FLUID AND ELECTROLYTE

THERAPY
DR. AZMAH BT. SA’AT
 Learning Objective

• Understand the physiology of the fluid and electrolyte

balance in the body.

• Discuss the different types of fluid and electrolyte

abnormalities.

• Able to understand and discuss the objectives of fluid

therapy.

• List the different types of solution used in fluid replacement

therapy and its indications.
 Physiology
• VOLUME: IVF (blood) = 5 Litres
• DISTRIBUTION: 2/3 of total body water = intracellular fluid (ICF)
• COMPOSITION: Electrolytes: Na+ , K+, Ca2+, HCO3-, Cl- & Proteins
• FUNCTION:
• Fluid: medium for Electrolytes & chemicals, for biochemical reactions,
maintain volume of body’s fluid compartments
• Electrolytes: Osmotic pressure (Na+, Proteins)
• Acid-Base balance (HCO3-, Cl-)
• Membrane potential (Na+, K+, Ca2+); for activity of
excitable tissues i.e. nerve, muscles, glands
Note: At birth, the kidneys are inefficient; these infant kidneys do not
concentrate urine or conserve water efficiently, putting infants at risk for
dehydration. Vomiting, diarrhoea, and a high rate of insensible water loss
also increase the risk for dehydration.
Insensible loss
- evaporation from the lungs and
skin.
- Warm environment , fever-
increase in sweat release.
- Generally calculated as 500ml per
day
Fluid and electrolyte abnormalities

• Changes in fluid volume; volume contraction

• Changes in osmolality

• Changes in acid-base balance

• Decreased plasma concentration of particular

electrolytes (Na+, K+, Ca2+)
 Function of fluid and electrolyte therapy
Resuscitation Replacement
Maintenance
• Goal: To replete • Goal: Replaces
• Goal: Delivery of intravascular volume the fluid and
ongoing fluid and electrolyte loses
electrolyte requirements. • Definition: Rapid
administration of large • Definition:
• Undertaken when the Provide
individual is not
volumes of fluid to
replace fluid lost from maintenance
expected to eat or drink requirements and
normally for a long intravascular space
and prevents further add replacements
period of time (i.e for fluid and
patients on ventilator). decompensation due to
low circulating electrolyte loses
• fluid only – patient does volume. • Mainly for
not have excess losses
above insensible loss. • Acute treatment of patients with non-
relative or absolute urgency loses
• approximately from intravascular
fluid deficit.
30ml/kg/24hrs. or other fluid
• Prescribing more than
• Correction of existing compartments.
2.5 litres a day increases abnormalities in
volume status or • Patients with burn,
the risk of hyponatremia. GI and urinary
serum electrolytes.
loses.
Goal of Fluid Therapy
• As replacement therapy (loss or insufficient intake)
• For correction of – volume contractions
• - changes in osmolality, hence fluid shift
• - changes in acid-base balance
• Restoration to normal plasma concentration of particular electrolytes, unless
or before the underlying cause is cured.
• Adequate urine output (0.5-1 ml/kg/hr).

Choice of appropriate fluid: need to find out

• Volume loss, or intake deficiency
• Possible type of loss: possible fluid shifts (Na>water, water>Na, Na=water)
• Acid-base balance: present or not
• Patient’s general condition: possibility of oral administration (severity,
consciousness, vomiting)
• Volume contractions:
Due to (1) Loss (2) insufficient intake

• Fluid Loss:-
(1) to outside with no change in osmolality
*IVF loss (hemorrhage, burns)
* GI fluid loss (vomiting, diarrhoea)
(2) fluid shift across compartment due to “change in osmolality”
(a) Hypotonic fluid loss (H2O loss> Na+ loss)
(b) Hypertonic fluid loss (Na+ loss >H2O loss)
• water moves freely across cell membranes, fluid compartments; from lower osmolality to
higher osmolality fluid shift
• Osmolality is maintained:- in ICF by K+, proteins
in ECF – IVF by Na+, proteins
- Interstitial Fluid (ISF) by Na+
• Insufficient intake: coma, unconsciousness, psychiatric
• Note: in practice, IVF is the 1st compartment to be affected compensation from ISF,
then ICF cell dehydration
Differences between ICF, ISF and ECF
 ORAL REHYDRATION SALTS (ORS)
• ORS salts dissolve in isotonic proportion, chemical composition similar to body
fluid***.
• ORS (WHO formula) contains, in 1 Litre of solutions, in Grams:
• NaCl=3.5, NaHCO3=2.5, KCL=1.5, Glucose=20

Other features:-
• Contains alkalinizing agent to counter acidosis.
• Slightly hypo-osmolar to prevent induction of osmotic diarrhoea.
• Addition of glucose enhance intestinal absorption of Na and water.

