Hostname: page-component-745bb68f8f-b6zl4 Total loading time: 0 Render date: 2025-02-04T10:31:25.823Z Has data issue: false hasContentIssue false
  • English
  • Français

Fluid, electrolytes and nutrition: physiological and clinical aspects

Published online by Cambridge University Press:  07 March 2007

Dileep N. Lobo
Dileep N. Lobo*
Affiliation:
Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
*
Corresponding author: Mr D. N. Lobo, fax +44 115 9709428, email dileep.lobo@nottingham.ac.uk
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Fluid and electrolyte balance is often poorly understood and inappropriate prescribing can cause increased post-operative morbidity and mortality. The efficiency of the physiological response to a salt or water deficit, developed through evolution, contrasts with the relatively inefficient mechanism for dealing with salt excess. Saline has a Na+:Cl-of 1:1 and can produce hyperchloraemic acidosis, renal vasoconstriction and reduced glomerular filtration rate. In contrast, the more physiological Hartmann's solution with a Na+:Cl-of 1·18:1 does not cause hyperchloraemia and Na excretion following infusion is more rapid. Salt and water overload causes not only peripheral and pulmonary oedema, but may also produce splanchnic oedema, resulting in ileus or acute intestinal failure. This overload may sometimes be an inevitable consequence of resuscitation, yet it may take 3 weeks to excrete this excess. It is important to avoid unnecessary additional overload by not prescribing excessive maintenance fluids after the need for resuscitation has passed. Most patients require 2–2·5 litres water and 60–100?mmol?Na\d for maintenance in order to prevent a positive fluid balance. This requirement must not be confused with those for resuscitation of the hypovolaemic patient in whom the main aim of fluid therapy is repletion of the intravascular volume. Fluid and electrolyte balance is a vital component of the metabolic care of surgical and critically-ill patients, with important consequences for gastrointestinal function and hence nutrition. It is also of importance when prescribing artificial nutrition and should be given the same careful consideration as other nutritional and pharmacological needs.

Keywords

SodiumWaterElectrolytesGastrointestinal functionAlbumin
Type
Sir David Cuthbertson Medal Lecture
Information
Proceedings of the Nutrition Society , Volume 63 , Issue 3 , August 2004 , pp. 453 - 466
Copyright
Copyright © The Nutrition Society 2004

References

Allison, SP (1996) Nutrition in Medicine: A Physician's View. Brussels, Belgium: Institut Danone.Google Scholar
Alsous, F, Khamiees, M DeGirolamo, A Amoateng-Adjepong, Y & Manthous, CA (2000) Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study. Chest 117, 1749–1754.CrossRefGoogle ScholarPubMed
Anderson, JA, Lobo, DN, Lawes, SC, Rowlands, BJ & Allison, SP (2002) Sequential changes in serum albumin, c-reactive protein and transcapillary escape rate of albumin in patients undergoing major abdominal surgery. Clinical Nutrition 21, Suppl. 1, 29.Google Scholar
Arieff, AI (1999) Fatal postoperative pulmonary edema: pathogenesis and literature review. Chest 115, 1371–1377.CrossRefGoogle ScholarPubMed
Aukland, K & Nicolaysen, G (1981) Interstitial fluid volume: local regulatory mechanisms. Physiological Reviews 61, 556–643.CrossRefGoogle ScholarPubMed
Ballmer-Weber, BK, Dummer, R, Kung, E, Burg, G & Ballmer, PE (1995) Interleukin 2-induced increase of vascular permeability without decrease of the intravascular albumin pool. British Journal of Cancer 71, 78–82.CrossRefGoogle ScholarPubMed
