ACANTO ANA PETH SUSEN D.

•Volume resuscitation
PHARMACOLOGY •Vehicle for i/v drugs
Intravenous Fluid •KVOKVO

TOTAL BODY WATER Types

•Approx. 60% Body weight • Crystalloids
● Varies with age, gender and body habitus • Colloids
•50% BW in females
•80% BW in infants Crystalloids
● Less in obese : fat contain little water •Clear fluids made up of water and electrolyte
solutions; Will cross a semipermeable membrane
Body Water Compartments •Grouped as isotonic, hypertonic, and hypotonic
•Intracellular volume : 2/3 of TBW •Extracellular •Eg:
volume : 1/3 of TBW ● Normal saline 0.9%,3 %
- Intravascular : Plasma volume (1/4) ● Dextrose solutions 5 %,10%,20%,25%
- Extravascular: Interstitial fluid & others(3/4) ● DNS
● Ringer’s lactate
Preoperative Evaluation of Fluid Status ● Isolyte P
- Mental status
- H/O intake and output Crystalloids
- Blood pressure: supine and standing •0.9% Normal Saline
- Heart rate •Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l •Osm
- Skin turgor - Urinary output : 308mosm/l, pH 6.0
- CVP •IsoOsmolar compared to normal plasma.
•Indication :
Orthostatic Hypotension ● Intravascular resuscitation and
• Systolic blood pressure decrease of greater than replacement of salt loss e.g. diarrhoea and
20mmHg from supine to standing vomiting.
• Indicates fluid deficit of 6-8% body weight ● Also for diluting packed RBCs prior to
- Heart rate should increase as a compensatory transfusion
measure ● Used for diluting Drugs
- If no increase in heart rate, may indicate •Distribution:
autonomic dysfunction or antihypertensive drug Stays almost entirely in the extracellular space. Of
therapy 1 litre - 750ml extravascular fluid; 250ml
intravascular fluid.
Osmoles :unit for conc. Of osmotically active •Complications: When given in large volume can
particles produce Hyperchloremic metabolic acidosis
Osmolality: osmotic active solute per volume of because of high Na+ and Cl- content.
solution ( mOsm/L)
Osmolarity : mOsm/Kg Plasma osmolarity : 290 3.0 % Saline = HYPERtonic saline
mOsm/kg •3% contain 513 mmol/l of Na+ and Cl- each,
Tonicity ( relative osmotic activity ) •osmol of 1026 mOsm/l; pH 5.0
Isotonic/ hypotonic/hypertonic

Intravenous Fluids Therapy •Indications :

Intravenous fluid therapy may consist of infusions
of crystalloids, colloids, or a combination of both.
INDICATIONS:
•Volume resuscitation
•Treatment of severe symptomatic hyponatremia
(coma, seizure) To resuscitate hypovolemic shock
•Must be administered slowly and preferably with
CV line because it carries risk of causing phlebitis,
necrosis, hemolysis.
•Complications : ● Maintenance solution
● Precaution in pt. with CHF ● Correction of fluid deficit with supply of
● severe renal insufficiency, edema with sod. energy
retention. ● Compatible with blood