Use:- Diarrhoea: to replace fluid and electrolytes lost.

• Effective for less severe cases of gastroenteritis***.
• Drug of first choice in treatment of diarrhoea.
 Contraindications to oral replacement therapy

• Diarrhoea at very high rate (>10-15 mg/kg/h)

• Persistent vomiting
• Severe dehydration
• Inability or refusal to drink
• Glucose malabsorption
• Andominal distension and ileus
 Parenteral fluid therapy
• Parenteral fluid therapy usually involves the intravenous administration
of crystalloid solutions, colloidal solutions, and/or blood products.
• The choice of fluid, the amount of fluid to be infused, and the rate of infusion are
determined by the indication for fluid therapy.
• Fluid therapy with crystalloid solutions is used to resuscitate patients who
are hypovolemic, to correct free water deficits in the case of dehydrated patients,
to replace ongoing fluid losses, and to meet the fluid requirements of patients
who cannot take fluids orally.
• The use of colloidal solutions is now controversial. However, colloidal
solutions (such as albumin solution) may be indicated either as a monotherapy or
in combination with crystalloid solutions in severe cases of low oncotic pressure,
especially in children.
• In the case of severe bleeding, the use of blood products must be considered.
• All patients on fluid therapy should be closely monitored using a combination of
clinical parameters and laboratory tests to determine the end-point of fluid
therapy.
Available fluid preparations for treatment
A. Correction of volume contractions: (no change in osmolality)
1. For replacement of intravascular fluid loss
(a) blood transfusion (for blood loss “hemorrhage”)
(b) plasma, plasma expanders (Dextran, Albumin) (for burns).
2. Replacement for GI fluid loss (cholera, diarrhoea, vomiting)
(a) Normal saline (0.9% NaCl in 500 ml) (isotonic saline)
(b) Dextrose saline (5%Dextrose+0.9%NaCl in 500 ml)
(c) Ringer’s lactate solution
(d) Oral rehydration salt (ORS)
B. Correction of osmolality:
1. For replacement of hypotonic loss (H2O>Na)
5%, 10% Dextrose solution
2. For replacement of hypertonic loss (Na>H2O)
(a) Hypertonic saline (3%, 5% NaCl)
(b) 1/6 Molar Na-lactate
(c) NaHCO
 HYPOTONIC FLUID LOSS
• Due to loss 1.diabetes insipidus due to lack of antidiuretic hormone
polyuria, hypernatremia
2. severe sweating (hyperhidrosis)
• Due to inadequate intake unconscious patient, dysphagia, elderly)
• Glucose (Dextrose) 5% solution causes inward fluid shift into the body

Hypotonic fluid Hypertonic Blood attracts water Water from cell & interstitium (ECF)
loss blood from interstitium & into blood
H2O>Na+ Na+ cells
Outward fluid shift

Replacement Addition of Water from H2O (Blood/Plasma) into cells

with Na+free water into hypotonic blood is
Fluid e.g. 5% bld. attracted into cells Inward fluid shift
Dextrose (hypotonic)
 HYPERTONIC FLUID LOSS
• Causes:
(a) hypertonic fluid loss (mineralocorticoid deficiency/ Addison’s disease)
(b) Diuretic therapy
(c) Salt losing nephropathy (chronic renal failure)
(d) Inappropriate fluid therapy

• For mild cases – isotonic saline can be used

• For severe cases

– need large volume of 5% NaCl.
- use hypertonic saline 1/6 M Na lactate or NaHCO3 alternately to avoid
hyperchloremic acidosis of NaCl.
 Hypertonic fluid loss
Hypertonic Hypotonic Water from hypotonic Water moves into
Fluid Loss blood blood is attracted into cell
Na+ > H2O interstitium (ECF)& cells
Na+ (ICF) Inward fluid shift

Replacement Addition of Na Hypertonic blood attracts H2O from cells

with saline e.g. into blood water from cells (ICF) and moves into blood
5% NaCl (hypertonic) interstitium (ECF)
Outward fluid shift
 ISOTONIC SALINE/NORMAL SALINE (PHYSIOLOGICAL
SALINE)
-Contains 0.9% sodium chloride (NaCl) in water.
-Same sodium content and osmolality as plasma***.
-Remains in ECF (IVF & ISF), not readily enter into intracellular compartment***.

Use:- (Can be used as fluid resuscitation or fluid maintenance).

