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I.V.Fluids
Presented by
Dr.JATINDER CHHABRA
Introduction
Can You Imagine life without water?
Of course not, because water is essential to sustain life.
Likewise, body fluids are vital to maintain normal body
functioning
Total body fluid (TBW), accounts for approximately 60% of
total body weight (this can be 70% or higher in a newborn
down to 50–55% in a mature woman).
Total Body Fluid can be divided into Intracellular and
Extracellular
Normal Water Balance
Food Oxidation = 300ml
2/3rd
1/3rd
Lungs = 400ml
Skin = 500ml
Intestine = 100ml
I.C.F.
E.C.F.
1000ml
Kidney - Urine Excertion
E.C.F = 75% interstial fluid + 25% plasma
Insensible fluid loss
• Insensible fluid input – 300 ml oxidation
• Insensible fluid loss –
skin+lung+stool=1000ml
• Normal daily insensible fluid loss = 700 ml
• Daily fluid requirement = UO + insensible
losses
Water requirements increase with:
• Fever
Sweating
• Burns
Tachypnea
•Surgical drains
Polyuria
•Gastrointestinal losses through Vomiting or diarrhea
Water requirements increase by 100 to 150 mL/day for each C degree of
body temperature elevation.
Electrolyte Composition of fluid
Compartments
INTRODUCTION TO IV FLUID THERAPY:
Must know……….
- illness first and its patho physiology including stage of illness
- Vital organs (Liver,Heart and Kidney) functioning
- Etiology of fluid deficit and type of electrolyte imbalance
• Associated illness (DM, HTN, IHD etc.)
• Clinical status (hydration, vital data, urine output etc.)
7
Based on above Information , Calculate/Plan
- To give fluid or no
If Yes - Amount
- type of fluid
- rate
- Electrolyte correction
- Contraindication
- Specific fluid
Intravenous fluid therapy
Indications
• Coma, anaesthesia, Severe vomiting and
diarrhoea,
•Dehydration and shock
•Hypoglycemia
•Vehicle for – antibiotics, chemotherapy agents
•TPN
•Critical problems – anaphylaxis, pancreatitis ,
forced diuresis in drug overdose, poisoning
Advantages
• Accurate , controlled and predictable way
of administration
•Immediate response due to direct infusion
•Prompt correction of electrolyte
disturbances
Disadvantages
•More expensive, need asepsis, and under
skilled supervision
•Improper selection of type, volume , rate
and technique can lead to serious problems
Contra indications
•Avoided if patient can take oral fluids
•CHF, pulmonary edema
Complications
• Local : hematoma , infusion phlebitis
• systemic :
•Large volume can lead to circulatory
overload
•Rigors, air embolism
•Septicemia
• others – fluid contamination, mixing of
incompatible drugs
Classification of iv fluids
1. Maintenance fluids : replaces insensible fluid losses
5 % dextrose, dextrose with 0.45 % NS
2. Replacement fluids : correct body fluid deficit
gastric drainage, vomiting,diarrhoea, infection , trauma,
burns
3. Special fluids :
Hypoglycemia – 25 % dextrose
Hypokalemia – inj Kcl
 Metabolic acidosis – inj soda bicarb
ISOTONIC
• Osmolality
of 250-375
mOsm/L
• No shifting
of fluid
• Only
serves to
increase
the ECF
HYPOTONIC
• Osmolarity of
>250 mOsm/L
• Shifting of fluid
from
intravascular to
both intracellular
and interstitial
spaces
• Hydrate the cells
causing them to
swell.
HYPERTONIC
• Osmolarity of 375
mOsm/L or
higher
• Water moves out
of the
intracellular
space increasing
ECF( volume
expanders)
• Dehydrate the
cells causing
shrinkage.