Dextrose IsoLyte -P
•5% Dextrose (often written D5W) •Multiple electrolyte & dextrose solution
• 50g/l of glucose, 252mOsm/l, pH 4.5 •Regarded ● Na+ : 26
as ‘electrolyte free’ – contains NO Sodium, ● K+ : 20
Potassium, Chloride or Calcium ● Mg++ : 03
•Indication : ● Cl- : 21
● To maintain water balance in patients who ● Acetate : 23
are not able to take anything by mouth; ● Ph+ : 03
● Used post-operatively in conjunction with ● Isotonic
salt retaining fluids ie saline •Indication :Pediatric maintenance fluid
● Hypernatremia treatment
•Less than 10% stays in the intravascular space Colloids
therefore it is of limited use in fluid resuscitation. •Particles which do not readily cross semi-
• Side effects: permeable membranes
● Iatrogenic hyponatremia in surgical patient •Stays (initially) almost entirely within the
● Hyperglycemia intravascular space .
● Not compatible with blood ,cause •Stay intravascular for a prolonged period
hemolysis conc 5% 10% 20% 25% plasma compared to crystalloids.
Osmolarity 252 505 1010 1262 290 •However they leak out of the intravascular space
when the capillary permeability significantly
Ringer Lactate changes e.g. Severe trauma or sepsis.
•Most physiological solution •Because of their gelatinous properties they cause
•Electrolyte composition similar to ECF platelet dysfunction and interfere with fibrinolysis
•One liter of lactated Ringer's solution contains: and coagulation factors (factor VIII) – thus they
● Sodium ion= 130 mmol/L. can cause significant coagulopathy in large
● Chloride ion = 109 mmol/L. volumes.
● Lactate = 28 mmol/L. •Natural : Albumin
● Potassium ion = 4 mmol/L. •Artificial : Gelatin and Dextran , HES
● Calcium ion = 1.5 mmol/L
● Osmolarity of 273 , pH of 6.5 1 ALBUMIN
•Lactate is converted to bicarbonate in liver •Principal natural colloid comprising 50-60% of all
•Indications : plasma proteins.
● Deficit ,Intraoperative fluid loss •Synthesized only in the liver and has a half life of
● Severe hypovolemia the app. 20 days.
Precautions: •5% soln is iso oncotic and leads to 80% initial vol
● Severe metabolic acidosis ( impaired expansion 25% soln leads to 200-400% increase in
lactate conversion) vol.
● Don’t give with blood product ( Ca bind •Used
with citrate reduced anticoagulant activity ● For emergency treatment of shock
) especially due to loss of plasma
DNS ○ acute management of burns
•0.9% saline & 5% dextrose ● Fluid resuscitation in ICU
•Na+ 154, Cl- 154, 5 gm. Glucose ● Hypoalbuminemia.
•Osm : 432 mosm/L •Side effects :
•Indication :
 ● pruritus, anaphylactoid reactions and
coagulation abnormalities as compared to
synthetic colloids.
•Disadvantages
● cost effectiveness
● volume overload (in septic shock pt
albumin add to interstitial edema)
DEXTRAN
•Highly branched polysaccharide molecules
•Produced by synthesis using the bacterial enzyme
dextran sucrase from the bacterium Leuconostoc
mesenteroids.
•Most widely used are 6%(dextran 70) and 10%
(dextran 40) soln.
•Excreted via kidney primarily.
•Used mainly to improve microcirculatory flow in
microsurgical re-implantation .
•Also used in extracorporeal circulation during
cardiopulmonary bypass.
•Side effects: Anaphylactic reactions, Coagulation
abn, Interference with cross match, Ppt of ARF
GELATINS
•Large mol. wt. proteins formed from hydrolysis of
collagen.
•Produced by thermal degradation of cattle- bone
gelatin.
•Gelatins lead to 70-80% of vol expansion
•Indication : Rapid expansion of intravascular
volume and correction of hypotension •Advantage
: cost effectiveness and no effect of renal
impairment ,does not affect coagulation
•Disadvantage : Hypersensitivity Anaphylactoid
reactions
HYDROXYETHYL STARCHES
•Derivatives of amylopectin, which is a highly
branched compound of starch.
•6% HES soln are iso oncotic
•10% soln are hyper oncotic , with a vol effect
exceeding the infused vol .(about 145%) •Duration
of vol expansion is usually 8-12 H.
•Advantage
● Cost effective: cheaper and comparable
vol of expansion to albumin
•Disadvantage: assoc. with 1st & 2nd generation
HES
- Coagulation abn
- Accumulation
- Anaphylactoid reactions
- Renal impairment
- Increase in amylase level
Colloid or Crystalloid Resuscitation
•Recommendations:
•Colloid should NOT be used as the sole fluid
replacement in resuscitation ,volumes infused
should be limited because of side effects and lack
of evidence for their continued use in the acutely
ill.
•Colloid may be used in limited volume to reduce
volume of fluids required or until blood products
