EM · Resuscitation
Fluid resuscitation in the emergency department
Also known as IV fluid resuscitation · Volume resuscitation · Crystalloid resuscitation · Fluid therapy in shock
Fluid resuscitation — the rapid restoration of the circulating volume to reverse tissue hypoperfusion; the fluid types (crystalloid vs colloid, balanced vs saline), the fluid-responsiveness assessment (passive leg raise, IVC variability, pulse-pressure variation), the targets (MAP, lactate, urine output, capillary refill), the doses (crystalloid 250 to 500 mL aliquots to a working ceiling of 30 mL/kg, noradrenaline 0.05 to 0.5 mcg/kg/min), the SMART trial (balanced crystalloids lower mortality and AKI than saline), the SAFE albumin controversy (no benefit, harmful in TBI), the abandoned hydroxyethyl starch (CHEST, 6S, Perel), and the disease-specific strategies (sepsis, trauma, DKA, burns). ACEM-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Only about half of haemodynamically unstable patients are fluid-responsive — give fluid only to a responder; a bolus in a non-responder causes harm without benefit
- Saline in volume causes a hyperchloraemic metabolic acidosis (chloride 154, pH in the low 7.2s) that mimics lactic acidosis and worsens the acute kidney injury — use a balanced crystalloid
- Hydroxyethyl starch is abandoned — it increases the acute kidney injury and the need for renal replacement therapy without any mortality benefit (CHEST, 6S, Perel)
- Albumin is harmful in traumatic brain injury (SAFE-TBI) — do not give albumin to the head-injured patient
- In the actively bleeding trauma patient, minimise the crystalloid — give blood products and target permissive hypotension, not a normal blood pressure
Meet the patient
A 62-year-old diabetic with chronic kidney disease is in resus: fever, confusion, RR 32, MAP 63, lactate 5.8, cold mottled peripheries, capillary refill 4 seconds. The registrar hangs a litre of saline and reaches for the next bag.[1]
Stop. Only about half of unstable patients are fluid-responsive, and a bolus in a non-responder does harm without benefit. This topic is the disciplined sequence — test the responsiveness, give a true bolus, declare the target, and stop at the down-arrow — that separates the resuscitator from the reflex.[15]
References21ShowHide
- [1]Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med, 2001.PMID 11794169
- [2]Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit N Engl J Med, 2004.PMID 15163774
- [3]Myburgh J, Cooper DJ, Finfer S, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury N Engl J Med, 2007.PMID 17761591
- [4]Semler MW, Self WH, Rice TW Balanced Crystalloids versus Saline in Critically Ill Adults N Engl J Med, 2018.PMID 29768150
- [5]Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev, 2013.PMID 23450531
- [6]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection N Engl J Med, 2011.PMID 21615299
- [7]Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care N Engl J Med, 2012.PMID 23075127
- [8]Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis N Engl J Med, 2012.PMID 22738085
- [9]Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial JAMA, 2015.PMID 26444692
- [10]Zampieri FG, Machado FR, Veiga VC, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial JAMA, 2021.PMID 34375394
- [11]Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults N Engl J Med, 2022.PMID 35041780
- [12]Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of Intravenous Fluid in ICU Patients with Septic Shock N Engl J Med, 2022.PMID 35709019
- [13]Shapiro NI, Douglas IS, Brower RG, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension N Engl J Med, 2023.PMID 36688507
- [14]Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock N Engl J Med, 2014.PMID 24635773
- [15]Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature Crit Care Med, 2009.PMID 19602972
- [16]Jabot J, Teboul JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change Intensive Care Med, 2009.PMID 18795254
- [17]Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries N Engl J Med, 1994.PMID 7935634
- [18]Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med, 2018.PMID 29485926
- [19]ZhangJian SJ, Niu KY, Chen CB, et al. Incidence of Adverse Events in Peripheral Intravenous Vasopressor Use: A Systematic Review and Meta-Analysis. JAMA Netw Open, 2026.PMID 41838001
- [20]Berikashvili LB, Kuznetsov IV, Yadgarov MY, et al. Assessment of Fluid Responsiveness via Central Venous Ultrasound Measurement: A Network Meta-Analysis. J Clin Med, 2025.PMID 39860497
- [21]Jairath V, Kahan BC, Gray A, et al. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial Lancet, 2015.PMID 25956718