ISOTONIC
HYPOTONIC
HYPERTONIC
• 0.9% Nacl
• 0.45% Nacl
• 3% Nacl
• Lactated
Ringer
• 0.33% Nacl
• 5% Nacl
• 0.2 % Nacl
• 3%Nacl or 5%
Nacl +D/W
• Ringers’
Solution
• 5% Dextrose in
water
• 2.5% Dextrose
water
• >5% D/W
example,D10W
Difference between NS and D5W in
distribution
Free water ICF
content
ECF
Interstitial
Intravascular
D5W
1000cc
660cc
340cc
226cc
114cc (11%)
NS
0
0
1000cc
660cc
330cc (33%)
5 % dextrose
Composition : Glucose 50 gms
Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L)
Indications :
• Pre and post op fluid replacement
• IV administration of various drugs
• Prevention of ketosis in starvation
•Adequate glucose infusion protects liver against toxic substances
•Correction of hypernatremia
•Avoid fast infusion as this may lead to swelling of hypotonic brain cells
Contra indications
• Cerebral edema, neuro surgical procedures
• Acute ischaemic stroke
• Hypovolemic shock
• Hyponatremia , water intoxication
• Same iv line blood transfusion – hemolysis ,
clumping occurs
• Uncontrolled DM , severe hyperglycemia
Rate of adminstration – 0.5 gm/kgBW/hr or
666ml/hr
5 % D or 333ml/hr 10 %D
Isotonic saline(0.9 % NS)
• Composition : Na 154 mEq, Cl 154 meq
• Pharmacological basis : provide major EC electrolytes..
corrects both water and electrolyte deficit.
increase the iv volume substantially
Contra indications
•Avoid in pre eclamptic patients, CHF, renal disease and
cirrhosis
•Dehydration with severe hypokalemia – deficit of IC
potassium
•Large volume may lead to hyperchloremic acidosis.
Indications
•Water and salt depletion – diarrhoea,
vomiting, excessive diuresis
•Hypovolemic shock
•Alkalosis with dehydration
•Severe salt depletion and hyponatremia
• Initial fluid therapy in DKA
•Hypercalcemia
•Fluid challenge in prerenal ARF
• Irrigation – washing of body fluids
DNS
Composition : Na Cl – 154 mEq, glucose 50 gm
Pharmacological basis :
• Supply major EC electrolytes, energy and fluid to correct
dehydration
Indications :
• Conditions with salt depletion ,hypovolemia
• Correction of vomiting or NGT aspiration induced
alkalosis and hypochloremia
Contra indications :
• Anasarca – cardiac, hepatic or renal
• Severe hypovolemic shock
Ringer’s lactate
Composition – Na, k , cl, lactate , ca
each 100 ml – sodium lactate 320 mg, Nacl 600mg, kcl-40mg, calcium chloride 27 mg
Pharmacological basis :
•Most physiological fluid , rapidly expand s iv
volume..
•Lactate metabolised in liver to bicarbonate
providing buffering capacity
•Acetate instead of lactate advantageous in severe
shock.
Indications
•Correction in severe hypovolemia
•Replacing fluid in post op patients, burns
•Diarrhoea induced hypokalemic metabolic
acidosis
•Fluid of choice in diarrhoea induced
dehydration
•DKA , provides water, correct metabolic
acidosis and supplies potassium
•Maintaining normal ECF fluid and electrolyte
balance
Contra indications
• Liver disease, severe hypoxia and shock
•Severe CHF , lactic acidosis takes place
•Addison’s disease
•Vomiting or NGT induced alkalosis
•Simultaneous infusion of RL and blood
•Certain drugs – amphotericin, thiopental,
ampicillin, doxycycline
Isolyte fluids
Isolyte G
Isolyte M
Isolyte P
Isolyte E
dextrose
50
50
50
50
Na
K
Cl
63
17
150
40
35
40
25
20
22
140
10
103
Acetate
Lactate
NH4Cl
----70
20
-----
23
-----
47
-----
Ca
Mg
-----
-----
-----
5
3
HPO4
---
15
3
---
Citrate
---
---
3
8
Mosm/L
580
410
368
595
Isolyte G :
•Vomiting or NGT induced hypochloremic, hypokalemic
metabolic alkalosis
•NH4 gets converted to H+ and urea in liver
•Treatment of metabolic alkalosis
• Contraindications : Hepatic failure, renal failure, metabolic
acidosis
Isolyte M
•Richest source of potassium (35 mEq)
•Ideal fluid for maintenance
•Correction of hypokalemia
•Contraindications : Renal failure, burns, adrenocortical
insufficiency
Isolyte P
• Maintenance fluid for children – as they require less
electrolytes and more water
• Excessive water loss or inability to concentrate urine
• Contraindications : hyponatremia, renal failure
Isolyte E
•Extracellular replacement solution, additional K and acetate
(47mEq)
•Only iv fluid to correct Mg deficiency
•Treatment of diarrhoea, metabolic acidosis , losses of lower
GI tract
•Contraindications – metabolic alkalosis
Effects of large volume crystalloid infusion.