are available
•In elective surgical patients
● Replace fluid loss with ‘physiological
Ringer’s solutions.
● Blood products and colloids may be
needed to replace intravascular volume
acutely.
Peri- operative Fluid Requirements
• The following factors must be taken into account:
•CVE
• Maintenance fluid
• Deficit
• Third space los
ses
• Replacement of loss
COMPENSATORY INTRAVASCULAR VOLUME
EXPANSION
•Fluid must be adm. to expand the blood vol to
compensate for venodilation (GA,RA) •Expansion
with 5-7ml/kg of crystalloid must occur before or
simultaneous with the onset of anesthesia .
Maintenance Fluid Requirements
• “4-2-1 Rule”
- 4 ml/kg/hr for the first 10 kg of body weight
- 2 ml/kg/hr for the second 10 kg body weight - 1
ml/kg/hr subsequent kg body weight
•Eg : 70 Kg pt Maintenance fluid : 40+20+50= 110
ml/hr
Deficit
• Deficit = number of hours NPO x maintenance
fluid requirement.
• Measurable fluid losses, e.g. NG suctioning,
vomiting, stoma output.
•70 kg pt fasting for 8 hrs
•Deficit : 8 X 110 = 880 ml
 ● Half in first hr
● One fourth each in next two hr
Third Space Losses
• Isotonic transfer of ECF from functional body
fluid compartments to non-functional
compartments.
• Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient
temperature, room ventilation.
•Replacing Third Space Losses
-Minimal Surgical Trauma: 0-2 ml/kg/hr - e.g.
herniorrhaphy
-Moderate Surgical Trauma: 2-4 ml/kg/hr - e.g.
cholecystectomy
-Severe surgical trauma: 4-6 ml/kg/hr (or even
more)
- e.g. major bowel resection
Blood Loss
• Replace 4 cc of crystalloid solution per cc of
blood loss (crystalloid solutions leave the
intravascular space)
• When using blood products or colloids replace
blood loss volume per volume. 40.
•Fluid management, starting with a hemoglobin
level of 15 g/dL, for a 70-kg patient undergoing
gastrectomy who has been fasting for 8 hours.
•Maintenance rate is 110 mL/hr,
•Deficit of 880 mL
•First hr = CVE+ Half of deficit + maintenance +
loss+ third space loss 350+440+110+50 + 420
•Second hr = one fourth of deficit + maintenance +
loss+ third space loss 220+ 110+ 250 + 420
•Third hr = one fourth of deficit + maintenance +
loss+ third space loss 220+ 110+ 250 + 420
•Fourth hr = Maintenance + loss+ third space loss
110+ 50 + 420
Patients are prescribed IV bags for any number of
reasons. To most patients, one IV bag can look
pretty much the same as the next. Your bag of
saline may have a different chemical composition
than the person next to you, even if they look the
same. It isn’t just a matter of the Myers' cocktail
versus other combinations of vitamins and
add-ins. The fluid itself may be a different solution.
Health complications, symptoms, and other
factors will influence what IV fluid a doctor
recommends for you.
Want to know what’s in your IV fluid? Here are the
different types of IV fluids you may get and what
each solution can be used for.
What Fluids Are in an IV Bag? An IV bag might look
like a bag of water, but there’s typically a lot more
than just H20 found in them.
The exact content of the IV bag will vary some
based on the needs of the recipient, but it always
contains a saline solution of some kind as a carrier
for fluids and electrolytes. If you’re getting IV
therapy, your fluid bag may also contain vitamins
and minerals to give you an extra boost.
The 4 main types of IV fluids include:
1.Normal Saline
2.Half Normal Saline
3.Lactated
4.RingersDextrose
What The Fluids Do To Your Cells Before we delve
into types of IV fluids, we first need to cover a few
basic definitions that will help you to better
understand what the bag of fluid is doing to your
cells.
Osmosis
Osmosis is an important mass transport process
in biology. It’s the process by which solvent
molecules move through a semipermeable
membrane from a dilute solution to a concentrated
solution. This serves to equalize the concentration
of solutes on both sides of the membrane.
In plain English, that means that molecules move
in or out of a membrane. When they do this, they
either create a more concentrated solution or a
more diluted solution, depending on the
circumstance.
This is best explained by water, the most common
culprit in osmosis. Water likes to balance itself out
(i.e. rush to places where there isn’t water). So if a
cell was low on water, water molecules would rush
into the cell, regulated by the cell membrane. If the
inside of the cell had more water molecules than
the outside of the cell, the water molecules would
rush out.
Osmotic Pressure
