Do Intensivists Need to Care About the Revised Starling Principle?

  • R. G. HahnEmail author
Part of the Annual Update in Intensive Care and Emergency Medicine book series (AUICEM)


The revised Starling and glycocalyx principles of transvascular fluid exchange are widely advocated as new paradigms for prescribing intravenous fluid therapy. Clinicians are concerned about whether their current standard approaches for fluid administration require revision due to the new considerations, although several of them can be questioned based on observations in humans. Glycocalyx degradation has been difficult to demonstrate in hypervolemic and normovolemic surgical patients, suggesting that a more severe physiological insult than previously believed is needed to cause acute glycocalyx injury. Three- to fourfold elevations in the plasma concentrations of syndecan-1 and heparan sulfate may even be explained by changes in kidney function. Impaired intravascular persistence of infusion fluids due to glycocalyx degradation has not yet been demonstrated in humans. The so-called non-absorption rule, which holds that hyperoncotic fluid cannot be used to recruit fluid from the interstitium, is poorly supported by studies involving 20% albumin, 7.5% saline, 7.5% saline in 6% dextran 70, and cardiopulmonary bypass. The traditional Starling principle fits studies of hypovolemia much better than the revised Starling principle does, except when there is arterial hypotension.


Microcirculation Starling principle Glycocalyx Fluid therapy Colloid fluid 


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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Research UnitSödertälje HospitalSödertäljeSweden
  2. 2.Karolinska Institutet at Danderyds Hospital (KIDS)StockholmSweden

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