Balogh, Z McKinley, BA Cocanour, CS, Kozar, RA, Valdivia, A, Sailors, RM & Moore, FA (2003) Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Archives of Surgery 138, 637–642.CrossRefGoogle ScholarPubMed
Barclay, RL, Depew, WT & Vanner, SJ (2002) Carbohydrate-electrolyte rehydration protects against intravascular volume contraction during colonic cleansing with orally administered sodium phosphate. Gastrointestinal Endoscopy 56, 633–638.CrossRefGoogle ScholarPubMed
Barden, RP, Thompson, WD, Ravdin, IS & Frank, IL (1938) The influence of the serum protein on the motility of the small intestine. Surgery Gynecology and Obstetrics 66, 819–821.Google Scholar
Beloosesky, Y, Grinblat, J, Weiss, A, Grosman, B, Gafter, U & Chagnac, A (2003) Electrolyte disorders following oral sodium phosphate administration for bowel cleansing in elderly patients. Archives of Internal Medicine 163, 803–808.CrossRefGoogle ScholarPubMed
Brandstrup, B, Tonnesen, H Beier-Holgersen, R Hjortso, E, Ording, H, Lindorff-Larsen, K. et al. (2003) Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Annals of Surgery 238, 641–648.CrossRefGoogle ScholarPubMed
Callum, KG, Gray, AJG, Hoile, RW, Ingram, GS, Martin, IC, Sherry, KM & Whimster, F (1999) Extremes of Age: The 1999 Report of the National Confidential Enquiry into Perioperative Deaths. London: National Confidential Enquiry into Perioperative Deaths.Google Scholar
Campbell, IT, Green, CJ & Jackson, MJ (1998) Muscle glycogen and electrolyte concentrations in multiple organ failure. Proceedings of the Nutrition Society 57, 111A.Google Scholar
Clark, RG (1977) Water and sodium metabolism after trauma In Folia Traumatologica Geigy: Metabolic Responses to Trauma, pp.5–8 [Stoner, HB, Clark, RG, Frayn, KN, and Fleck, A, editors]. Basle: CIBA-Geigy.Google Scholar
Coller, FA, Bartlett, RM, Bingham, DLC, Maddock, WG & Pedersen, S (1938) The replacement of sodium chloride in surgical patients. Annals of Surgery 108, 769–782.CrossRefGoogle ScholarPubMed
Coller, FA, Campbell, KN, Vaughan, HH, Iob, LV & Moyer, CA (1944) Postoperative salt intolerance. Annals of Surgery 119, 533–541.CrossRefGoogle ScholarPubMed
Coller, FA, Dick, VS & Maddock, WG (1936) Maintenance of normal water exchange with intravenous fluids. Journal of the American Medical Association 107, 1522–1527.CrossRefGoogle Scholar
Cuthbertson, DP (1930) Effect of injury on metabolism. Biochemical Journal 2, 1244–1263.CrossRefGoogle Scholar
Cuthbertson, DP (1932) Observations of the disturbance of metabolism produced by injury to the limbs. Quarterly Journal of Medicine 1, 233–246.Google Scholar
Dick, M, Dasta, JF, Choban, PS, Sinha, R & Flancbaum, L (1994) Serum aldosterone concentrations and urine output in oliguric intensive care patients receiving low dose dopamine. Annals of Pharmacotherapy 28, 837–841.CrossRefGoogle ScholarPubMed
Drummer, C, Gerzer, R, Heer, M, Molz, B, Bie, P, Schlossberger, M, Stadaeger, C, Rocker, L, Strollo, F & Heyduck, B (1992) Effects of an acute saline infusion on fluid and electrolyte metabolism in humans. Americal Journal of Physiology 262, F744–F754.Google ScholarPubMed
Edelman, IS & Leibman, J (1959) Anatomy of body water and electrolytes. American Journal of Medicine 27, 256–277.CrossRefGoogle ScholarPubMed
Evans, GH (1911) The abuse of normal salt solution. Journal of the American Medical Association 57, 2126–2127.CrossRefGoogle Scholar
Flear, CT & Singh, CM (1973) Hyponatraemia and sick cells. British Journal of Anaesthesia 45, 976–994.CrossRefGoogle ScholarPubMed
Flear, CT & Singh, CM (1982) The sick cell concept and hyponatremia in congestive heart failure and liver disease. Lancet ii, 101–102.CrossRefGoogle Scholar