Osmosis is regulated by osmotic pressure, which
is the pressure necessary to prevent the inward
flow of water across a membrane. This is what
protects a cell from taking in more water than it
can handle, which would cause the cell to burst.
Simply put, it’s the pressure necessary to stop
osmosis from occurring. The Basics of IV Fluids
Osmosis and osmotic pressure are essential
players when it comes to IV fluids and your cells.
IV fluids are specifically designed to create a
certain reaction in your cells based on osmosis,
depending on what you’re trying to achieve.
Whether something flows into or out of your cells
has a significant impact on how your body
responds to it. So when we talk about IV fluids and
IV solutions, what we’re discussing is how these
solutions affect osmosis and osmotic pressure in
your cells.
IV fluids are either crystalloids or colloids. A
crystalloid or colloid solution can also be isotonic,
hypotonic, or hypertonic, and that directly affects
what that solution is used for.
Crystalloids
Crystalloid solutions contain small molecules that
easily flit across semi-permeable membranes.
Think of your cell membrane like a strainer.
Crystalloid solutions (or rather, the particles in
crystalloid solutions) are small enough that they
can get through the holes in the cell membrane.
This means that crystalloid solutions are good at
traveling into your cells and making the contents
of the solution available for use. Because of this,
crystalloids are used when healthcare
professionals want to increase fluid volume and
intravascular space, as in the case of hypovolemia
(loss of plasma) caused by burns, trauma, or
post-operative recovery.
Colloids
Colloid solutions, unlike crystalloid solutions,
contain larger molecules. Because of this, they do
not cross semi-permeable membranes as readily
as crystalloid solutions.
In healthcare terms, this means that colloid
solutions, unlike crystalloid solutions, remain
intravascular. In other words, they remain in your
bloodstream rather than entering your cells. This
also means that they stay in your blood longer
than crystalloid solutions. For this reason, they’re
used as plasma expanders as a form of fluid
resuscitation in cases of severe hypovolemic
shock. Isotonic, Hypotonic, and Hypertonic -
What's The Difference Crystalloid and colloid
solutions can be isotonic, hypotonic, or hypertonic.
Isotonic solutions have solute concentrations that
are different from those of your cells. This means
that there is no concentration gradient across the
cell membrane, which means that your cells
neither expand nor shrink in the presence of an
isotonic solution.
Hypotonic solutions have solute concentrations
lower than those of your cells. This means that to
balance the solute concentration, water will rush
into the cell, causing it to expand.
Hypertonic solutions have higher solute
concentrations than those of your cells. In order to
balance the solution, water will flow out of the cell,
causing it to shrink.
A professional will make a choice between
isotonic, hypotonic, and hypertonic solutions
based on which way they want osmosis to work.
For example, since isotonic solutions maintain
osmotic pressure on the inside and outside of the
cell, they’re often used to treat vomiting, diarrhea,
shock, and metabolic acidosis, among other
conditions.
On the other hand, because hypotonic solutions
create cell swelling, patients who receive these
solutions have to be monitored for hypovolemia
and hypertension. These solutions should not be
administered to patients with increased
intracranial pressure as they may exacerbate the
effects of cerebral edema (a.k.a. brain swelling).
Hypertonic solutions draw fluids out of the cells,
which means that patients must be monitored
carefully. Any IV solution comes with its own
associated risk, but hypertonic solutions are
especially risky because they can result in
intravascular fluid overload and pulmonary edema
(excess fluid in the lungs). For this reason,
hypertonic solutions cannot be used for extended
periods.
The 4 Main Types of IV Fluids
All of these solutions can be classified as
crystalloid or colloid and as isotonic, hypotonic, or
hypertonic, which has a direct impact on how the
fluids can be used. Crystalloid solutions remain by
far the most common, largely due to the
overwhelming presence of normal saline in most
hospital and healthcare settings.
1. Normal Saline
The best-known name is normal saline, sometimes
called 9% normal saline, NS, or 0.9NaCL.