• Extravascular accumulation in skin,
connective tissue , lungs and kidney
• Inhibition of GI motility
• Delayed healing of anastomosis
• Large volume ,rapid infusion crystalloids
causes hypercoagulability.. Due to reduction
in AT 3
Ruttmann TG, James MF. Effects on coagulation due to intravenous
crystalloid or colloid in patients undergoing vascular surgery.
Br J Anesth 2002 ; 89 : 999 - 1003
Holiday Segar Method
Colloids
Colloids : large molecular wt substances
that largely remains in the intravascular
compartment thereby generating oncotic
pressure
•3 times more potent
•1 ml blood loss = 1ml colloid = 3ml
crystalloids
Type of fluid
Effective plasma volume
expansion/100ml
duration
5% albumin
70 – 130 ml
16 hrs
25% albumin
400 – 500 ml
16 hrs
6% hetastarch
100 – 130 ml
24 hrs
10% pentastarch
150 ml
8 hrs
10% dextran 40
100 – 150 ml
6 hrs
6% dextran 70
80 ml
12 hrs
Albumin
•Maintain plasma oncotic pressure – 80 %
•Heat treated preparation of albumin – 5%, 20% and 25%
commercially available
Pharmacalogical basis :
• 5% albumin – COP of 20 mmHg
•25% albumin – COP of 70mmHg ,expands plasma volume
to 4-5 times the volume infused
Rate of infusion :
• Adults – initial infusion of 25 gm
• 1 to 2 ml/min – 5% albumin
• 1 ml/min
- 25% albumin
Indications :
•Plasma volume expansion in acute hypovolemic
shock, burns, severe hypo albuminemia
•Hypo proteinemia – liver disease, Diuretic resistant
nephrotic syndrome
•In therapeutic plasmapheresis , as an exchange
fluid
Contra indications :
• Severe anaemia, cardiac failure
• Hypersensitive reaction
Dextran
•Dextran are glucose polymers produced by
bacteria(leuconostoc mesenteroides)
2 forms : dextran 70(MW 70,000) and dextran
40(40,000)
Pharmacological basis :
•Effectively expand iv volume
•Dextran 40 as 10% sol greater expansion , short duration(
6hrs) – rapid renal excretion
•Anti thrombotic , inhibits platelet aggregation
•Improves micro circulatory flow
Indications :
• Hypovolemia correction
• Prophylaxis of DVT and post operative thromboembolism
• Improves blood flow and micro circulation in threatened
vascular gangrene
• Myocardial ischemia, cerebral ischemia, PVD and
maintaining vacular graft patency
•Priming in ECC
Adverse effects
•Acute renal failure
•Interfere with blood grouping and cross matching
•Hypersensitive reaction
Precautions/CI :
• Severe oligo-anuria
• CHF, circulatory overload
•Bleeding disorders like thrombocytopenia.