Fleck, A, Raines, G, Hawker, F, Trotter, J, Wallace, PI, Ledingham, IM & Calman, KC (1985) Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury. Lancet i, 781–784.CrossRefGoogle Scholar
Frost, A, Wakefield, CH, Sengupta, F & Fearon, KCH (2001) Relationship between fluid administrations and outcome in colorectal surgery. Proceedings of the Nutrition Society 60, 113A.Google Scholar
Gil, MJ, Franch, G, Guirao, X, Oliva, A, Herms, R, Salas, E, Girvent, M & Sitges-Serra, A (1997) Response of severely malnourished patients to preoperative parenteral nutrition: a randomized clinical trial of water and sodium restriction. Nutrition 13, 26–31.CrossRefGoogle ScholarPubMed
Gosling, P (1999) Fluid balance in the critically ill: the sodium and water audit. Care of the Critically Ill 15, 11–16.Google Scholar
Grathwohl, KW, Bruns, BJ LeBrun, CJ Ohno, AK, Dillard, TA & Cushner, HM (1996) Does hemodilution exist? Effects of saline infusion on hematologic parameters in euvolemic subjects. Southern Medical Journal 89, 51–55.CrossRefGoogle ScholarPubMed
Greenfield, RH, Bessen, HA & Henneman, PL (1989) Effect of crystalloid infusion on hematocrit and intravascular volume in healthy, nonbleeding subjects. Annals of Emergency Medicine 18, 51–55.CrossRefGoogle ScholarPubMed
Guyton, AC (1959) Effect of elevated left atrial pressure and decreased plasma protein concentration on the development of pulmonary oedema. Circulation Research 7, 649–657.CrossRefGoogle Scholar
Hahn, RG & Drobin, D (1998) Urinary excretion as an input variable in volume kinetic analysis of Ringer's solution. British Journal of Anaesthesia 80, 183–188.CrossRefGoogle ScholarPubMed
Hahn, RG & Svensen, C (1997) Plasma dilution and the rate of infusion of Ringer's solution. British Journal of Anaesthesia 79, 64–67.CrossRefGoogle ScholarPubMed
Hartmann, AF (1934) Theory and practice of parenteral fluid administration. Journal of the American Medical Association 103, 1349–1354.CrossRefGoogle Scholar
Heller, MB, Crocco, T, Prestosh, JC & Patterson, JW (1996) Effectiveness of different crystalloid i.v. solutions in establishing urine flow. Journal of Emergency Medicine 14, 1–3.CrossRefGoogle ScholarPubMed
Heyland, DK, Tougas, G, King, D & Cook, DJ (1996) Impaired gastric emptying in mechanically ventilated, critically ill patients. Intensive Care Medicine 22, 1339–1344.CrossRefGoogle ScholarPubMed
Ho, AM, Karmakar, MK, Contardi, LH, Ng, SS & Hewson, JR (2001) Excessive use of normal saline in managing traumatized patients in shock: a preventable contributor to acidosis. Journal of Trauma 51, 173–177.CrossRefGoogle Scholar
Holte, K, Sharrock, NE & Kehlet, H (2002) Pathophysiology and clinical implications of perioperative fluid excess. British Journal of Anaesthesia 89, 622–632.CrossRefGoogle ScholarPubMed
Kamp-Jensen, M, Olesen, KL, Bach, V, Schutten, HJ & Engquist, A (1990) Changes in serum electrolyte and atrial natriuretic peptide concentrations, acid-base and haemodynamic status after rapid infusion of isotonic saline and Ringer lactate solution in healthy volunteers. British Journal of Anaesthesia 64, 606–610.CrossRefGoogle ScholarPubMed
Kaye, AD & Grogono, AW (2000) Fluid and electrolyte physiology. In Anesthesia, pp. 1586–1612 [Miller, RD, Cucchiara, RF, Miller, ED Jr, Reves, JG, Roizen, MF, and Savarese, JJ, editors]. Philadelphia, PA: Churchill Livingstone.Google Scholar
Keys, A, Brozek, J, Henschel, A, Mickelsen, O & Taylor, HF (1950) The Biology of Human Starvation. Minneapolis, MN: University of Minnesota Press.CrossRefGoogle Scholar