Normal saline is a sterile, nonpyrogenic solution.
It’s a crystalloid fluid (easily passes through the
cell membrane) and is generally isotonic.
It’s the most widely used fluid because it’s the
most effective fluid for the widest variety of
conditions. It’s the fluid of choice for fluid
resuscitation and works well for most hydration
needs due to hemorrhage, vomiting, diarrhea, or
even shock.
It’s most often used to increase the volume of
circulating plasma (assuming that the patient has
sufficient red blood cells). It can be used for things
like:
● Blood transfusion
● Fluid replacement for patients suffering
from diabetic ketoacidosis
● Metabolic alkalosis
● Hypercalcemia
● Hyponatremia
Normal saline is also the only fluid that can be
used in conjunction with blood administration.
That said, it has to be used with caution in patients
who have cardiac or renal complications, as the
high sodium content can cause excess fluid
retention, which in turn puts additional stress on
the already-weakened heart and kidneys.
2. Half Normal Saline
Half normal saline is also a widespread fluid. It’s
sometimes called 45% normal saline or 0.45NaCl.
It’s a hypotonic, crystalloid solution of sodium
chloride dissolved in sterile water (as opposed to
normal saline, which is an isotonic solution). The
difference is that half normal saline contains half
the chloride concentration of normal saline.
It’s designed to treat patients suffering from
cellular dehydration and can be used for things
like:
● Raising your overall fluid volume
● Water replacement
● Sodium chloride depletion
● Gastric fluid loss
● DKA after normal saline and before
dextrose infusions
It’s especially helpful for patients such as those
who are diabetic who cannot handle additional
glucose. It is always avoided in patients who have
burns, liver disease, or trauma, as the solution
depletes intravascular fluids in a way that can be
dangerous for patients whose intravascular fluid
levels are already low. Like normal saline, the
solution can pose a risk for those with
cardiovascular disease or increased intracranial
pressure. Half normal saline is less useful in
replenishing sodium chloride deficit than normal
saline, as it has half the concentration of sodium
chloride. That said, it does still have uses in
maintaining daily fluid levels, much like normal
saline.
3. Lactated Ringers
Lactated Ringer’s is another highly common IV
fluid used in fluid resuscitation. It’s been offered up
in many circles as an alternative to normal saline.
Either way, if you’ve been injured and received
surgery, there’s a decent chance you’ve received an
injection of lactated ringers.
Lactated Ringer's are named after the physician
who invented them. Sydney Ringer, a physician in
the late 1800s, came up with a solution containing
sodium, chloride, calcium, and potassium. The
“lactated” part of Lactated Ringers comes from
Alexis Hartmann, who figured out that adding
lactate to the solution made it more suitable for
use in pediatric patients.
Lactate is a chemical that’s most commonly
encountered in milk, though our muscles also
produce it when we exercise.
It’s normal saline with the addition of electrolytes
and a buffer (lactate), which helps explain why the
solution is also isotonic.
It’s the solution that’s most similar to the body’s
natural plasma and serum concentration (but
unlike serum, it doesn’t contain magnesium). It’s
used to treat:
● Dehydration
● Burn victims
● Hypovolemia resulting from third-space
fluid shifts
● Fluid loss in the lower gastrointestinal
tract
● Acute blood loss
● Replacement of fluid and pH buffers
Because Lactated Ringer’s contain potassium, it
cannot be used in patients with renal failure or
renal complications as it can result in
hyperkalemia. It also should not be used in
patients with liver disease, as they cannot
successfully metabolize the lactate. It also should
not be administered if patients have a pH level
greater than 75.
4. Dextrose
Finally, there are many variations on dextrose.
Dextrose itself is a type of simple sugar made
from corn. It’s chemically identical to glucose,
which you should recognize as your old pal sugar.
It’s often used in processed foods and added to
baking products as a sweetener, but it has several
uses in a medical setting.
It’s useful specifically because it’s a simple
sugar--that is, your body can quickly make use of it
for energy.
There are three main versions of dextrose
solutions:
Dextrose in waterDextrose in salineDextrose in
Lactated Ringer’s
Regardless of the type of dextrose solution, the
basic principle is the same. The IV fluid acts as a
carrier for dextrose, which acts as sugar readily
available for cells to gobble up and use as energy.
Dextrose in Water
One of the more common iterations of dextrose is
a solution of dextrose in water.
Dextrose in water is a crystalloid solution. In the
bag, it’s isotonic, but the solution itself is
physiologically hypotonic. That’s a fancy way of
saying that it enters your body as an isotonic
solution (that is when there’s still sugar in the
solution), but when the sugar is absorbed by your
cells, you’re left with a hypotonic solution.
Unlike other fluids we’ve listed thus far, dextrose in
water is not used in fluid resuscitation, as it can
cause hyperglycemia. Instead, it is used to:
● Raise your total fluid volume
● Rehydration
● Hypernatremia (an electrolyte problem
caused by a decrease in total body water
relative to electrolyte content)
Dextrose in water is often used to treat diabetic
patients who are not eating anything by mouth for
various reasons. That said, although the solution
contains about 170 calories per liter, it is not
sufficient to replace normal daily calories and
should not be used for long-term food
replacement.

