Similar articles

Abstract: The purpose of this review is to objectively evaluate the biochemical and pathophysiological properties of 0.9% saline (henceforth: saline) and to discuss the impact of saline infusion, specifically on systemic acid-base balance and renal hemodynamics. Studies have shown that electrolyte balance, including effects of saline infusion on serum electrolytes, is often poorly understood among practicing physicians and inappropriate saline prescribing can cause increased morbidity and mortality. Large-volume (>2 L) saline infusion in healthy adults induces hyperchloremia which is associated with metabolic acidosis, hyperkalemia, and negative protein balance. Saline overload (80 ml/kg) in rodents can cause intestinal edema and contractile dysfunction associated with activation of sodium-proton exchanger (NHE) and decrease in myosin light chain phosphorylation. Saline infusion can also adversely affect renal hemodynamics. Microperfusion experiments and real-time imaging studies have demonstrated a reduction in renal perfusion and an expansion in kidney volume, compromising O₂ delivery to the renal parenchyma following saline infusion. Clinically, saline infusion for patients post abdominal and cardiovascular surgery is associated with a greater number of adverse effects including more frequent blood product transfusion and bicarbonate therapy, reduced gastric blood flow, delayed recovery of gut function, impaired cardiac contractility in response to inotropes, prolonged hospital stay, and possibly increased mortality. In critically ill patients, saline infusion, compared to balanced fluid infusions, increases the occurrence of acute kidney injury. In summary, saline is a highly acidic fluid. With the exception of saline infusion for patients with hypochloremic metabolic alkalosis and volume depletion due to vomiting or upper gastrointestinal suction, indiscriminate use, especially for acutely ill patients, may cause unnecessary complications and should be avoided. More education regarding saline-related effects and adequate electrolyte management is needed.

0.9%盐水既不正常也不生理

[1]Awad, S., Allison, S.P., Lobo, D.N., 2008. The history of 0.9% saline. Clin. Nutr., 27(2):179-188.

[2]Ballmer, P.E., McNurlan, M.A., Hulter, H.N., et al., 1995. Chronic metabolic acidosis decreases albumin synthesis and induces negative nitrogen balance in humans. J. Clin. Invest., 95(1):39-45.

[3]Barak, M., Rudin, M., Vofsi, O., et al., 2004. Fluid administration during abdominal surgery influences on coagulation in the postoperative period. Curr. Surg., 61(5):459-462.

[4]Bell, P.D., Lapointe, J.Y., Cardinal, J., et al., 1989. Direct measurement of basolateral membrane potentials from cells of the macula densa. Am. J. Physiol., 257(3 Pt 2):F463-F468.

[5]Bell, P.D., Komlosi, P., Zhang, Z.R., et al., 2009. ATP as a mediator of macula densa cell signalling. Purinergic Signal., 5(4):461-471.

[6]Brandstrup, B., Tønnesen, H., Beier-Holgersen, R., et al., 2003. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann. Surg., 238(5):641-648.

[7]Chowdhury, A.H., Cox, E.F., Francis, S.T., et al., 2012. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann. Surg., 256(1):18-24.

[8]Day, S.M., Westfall, M.V., Fomicheva, E.V., et al., 2006. Histidine button engineered into cardiac troponin I protects the ischemic and failing heart. Nat. Med., 12(2):181-189.

[9]Day, S.M., Westfall, M.V., Metzger, J.M., 2007. Tuning cardiac performance in ischemic heart disease and failure by modulating myofilament function. J. Mol. Med., 85(9):911-921.

[10]Debold, E.P., Beck, S.E., Warshaw, D.M., 2008. Effect of low pH on single skeletal muscle myosin mechanics and kinetics. Am. J. Physiol. Cell Physiol., 295(1):C173-C179.

[11]Fujita, H., Ishiwata, S., 1999. Tropomyosin modulates pH dependence of isometric tension. Biophys. J., 77(3):1540-1546.

[12]Hansen, P.B., Jensen, B.L., Skott, O., 1998. Chloride regulates afferent arteriolar contraction in response to depolarization. Hypertension, 32(6):1066-1070.

[13]Herrler, T., Tischer, A., Meyer, A., et al., 2010. The intrinsic renal compartment syndrome: new perspectives in kidney transplantation. Transplantation, 89(1):40-46.