-severe gastroenteritis with impending or overt hypovolaemic shock (first 1-2 bottles rapid
if necessary).
-To open a drip line in emergency, for rapid drug administration.
-Any type of fluid loss, corrects both hypertonic and hypotonic fluid loss (safest fluid if
unsure)***.
-Temporarily measure before specific fluid is available (used as fluid resuscitation) e.g.
blood, plasma (check signs of volume overload and pulmonary oedema to prevent
excessive administration).

Limitations: with large volume, can cause hyperchloremic acidosis, change in acid-base
balance, avoid in pre-eclamptic patients, CHF, renal disease and liver cirrhosis. Oxidizes
noradrenaline to adenochrome (brown colour, non toxic).
Dextrose saline (sodium chloride and glucose)

• 1:1 mixture of 0.9% NaCl and 5% or 3% glucose (solutions with

lower concentrations of NaCl 0.45 or 0.18%)
• Addition of glucose provides greatly increase intestinal absorption of
electrolytes and water and also provides energy.
• A portion enters the cell, some retain in ECF – reaches all
compartment
• Use :- salt and water depletion (Replaces sodium, chloride and
calories)
• Limitation: same as normal saline solution
 ISOTONIC SOLUTION
• RINGER’S LACTATE:-
-Hartmann’s solution; Compound Sodium Lactate
-Contains in mEq/L, Na = 131, K = 5, Ca = 4, HCO3 as lactate=29, Cl=111.
-Similar in chemical composition to body fluid***.

Use:-
-Ringer's lactate solution is very often used for fluid resuscitation after a blood
loss due to trauma, surgery, or a burn injury.
-Acute salt and water depletion e.g. severe gastroenteritis.
-( alternative to normal saline, more physiological).
RL is not suitable for maintenance therapy (i.e., maintenance fluids) because the
sodium content (131 mEq/L) is considered too low, particularly for children, and the
potassium content (5 mEq/L) is too low, in view of electrolyte daily requirement.
Moreover, since the lactate is converted into bicarbonate, long term use will cause
patients to become alkalotic
 5% Dextrose
-Contains 5% glucose (Dextrose) in water
-Glucose is rapidly utilized, leaving water haemodilution
Inward water shift
Use:- Hypernatremia – hypotonic fluid loss (Diabetes insipidus), inadequate
fluid intake.
-Emergency management of hyperkalemia (together with Ca gluconate and
insulin).
-Management of diabetic ketoacidosis (with insulin, after correcting
hyperglycemia).
-Correct and prevent hypoglycemia and to provide a source of energy.
-Used in early postoperative period.
Limitation: Large volume hyponatremia osmolality of IVF
waterlogging of cells (water intoxication). Not used for fluid resuscitation and
in cases of increase intracranial pressure and renal failures or cardiac
problem.
Note: Solutions with higher concentrations of glucose are also available.
(10%, 20%, 50%) for other uses.
Isotonic solutions
Hypotonic solutions
Hypertonic solutions

Precautions:
• Should be administered in high acuity areas with constant surveillance.
• Potential to cause intravascular volume overloaded and pulmonary edema.
• Shouldn’t be given in indefinite period
Colloidal solutions
• A colloid is a high molecular weight substance that mostly remains confined to
the intravascular compartment and thus generates oncotic pressure
• Examples:
• Natural colloids: albumin, fresh frozen plasma (FFP)
• Artificial colloids: gelatins, dextrans, hydroxyethyl starch
• Effects
• Colloids have a greater effect on intravascular volume than crystalloids
• The fluid administered tends to remain in the intravascular compartment.
• Decreased blood coagulability
• Colloids such as dextran decrease platelet adhesiveness and serum factor VIII levels; this effect is used
therapeutically to improve blood flow during cardiopulmonary bypass and microvascular surgeries.
• Anti-inflammatory effect
• Colloids such as albumin and dextran have anti-inflammatory properties; this effect may be used
therapeutically in the treatment of sepsis resulting from spontaneous bacterial peritonitis.

• Administration: Their use is controversial, but they may be indicated in

combination with crystalloids
Plasma Expanders (Colloids)

-Preparations: Albumin (Mol. Wt. 69,000), Dextran150,110, 75, 70.

(Molecular Weight of Dextrans in thousands: Dextran150=150,000
Mol. Wt.)

-Dextran with larger mol.wt. than albumin are good plasma expanders.

Note: Dextran 40 does not act as plasma expander ***

Dextrans: branched polysaccharides, correct hypovolaemia by

retaining circulatory volume.