Kramer, GC, Svensen, CH & Prough, DS (2001) To bolus or not to bolus – is that the question?. Clinical Science 101, 181–183.CrossRefGoogle ScholarPubMed
Lamke, LO & Liljedahl, SO (1976) Plasma volume changes after infusion of various plasma expanders. Resuscitation 5, 93–102.CrossRefGoogle ScholarPubMed
Lane, N & Allen, K (1999) Hyponatraemia after orthopaedic surgery. British Medical Journal 318, 1363–1364.CrossRefGoogle ScholarPubMed
Latta, T (1832) Malignant cholera. Documents communicated by the Central Board of Health, London, relative to the treatment of cholera by copious injection of aqueous and saline fluids into the veins. Lancet ii, 274–277.Google Scholar
Le Quesne, LP & Lewis, AAG (1953) Postoperative water and sodium retention. Lancet i, 153–158.CrossRefGoogle Scholar
Lobo, DN, Bjarnason, K, Field, J, Rowlands, BJ & Allison, SP (1999) Changes in weight, fluid balance and serum albumin in patients referred for nutritional support. Clinical Nutrition 18, 197–201.CrossRefGoogle ScholarPubMed
Lobo, DN, Bostock, KA, Bush, D, Macdonald, IA, Perkins, AC, Neal, KR, Rowlands, BJ & Allison, SP (2002a) Reproducibility and normal ranges for gastric emptying in normal volunteers using a test meal designed for postoperative patients. Nuclear Medicine Communications 23, 97–101.CrossRefGoogle Scholar
Lobo, DN, Bostock, KA, Neal, KR, Perkins, AC, Rowlands, BJ & Allison, SP (2002b) Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 359, 1812–1818.CrossRefGoogle ScholarPubMed
Lobo, DN, Dube, MG, Neal, KR, Allison, SP & Rowlands, BJ, (2002c) Peri-operative fluid and electrolyte management: a survey of consultant surgeons in the UK. Annals of the Royal College of Surgeons of England 84, 156–160.Google ScholarPubMed
Lobo, DN, Dube, MG, Neal, KR, Simpson, J, Rowlands, BJ & Allison, SP, (2001a) Problems with solutions: drowning in the brine of an inadequate knowledge base. Clinical Nutrition 20, 125–130.CrossRefGoogle ScholarPubMed
Lobo, DN, Myhill, DJ, Stanga, Z, Broughton, F & Allison, SP (2002d) The effect of volume loading with 1 litre intravenous infusions of 0·9% saline and 5% dextrose on the renin angiotensin system (RAS) and volume controlling hormones: a randomised, double blind, crossover study. Clinical Nutrition 21, Suppl. 1, 9– 10.Google Scholar
Lobo, DN, Stanga, Z, Simpson, JAD, Anderson, JA, Rowlands, BJ & Allison, SP (2001b) Dilution and redistribution effects of rapid 2-litre infusions of 0·9% (w/v) saline and 5% (w/v) dextrose on haematological parameters and serum biochemistry in normal subjects: a double-blind crossover study. Clinical Science 101, 173–179.CrossRefGoogle ScholarPubMed
Lucas, CE, Weaver, D, Higgins, RF, Ledgerwood, AM, Johnson, SD & Bouwman, DL (1978) Effects of albumin versus non-albumin resuscitation on plasma volume and renal excretory function. Journal of Trauma 18, 564–570.CrossRefGoogle ScholarPubMed
Mayberry, JC, Welker, KJ, Goldman, RK & Mullins, RJ (2003) Mechanism of acute ascites formation after trauma resuscitation. Archives of Surgery 138, 773–776.CrossRefGoogle ScholarPubMed
Mecray, PM, Barden, RP & Ravdin, IS (1937) Nutritional edema: its effect on the gastric emptying time before and after gastric operations. Surgery 1, 53–64.Google Scholar
Mitchell, JP, Schuller, D, Calandrino, FS & Schuster, DP (1992) Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterisation. American Review of Respiratory Disease 145, 990–998.CrossRefGoogle Scholar
Moore, FD (1959) Metabolic Care of the Surgical Patient. Philadelphia, PA: W.B. Saunders.Google Scholar
Moore, FD & Shires, G (1967) Moderation. Annals of Surgery 166, 300–301.Google ScholarPubMed