[14]Ho, A.M.H., Karmakar, M.K., Contardi, L.H., et al., 2001. Excessive use of normal saline in managing traumatized patients in shock: a preventable contributor to acidosis. J. Trauma, 51(1):173-177.

[15]Jensen, B.L., Ellekvist, P., Skott, P., et al., 1997. Chloride is essential for contraction of afferent arterioles after agonists and potassium. Am. J. Physiol., 272(3 Pt 2):F389-F396.

[16]Kapur, S., Wasserstrom, J.A., Skøtt, O., 2009. Acidosis and ischemia increase cellular Ca²⁺ transient alternans and repolarization alternans susceptibility in the intact rat heart. Am. J. Physiol. Heart Circ. Physiol., 296(5):H1491-H1512.

[17]Kellum, J.A., Song, M., Almasri, E., 2006. Hyperchloremic acidosis increases circulating inflammatory molecules in experimental sepsis. Chest, 130(4):962-967.

[18]Kessler, R., Leibhammer, S., Laue, O., et al., 1997. Acute saline infusion induces extracellular acidification and activation of the Na⁺/H⁺ exchanger in man. Eur. J. Clin. Invest., 27(7):558-565.

[19]Koch, S.M., Taylor, R.W., 1992. Chloride ion in intensive care medicine. Crit. Care Med., 20(2):227-240.

[20]Knuth, S.T., Dave, H., Peters, J.R., et al., 2006. Low cell pH depresses peak power in rat skeletal muscle fibres at both 30°C and 15°C: implications for muscle fatigue. J. Physiol., 575(Pt 3):887-899.

[21]Levy, B., Collin, S., Sennoun, N., et al., 2010. Vascular hyporesponsiveness to vasopressors in septic shock: from bench to bedside. Intensive Care Med., 36(12):2019-2029.

[22]Lobo, D.N., Dube, M.G., Neal, K.R., et al., 2001. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin. Nutr., 20(2):125-130.

[23]Lobo, D.N., Bostock, K.A., Neal, K.R., et al., 2002a. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet, 359(9320):1812-1818.

[24]Lobo, D.N., Dube, M.G., Neal, K.R., et al., 2002b. Peri-operative fluid and electrolyte management: a survey of consultant surgeons in the UK. Ann. R. Coll. Surg. Engl., 84(3):156-160.

[25]Mitchell, J.H., Wildenthal, K., Johnson, R.L.Jr., et al., 1972. The effects of acid-base disturbances on cardiovascular and pulmonary function. Kidney Int., 1(5):375-389.

[26]Mitchell, K.D., Navar, L.G., 1988. Enhanced tubuloglomerular feedback during peritubular infusions of angiotensins I and II. Am. J. Physiol., 255(3 Pt 2):F383-F390.

[27]Mitchell, K.D., Navar, L.G., 1990. Interactive effects of angiotensin II on renal hemodynamics and tubular reabsorptive function. Kidney Int. Suppl., 30:S69-S73.

[28]Modi, M.P., Vora, K.S., Parikh, G.P., et al., 2012. A comparative study of impact of infusion of Ringer’s Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J. Kidney Dis. Transpl., 23(1):135-137.

[29]Moopanar, T.R., Allen, D.G., 2005. Reactive oxygen species reduce myofibrillar Ca²⁺ sensitivity in fatiguing mouse skeletal muscle at 37°C. J. Physiol., 564(Pt 1):189-199.

[30]Moopanar, T.R., Allen, D.G., 2006. The activity-induced reduction of myofibrillar Ca²⁺ sensitivity in mouse skeletal muscle is reversed by dithiothreitol. J. Physiol., 571(Pt 1):191-200.

[31]Morimoto, S., Harada, K., Ohtsuki, I., et al., 1999. Roles of troponin isoforms in pH dependence of contraction in rabbit fast and slow skeletal and cardiac muscles. J. Biochem., 126(1):121-129.

[32]O'Malley, C.M., Frumento, R.J., Hardy, M.A., et al., 2005. A randomized, double-blind comparison of lactated Ringer’s solution and 0.9% NaCl during renal transplantation. Anesth. Analg., 100(5):1518-1524.

