I have just read Dr Soni's critique of the recent GIFTASUP guidelines. It contains many interesting and relevant observations, the most pertinent relating to the 'guidelines vs current opinion' discussion and the potentially misleading use of evidence scoring. I do feel that he has somehow failed to see the point.

Fluid prescription is ubiquitous in our hospitals and in the majority of cases, is extremely poorly done. The  reasons for this are well rehearsed but include confusion over available products, lack of education, lack of seniority and lack of sufficient trials. What we do not lack is evidence of harm to patients from CEPOD downwards. Hartmann himself detailed the dangers of saline loading in 1932. The harm due to the acidosis produced by hyperchloraemia is debateable but evolution (level 3?) or the Good Lord (level 5) designed us to work with a plasma sodium concentration of 135 mmol.l and a chloride of 95 mmol/l. To deliberately use a solution that moves a patient away from normality seems illogical. Even if we don't have level 1a studies, common sense must come into it somewhere.

What studies we do have are variable in quality. The SAFE study is much praised, chiefly for being an example of how to conduct a high quality, multi-centre RCT. Even this, however, only told us two things. First, that the famous albumin meta-analysis was bogus (we knew this already) and second, that albumin was just as dangerous as saline. Other studies of comparable size and quality for fluids we do actually use are currently lacking.

The benefits of GIFTASUP are to raise awareness of the issues surrounding fluid prescription, and to provide a baseline of expert opinion to at least help guide the confused traijnees what may or may not be a sensible thing to write on the chart. I would tentatively compare the document to the ATLS course in that it is by no means universally accepted or indeed the only way of treating trauma patients but it is a logical start from which the educated can deviate. It certainly cannot fail to improve on the existing situation of overwhelming ignorance.