tutor. And then I also help with ERAS applications, mock interviews, personal statement, let over recommendation editing. If you're interested in any of those things, just shoot me an email or if you have like just a tricky situation with your ERAS process, just reach out to me. I'll meet you one on one and we can hash hash those things for step two. I do offer of course for step one, of course for step two, I do offer of course for step three, right? The step two, step three course is the same. I offer a step one course and then I have the MB and E-Testicking Strategies class and the BIOS Statistics class. So again, I think those are things you would find to be extremely helpful. And then finally, I do have another website called divininginterventionlifelessens.com. I make like two podcasts every week about 10 to 20 minutes long each and I use the Bible to give a life lesson, right? Address a problem that is faced by many people in the world. And then finally, I also have a You Tube channel called divininginterventionus, mainly podcasts and videos. That's where I post the videos that I make.

So thank you for listening to me today. I really hope you find this podcast to be helpful. And hopefully, again, time goes on our continuous ICU series as I just have more time in my schedule. Thank you. God bless you and bye for now.

To raise cardiac output and increase tissue perfusion.

Normal Saline (0.9% NaCl), Lactated Ringer's Solution (LR), and Plasma-Lyte.

The high chloride load, which can cause metabolic acidosis and AKI.

It stimulates the macula densa cells, leading to reduced prostaglandin synthesis and subsequent renal vasoconstriction.

Lactate in LR is metabolized into bicarbonate ($\text{HCO}_3^-$), providing a buffer.

Used for severe hyponatremia or increased ICP; rapid correction must be avoided to prevent ODS/CPM.

Normal Saline (NS); its high chloride load can cause metabolic acidosis and AKI.

Lactated Ringer's Solution (LR).

Osmotic Demyelination Syndrome (ODS) or Central Pontine Myelinolysis (CPM).

Its electrolyte profile is nearly identical to plasma; it is very expensive.

Constriction of the off-renaterium (due to macula densa signaling), potentially leading to pre-renal AKI.

Normal Saline or Hypertonic saline (with caution); LR/PL are better overall choices if acidosis is present.

Normal Saline (NS); its high chloride load can cause metabolic acidosis and AKI.

Lactated Ringer's Solution (LR).

Osmotic Demyelination Syndrome (ODS) or Central Pontine Myelinolysis (CPM).

Its electrolyte profile is nearly identical to plasma; it is very expensive.

Constriction of the off-renaterium (due to macula densa signaling), potentially leading to pre-renal AKI.

Normal Saline or Hypertonic saline (with caution); LR/PL are better overall choices if acidosis is present.