[33]Oppermann, M., Mizel, D., Huang, G., et al., 2006. Macula densa control of renin secretion and preglomerular resistance in mice with selective deletion of the B isoform of the Na,K,2Cl co-transporter. J. Am. Soc. Nephrol., 17(8):2143-2152.

[34]Oppermann, M., Mizel, D., Kim, S.M., et al., 2007. Renal function in mice with targeted disruption of the A isoform of the Na-K-2Cl co-transporter. J. Am. Soc. Nephrol., 18(2):440-448.

[35]Powers, F., 1999. The role of chloride in acid-base balance. J. Intraven. Nurs., 22(5):286-291.

[36]Puljak, L., Kilic, G., 2006. Emerging roles of chloride channels in human diseases. Biochim. Biophys. Acta, 1762(4):404-413.

[37]Reid, F., Lobo, D.N., Williams, R.N., et al., 2003. (Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study. Clin. Sci., 104(1):17-24.

[38]Ren, Y., Garvin, J.L., Liu, R., et al., 2004. Role of macula densa adenosine triphosphate (ATP) in tubuloglomerular feedback. Kidney Int., 66(4):1479-1485.

[39]Scheingraber, S., Rehm, M., Sehmisch, C., et al., 1999. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology, 90(5):1265-1270.

[40]Schotola, H., Toischer, K., Popov, A.F., et al., 2012. Mild metabolic acidosis impairs the β-adrenergic response in isolated human failing myocardium. Crit. Care, 16(4):R153.

[41]Shaw, A.D., Bagshaw, S.M., Goldstein, S.L., et al., 2012. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann. Surg., 255(5):821-829.

[42]Shires, G.T., Holman, J., 1948. Dilution acidosis. Ann. Intern. Med., 28(3):557-559.

[43]Snook, J.H., Li, J., Helmke, B.P., et al., 2008. Peroxynitrite inhibits myofibrillar protein function in an in vitro assay of motility. Free Radic. Biol. Med., 44(1):14-23.

[44]Stewart, P.A., 1983. Modern quantitative acid-base chemistry. Can. J. Physiol. Pharmacol., 61(12):1444-1461.

[45]Stone, H.H., Fulenwider, J.T., 1977. Renal decapsulation in the prevention of post-ischemic oliguria. Ann. Surg., 186(3):343-355.

[46]Tang, Y.B., Zhou, J.G., Guan, Y.Y., 2010. Volume-regulated chloride channels and cerebral vascular remodelling. Clin. Exp. Pharmacol. Physiol., 37(2):238-242.

[47]Traynor, T., Yang, T., Huang, Y.G., et al., 1998. Inhibition of adenosine-1 receptor-mediated preglomerular vasoconstriction in AT receptor-deficient mice. Am. J. Physiol., 275(6 Pt 2):F922-F927.

[48]Uray, K.S., Shah, S.K., Radhakrishnan, R.S., et al., 2011. Sodium hydrogen exchanger as a mediator of hydrostatic edema-induced intestinal contractile dysfunction. Surgery, 149(1):114-125.

[49]Veech, R.L., 1986. The toxic impact of parenteral solutions on the metabolism of cells: a hypothesis for physiological parenteral therapy. Am. J. Clin. Nutr., 44(4):519-551.

[50]Veizis, I.E., Cotton, C.U., 2007. Role of kidney chloride channels in health and disease. Pediatr. Nephrol., 22(6):770-777.

[51]Waters, J.H., Gottlieb, A., Schoenwald, P., et al., 2001. Normal saline versus lactated Ringer’s solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth. Analg., 93(4):817-822.

[52]Wilcox, C.S., 1983. Regulation of renal blood flow by plasma chloride. J. Clin. Invest., 71(3):726-735.

[53]Wilkes, N.J., Woolf, R., Mutch, M., et al., 2001. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth. Analg., 93(4):811-816.

[54]Williams, E.L., Hildebrand, K.L., McCormick, S.A., et al., 1999. The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth. Analg., 88(5):999-1003.

[55]Yunos, N.M., Bellomo, R., Story, D., et al., 2010. Bench-to-bedside review: chloride in critical illness. Crit. Care, 14(4):226.

[56]Zand, L., King, B.F., Qian, Q., 2014. Role of kidney Doppler ultrasonography in the diagnosis and management of anuric kidney failure. Clin. Nephrol., 82(2):122-127.