INTRAVENOUS FLUIDS

TOTAL BODY WATER

Approx. 60% Body weight
 Varies with age, gender and body habitus

50% BW in females

80% BW in infants
 Less in obese : fat contain little water

Body Water Compartments

Intracellular volume : 2/3 of TBW

Extracellular volume : 1/3 of TBW

 Intravascular : Plasma volume (1/4)

 Extravascular: Interstitial fluid & others(3/4)

Preoperative Evaluation of Fluid Status

Mental status Heart rate

H/O intake and output Skin turgor

Blood pressure: Urinary output

supine and standing
CVP

Page-1
BASICS
 Osmoles :unit for conc. Of osmotically active particles

 Osmolality: osmotic active solute per volume of solution

GFFGFGF(mOsm/L)

 Osmolarity : mOsm/Kg

 Plasma osmolarity : 290 mOsm/kg

 Tonicity ( relative osmotic activity )

 |sotonic/ hypotonic/hypertonic

ISOTONIC HYPOTONIC HYPERTONIC

1.Osmolarity of
1.Osmolality of 1.Osmolarity of
375 mOsm/L or
250-375 mOsm/L >250 mOsm/L
higher

2.Shifting of fluid 2.Water moves out

2.No shifting of from intravascular of the intracellular
fluid to both space increasing
intracellular and ECF (volume
interstitial spaces expanders)

3.Hydrate the cells 3.Dehydrate the

3.Only serves to increase
causing them to cells causing
the ECF
swell. shrinkage.

Page-2
 Intravenous Fluids Therapy
Intravenous fluid therapy may consist of infusions of
crystalloids, colloids, or a combination of both.

Indications
 Volume resuscitation

 Vehicle for i/v drugs

 KVO

Types

Crystalloids
Colloids

Page-3
 Crystalloids
Clear fluids made up of water and electrolyte solutions;
Will cross a semi-permeable membrane

Grouped as isotonic, hypertonic, and hypotonic

Eg:

Normal saline 0.9%,3 %

Dextrose solutions 5 %,10%,20%,25%
DNS
Ringer’s lactate
Isolyte P

Normal saline 0.9%,3 %

0.9% Normal Saline

Contains: Na+ 154 mmol/l, Cl- 154 mmol/l

Osm : 308mosm/1, pH 6.0

IsoOsmolar compared to normal plasma.

Indication:

 Intravascular resuscitation and replacement of salt loss

e.g. diarrhoea and vomiting.

 Also for diluting packed RBCs prior to transfusion

 Used for diluting Drugs

Page-4
Distribution:

Stays almost entirely in the extracellular space. Of 1 litre -

750ml extra vascular fluid; 250ml intravascular fluid.

Complications:

When given in large volume can produces Hyperchloremic

metabolic acidosis because of high Na+ and Cl- content.

3.0 % Saline = HYPERtonic saline

3% contain 513 mmol/l of Na+ and Cl-each

osmol of 1026 mOsm/1; pH 5.0

Indications :

 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 :

 Precaution in pt. with CHF

 severe renal insufficiency, edema with sod. retention.

Page-5
 Dextrose solutions 5 %,10%,20%,25%
Dextrose
5% Dextrose (often written D5W)
50g/l of glucose, 252mOsm/I, pH 4.5

Regarded as ‘electrolyte free’ — contains NO Sodium,

Potassium, Chloride or Calcium

Indication:

 To maintain water balance in patients who are not able to

take anything by mouth

 Used post-operatively in conjunction with salt retaining

fluids ie saline

 Hypernatremia treatment

Less than 10% stays in the intravascular space therefore it

is of limited use in fluid resuscitation.

Side effects:

 Jatrogenic hyponatraemia in surgical patient

 Hyperglycemia

 Not compatible with blood ,cause hemolysis

Conc 5% 10% 20% 25% plasma

Osmolarity 252 505 1010 1262 290

Page-6
 Ringer Lactate
Most physiological solution

Electrolyte composition similar to ECF

One litre of lactated Ringer's solution contains:

 Sodium ion= 130 mmol/L.

 Chloride ion = 109 mmol/L.

 Lactate = 28 mmol/L.

 Potassium ion = 4 mmol/L.

 Calcium ion = 1.5 mmol/L

 Osmolarity of 273 , pH of 6.5

Lactate is converted to bicarbonate in liver

Indications :

 Deficit ,Intraoperative fluid loss

 Severe hypovolemia

Precautions:

 Severe metabolic acidosis ( impaired lactate conversion)

 Don’t give with blood product (Ca bind with citrate =>
reduced anticoagulant activity )

Page-7
 DNS
0.9% saline & 5% dextrose

Na+ 154, Cl- 154, 5 gm. Glucose

Osm : 432 mosm/L

Indication :

 Maintenance solution

 Correction of fluid deficit with supply of energy

 Compatible with blood

IsoLyte –P
Multiple electrolyte & dextrose solution

Na+ : 26
K+: 20
Mg++ : 03
Cl- : 21
Acetate : 23
Ph+ : 03
Isotonic

Indication :Pediatric maintenance fluid

Page-8
 ISOTONIC HYPOTONIC HYPERTONIC

0.9% Nacl 0.45% Nacl 3% Nacl

Lactated Ringer 0.33% Nacl 5% Nacl

Ringers’ 3%Nacl or 5%
0.2 % Nacl
Solution Nacl +D/W

5% Dextrose in 2.5% Dextrose >5% D/W

water water example,D10W

Colloids
Particles which do not readily cross semi- permeable
membranes.

Stays (initially) almost entirely within the intravascular

space.

Stay intravascular for a prolonged period compared to

crystalloids.

However they leak out of the intravascular space when the

capillary permeability significantly changes e.g. Severe
trauma or sepsis.

Page-9
Because of their gelatinous properties they cause platelet
dysfunction and interfere with fibrinolysis and coagulation
factors (factor VHI) — thus they can cause significant
coagulopathy in large volumes.

Natural : Albumin

Artificial : Gelatin and Dextran , HES

Natural

ALBUMIN
Principal natural colloid comprising of 50-60% of all
plasma proteins.

Synthesized only in liver and has a half life of app. 20 days.

5% soln is iso oncotic and leads to 80% initial vol expansion
25% soln leads to 200-400% increase in vol.

Used

 For emergency treatment of shock especially due to loss

of plasma

 acute management of burns

 Fluid resuscitation in ICU

 Hypoalbumineamia.

Page-10
Side effects:

 pruritis, anaphylactoid reactions and coagulation

abnormalities as compared to synthetic colloids.

Disadvantages

 cost effectiveness

 volume overload (in septic shock pt albumin add to

interstitial edema)

Artificial

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 cardiopulmnary

bypass.

 Side effects: Anaphylactic reactions, Coagulation abn, Interference

with cross match, Ppt of ARF.

Page-11
 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

Page-12
 HYDROXYETHYL STARCHES
Derivatives of amylopectin, which is a highly branched
compound of starch.

6% HES soln are isooncotic

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 1‘ & 2" generation HES

-Coagulation abn

-Accumulation

-Anaphylactoid reactions

-Renal impairment

-Increase in amylase level

Page-13
 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 colloid 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 losses
Replacement of loss

Page-14
 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 anaesthesia.

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.

Page-15
 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

Page-16
 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.

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

Page-17
 Summary
Most physiological :RL

Rich in sodium : NS,DNS

Rich in potassium :ISo —p

Glucose free: ?RL,NS,3% saline

Sodium free: Dextrose

Potassium free: NS,DNS,Dextrose

Can correct acidosis directly : RL,ISo-p

Page-18