Mullins, RJ & Bell, DR (1982) Changes in interstitial volume and masses of albumin and IgG in rabbit skin and skeletal muscle after saline volume loading. Circulation Research 51, 305–313.CrossRefGoogle ScholarPubMed
Mullins, RJ & Garrison, RN (1989) Fractional change in blood volume following normal saline infusion in high-risk patients before noncardiac surgery. Annals of Surgery 209, 651–659.CrossRefGoogle ScholarPubMed
Perl, W (1975) Convection and permeation and albumin between plasma and interstitium. Microvascular Research 10, 83–94.CrossRefGoogle ScholarPubMed
Plank, LD, Connolly, AB & Hill, GL (1998) Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis. Annals of Surgery 228, 146–158.CrossRefGoogle ScholarPubMed
Plank, LD & Hill, GL (2000) Similarity of changes in body composition in intensive care patients following severe sepsis or major blunt injury. Annals of the New York Academy of Sciences 904, 592–602.CrossRefGoogle ScholarPubMed
Plante, GE, Chakir, M, Lehoux, S & Lortie, M (1995) Disorders of body fluid balance: a new look into the mechanism of disease. Candian Journal of Cardiology 11, 788–802.Google Scholar
Power, FH, Pedersen, S & Maddock, WG (1942) Clinical experience with sodium chloride replacement. Surgery 12, 438–444.Google Scholar
Price, J, Sear, J & Venn, R (2002) Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database of Systematic Reviews CD003004.Google Scholar
Pringle, H, Maunsell, RCB & Pringle, S (1905) Clinical effects of ether anaesthesia on renal activity. British Medical Journal ii, 542–543.CrossRefGoogle Scholar
Ravdin, IS (1938) Factors involved in the retardation of gastric emptying after gastric operations. Pennsylvania Medical Journal 41, 695–700.Google Scholar
Reid, F, Lobo, DN, Williams, RN, Rowlands, BJ & Allison, SP (2003) (Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study. Clinical Science 104, 17–24.CrossRefGoogle ScholarPubMed
Rhoads, JE (1957) Fluid and electrolytes. In Surgery Principles and Practice, pp. 65– 79 [Allen, JG, Harkins, HH, Moyer, CA, and Rhoads, JE, editors]. London: Pitman Medical Publishing.Google Scholar
Rose, BD & Post, TW (2001) Clinical Physiology of Acid-base and Electrolyte Disorders. New York: McGraw-Hill.Google Scholar
Roth, E, Lax, LC & Maloney, JV Jr (1969) Ringer's lactate solution and extracellular fluid volume in the surgical patient: a critical analysis. Annals of Surgery 169, 149–164.CrossRefGoogle ScholarPubMed
Sanders, G, Mercer, SJ, Saeb-Parsey, K, Akhavani, MA, Hosie, KB & Lambert, AW (2001) Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery. British Journal of Surgery 88, 1363–1365.CrossRefGoogle ScholarPubMed
Seinela, L, Pehkonen, E, Laasanen, T & Ahvenainen, J (2003) Bowel preparation for colonoscopy in very old patients: a randomized prospective trial comparing oral sodium phosphate and polyethylene glycol electrolyte lavage solution. Scandinavian Journal of Gastroenterology 38, 216–220.CrossRefGoogle ScholarPubMed
Shafiee, MA, Bohn, D, Hoorn, EJ & Halperin, ML (2003) How to select optimal maintenance intravenous fluid therapy. Quarterly Journal of Medicine 96, 601–610.CrossRefGoogle ScholarPubMed
Shires, GT, Brown, FT, Canizaro, PC & Somerville, N (1960) Distributional changes in extracellular fluid during acute hemorrhagic shock. Surgical Forum 11, 115–117.Google Scholar
Shires, GT, Williams, J & Brown, F (1961) Acute changes in extracellular fluids associated with major surgical procedures. Annals of Surgery 154, 803–810.CrossRefGoogle ScholarPubMed
Shizgal, HM (1981) The effect of malnutrition on body composition. Surgery Gynecology and Obstetrics 152, 22–26.Google ScholarPubMed