Other plasma expanders: Gelatin, Hexastarch, Pentastarch,

Hydrxyvethylstarch.
DEXTRAN 70 (High molecular weight Dextrans, >
70,000)
• Branched polysaccharides, slowly metabolized-duration 24 hr or longer
• Expand and maintain blood volume
Use:
- immediate short-term measure to treat haemorrhage until blood is
available
-immediate treatment of shock due to burns, septicaemia, but not for
maintenance.
Limitations
- not suitable for shock due to depletion of water & electrolytes
(Gastroenteritis).
• Not suitable for long-term used as plasma expander of ANY condition.
• Interfere with blood group cross-matching or biochemical measurements.
• Side effect: Hypersensitivity, anaphylaxis
 HUMAN ALBUMIN SOLUTION
• Contains soluble proteins: 4-5% (isotonic) or 15-20% (concentrated preparations). At
least 95% of proteins is albumin.
• Contains electrolytes, but no clotting factors, blood group antibodies, plasma
anticholinesterases.
• May be given without regard to recipient’s blood group.
Use :
• - loss of plasma volume (however not as an immediate fluid replacement) e.g. burns,
trauma, complications of surgery (isotonic albumin solution only).
• -severe hypoalbuminaemia associated with low plasma volume and generalised oedema
(concentrated albumin solution). (e.g.in nephrotic synd.)
• -to obtain a diuresis in hypoalbuminaemic patients (e.g. in liver cirrhosis).
Limitations:
• - history of cardiac or circulatory disease (administer slowly to avoid rapid rise in blood
pressure and heart failure).
• -not suitable for acute plasma or blood loss.
Side effect: Hypersensitivity reactions
 Electrolyte Therapy
Potassium: Compensation for K+ loss (hypokalemia) is especially
necessary in
-those taking digoxin and anti-arrhythmic drugs (because hypokalemia
induce arrhythmia)
-Hyperaldosteronism,
-excessive GI loss (chronic diarrhoea with malabsorption, laxative
abuse).
-Renal loss (Thiazides, Loop diuretics).

Note: Oral and parenteral potassium chloride preparations are

available. IV infusion of KCl + NaCl, KCl + glucose or KCl +NaCl+
glucose.
1/6 MOLAR SODIUM LACTATE (Sodium lactate)
(1/6 of molecular weight of Sodium Lactate salt)
Provides Na without Cl.
• Use: to supplement normal saline when large volume of fluid
required, to prevent hyperchloraemic acidosis.

Oral NaCl tablet

NaCl is the chemical name for salt.
• Use: severe hyponatremia or prevent sodium loss due to
dehydration or excessive sweating
• Contraindicated: hypertension, preeclampsia, liver disease
(especially cirrhosis), congestive heart failure, kidney disease.
SODIUM BICARBONATE (Soda bicarb)
• Contains 1.26% (normal strength) or 4.2%, 8.4%
(hypertonic NaHCO3).
• An alkali. It raises blood pH and plasma HCO3, also
causes inward chloride shift (into cells).
Uses:
• severe metabolic acidosis.
• Shock due to cardiac arrest which causes metabolic
acidosis without Na and water depletion.
Side effect: Sodium and volume overload, alkalosis
overshoot.
Calcium:
• only required deficient intake or increased dietary requirement.
• -increased requirement in pregnancy, old age (due to impaired
absorption), childhood and lactation, osteoporosis (to reduce rate
of bone loss)

(Oral Ca gluconate, Ca lactate, Ca carbonate tablets, syrup,

effervescent)

-Hypocalcaemic tetany (IV Ca gluconate followed by infusion)

-emergency management of hyperkalaemia

(IV Ca gluconate with insulin and glucose)
 Parameters for controlling parenteral (IV) fluid
therapy
• The indication for fluid therapy determines the amount of fluid
administered and the rate of fluid therapy (see “Goal of fluid therapy”
above).
• Hemodynamic measures: pulse, blood pressure, capillary
refill time, jugular venous pressure (or central venous pressure)
• Monitor for complications of IV fluid therapy, which include:
• Signs of fluid overload : pedal edema, fine crackles on pulmonary auscultation
• Electrolyte imbalances: monitor sodium, potassium, calcium level (renal function
test)
• Fluid balance charts: These charts should record the fluid intake (total
amount of fluid administered) and fluid output (urine output, output
from surgical drains, and, if applicable, the volume of loose stools or
vomit)
Which patient is at more risk for an electrolyte
imbalance?

A. An 8 month old with a fever of 102.3 'F and diarrhoea

B. A 55 year old diabetic with nausea and vomiting
C. A 5 year old with RSV
D. A healthy 87 year old with intermittent episodes of gout

Answer: A