Interestingly, it’s sometimes used as a diluent for
preparing injectable medications for an IV bag (a
lot of fluid in which to dilute a small dose of
medicine). This is likely because dextrose is
absorbed so readily. It should always be avoided in
patients with cardiac problems, renal failure, and
increased intracranial pressure (much like the
other fluids on this list) as it can cause fluid
overload.
Dextrose in Saline
Another common alternative is dextrose in saline,
which is pretty much exactly what it sounds like.
It’s a sterile, nonpyrogenic solution. As the name
implies, it's a solution of 5% dextrose in normal
saline. Like normal saline, it’s isotonic at first, but it
becomes hypertonic when the dextrose is
absorbed (remember earlier when we said that
hypertonic solutions are particularly risky to work
with?)
electrolyte replenishment. Like other dextrose
solutions, it’s isotonic until the dextrose is
absorbed. This particular solution becomes
hypotonic after the dextrose is metabolized.
It serves much the same purpose as Lactated
Ringer’s, with the addition of 180 calories per liter,
though it can be used as an alkalinizing agent.
Because it’s Lactated Ringer’s with dextrose, it has
many of the same contraindications as Lactated
Ringer’s. It isn’t advisable in patients with renal
issues due to hyperkalemia concerns, nor should it
be used in patients with liver failure (again, they
cannot metabolize the lactate).
Dr ordered to infuse 1L of D5LR for 6 hours
cc/hr cc/hr= Total volume of solutions in cc or ml/
total number of hour to tun
1000ml or cc / 6 = 166.67 cc/hr

Because dextrose in saline is such a specialized gtts/min

fluid, it’s used for extremely specific cases, gtts/min = cc/hr x drop factor / 60 minutes/hr
including:
166.67 x 20 = 3333.4
3333.4/60 = 55.55 55 to 5g gtts/min

● Temporary treatment of circulatory

Doctor's ordered 1L of LR solution to run for 12
insufficiency, but only if other plasma
hours. Compute for the cc/hr and gtts/min.
expanders are unavailable
● Hypotonic dehydration
27.28 or 28 gtts/min
● Addisonian crisis (a potentially
life-threatening condition resulting from
acute insufficiency of adrenal hormones)
● Syndrome of inappropriate antidiuretic
hormone/SIADH (when the brain makes
too much antidiuretic hormone)

Like many other fluids on this list, dextrose in

saline should not be used in patients with renal or
cardiac complications, as it can cause heart failure
or pulmonary edema.

Dextrose in Lactated Ringers

Finally, dextrose in Lactated Ringer’s is...well,
exactly what the name implies.

It’s a solution of 5% dextrose in Lactated Ringer’s,

a sterile, nonpyrogenic solution used for fluid and