Sinclair, S, James, S & Singer, M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. British Medical Journal 315, 909–912.CrossRefGoogle ScholarPubMed
Singer, DRJ, Shore, AC, Markandu, ND, Buckley, MG, Sagnella, GA & Macgregor, GA (1987) Dissociation between plasma atrial-natriuretic-peptide levels and urinary sodium-excretion after intravenous saline infusion in normal man. Clinical Science 73, 285–289.CrossRefGoogle ScholarPubMed
Starker, PM, Lasala, PA, Askanazi, J, Gump, FE, Forse, RA & Kinney, JM (1983) The response to TPN. A form of nutritional assessment. Annals of Surgery 198, 720–724.CrossRefGoogle ScholarPubMed
Starling, EH (1896) On the absorption of fluids from connective tissue spaces. Journal of Physiology, London 19, 312–326.CrossRefGoogle ScholarPubMed
Sterns, RH & Silver, SM (2003) Salt and water: read the package insert. Quarterly Journal of Medicine 96, 549–552.CrossRefGoogle ScholarPubMed
Stone, HH & Fulenwider, JT (1977) Renal decapsulation in the prevention of post ischemia oliguria. Annals of Surgery 186, 343–355.CrossRefGoogle ScholarPubMed
Stoneham, MD & Hill, EL (1997) Variability in post-operative fluid and electrolyte prescription. British Journal of Clinical Practice 51, 82–84.Google ScholarPubMed
Svensen, C & Hahn, RG (1997) Volume kinetics of Ringer solution, dextran 70, and hypertonic saline in male volunteers. Anesthesiology 87, 204–212.CrossRefGoogle ScholarPubMed
Tindall, SF & Clark, RG (1981) The influence of high and low sodium intakes on post-operative antidiuresis. British Journal of Surgery 68, 639–644.CrossRefGoogle ScholarPubMed
Tournadre, JP, Allaouchiche, B, Malbert, CH & Chassard, D (2000) Metabolic acidosis and respiratory acidosis impair gastro-pyloric motility in anesthetized pigs. Anesthesia and Analgesia 90, 74–79.CrossRefGoogle ScholarPubMed
Trout, HM (1913) Proctoclysis – an experimental study. Surgery Gynecology and Obstetrics 16, 560–562.Google Scholar
Veech, RL (1986) The toxic impact of parenteral solutions on the metabolism of cells: a hypothesis for physiological parenteral therapy. American Journal of Clinical Nutrition 44, 519–551.CrossRefGoogle Scholar
Venn, R, Steele, A, Richardson, P, Poloniecki, J, Grounds, M & Newman, P (2002) Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. British Journal of Anaesthesia 88, 65–71.CrossRefGoogle ScholarPubMed
Wakim, KG (1970) Normal 0·9 per cent salt solution is neither 'normal' nor physiological. Journal of the American Medical Association 214, 1710.CrossRefGoogle ScholarPubMed
Wilkes, NJ, Woolf, R, Mutch, M, Mallett, SV, Peachey, T, Stephens, R & Mythen, MG (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. Anesthesia and Analgesia 93, 811–816.CrossRefGoogle ScholarPubMed
Wilkinson, AW, Billing, BH, Nagy, G & Stewart, CP (1949) Excretion of chloride and sodium after surgical operations. Lancet i, 640–644.CrossRefGoogle Scholar
Wilkinson, AW, Billing, BH, Nagy, G & Stewart, CP (1950) Excretion of potassium after partial gastrectomy. Lancet ii, 135–137.CrossRefGoogle Scholar
Williams, EL, Hildebrand, KL McCormick, SA & Bedel, MJ (1999) The effect of intravenous lactated Ringer's solution versus 0·9% sodium chloride solution on serum osmolality in human volunteers. Anesthesia and Analgesia 88, 999–1003.Google ScholarPubMed
Winick, M (1979) Hunger Disease: Studies by the Jewish Physicians in the Warsaw Ghetto. New York: Wiley.Google Scholar
Woods, MS & Kelley, H (1993) Oncotic pressure, albumin and ileus: the effect of albumin replacement on postoperative ileus. American Surgeon 59, 758–763.Google ScholarPubMed