•Severe dehydration
•Anticoagulant effect of heparin enhanced
•Hypersensitive to dextran
Administration :
•Adult patient in shock – rapid 500 ml iv infusion
•First 24 hrs – dose should not exceed 20ml/kg
•Next 5 days – 10 ml/kg/ day
Gelatin polymers( haemaccel)
• Sterile, pyrogen free 3.5 % solution
• Polymer of degraded gelatin with electrolytes
• 2 types
• Succinylated gelatin (modified fluid gelatin)
• Urea cross linked gelatin ( polygeline)
Composition : Na Cl 145 mEq, Ca 12.5 mEq,
potassium 5.1 mEq
Indications :
•Rapid plasma volume expansion in hypovolemia
•Volume pre loading in regional anesthesia
•Priming of heart lung machines
Advantages :
• Does not interfere with coagulation, blood
grouping
• Remains in blood for 4 to 5 hrs
• Infusion of 1000ml expands plasma volume
by
300 to 350 ml
Side effects :
•Hypersensitivity reaction
•Should not be mixed with citrated blood
Hydroxyethyl starch
Hetastarch :
• It is composed of more than 90% esterified
amylopectine.
• Esterification retards degradation leading
to longer plasma expansion
• 6% starch - MW 4,50,000
Pharmacological basis :
•Osmolality – 310 mosm/L
•Higher colloidal osmotic pressure
•LMW substances excreted in urine in 24 hrs
Physiochemical characteristics :
•Substitution of hydroxy ethyl groups at C2, C3 and C6
•Concentration : low( 6%), high(10%)
• MW : Low( <70kDa), med and high(>450kDa)
• Degree of substitution : low(0.45 – 0.58),
high( 0.62 – 0.70)
•C2/C6 : low(<8) , high(>8)
Metabolism :
Rapid amylase dependent breakdown and renal excretion
upto 50% in 24 hrs
Advantages :
•Non antigenic
•Does not interfere with blood grouping
•Greater plasma volume expansion
•Preserve intestinal micro vascular perfusion in
endotoxaemia
•Duration – 24 hrs
Disadvantages :
• Increase in S amylase concentration upto 5 days after
discontinuation
•Affects coagulation by prolonging PTT, PT and bleeding
time by lowering fibrinogen
•Decrease platelet aggregation , VWF , factor VIII
Crystalloids or colloids…???
•Crystalloids – recommended as the initial fluid of choice
in resuscitating patients from hemorrhagic shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip
fracture. Canadian journal of anesthesia 1999 ; 46 : 133 - 141
• COCHRANE Collaboration in critically ill patients –
“ No evidence from RCT that resuscitation with colloids
reduces the risk of death, compared with crystalloids in
patients with trauma or burns after surgery”
Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid
resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD
000567, 2004
CAUTION :
HYPOKALAEMIA
HYPERKALAEMIA
Inappropriate IV therapy is a significant cause of pt mortality
and morbidity and may result from either too much or too
little volume.
TOO MUCH!
•Fluid overload has no precise definition but complications
usually arise in the context of preexisting cardiorespiratory
disease and severe acute illness.
TOO LITTLE!
•Insufficient fluid administration is readily identified by signs
and symptoms of inadequate circulation and decreased organ
perfusion .
INFUSION OF WRONG TYPE OF FLUID!!!
This results in derangement of serum sodium
concentration,which if severe,leads to changes in cell volume
and function and may result in serious neurological injury.
PULMONARY
EDEMA
PERIPHERAL
EDEMA
HYPONATREMIA
HYPERNATREMIA
HYPOVOLAEMIA
Calculation of fluid infusion
1. FOR ROUTINE I.V. SET
A. 15 drops = 1 ml
B. "RULE OF TEN" for fluid calculation for 24 hours.
I.V.fluid in litre / 24 hours X 10 = Drop rate / minute
Drop rate per minute / 10 =I.V.fluid in litre / 24 hours.
C."RULE OF FOUR'' for fluid calculation for one hour.
Volume in ml / hour / 4 = Drop rate / minute
Drop rate / minute X 4 = Volume in ml / hour
D.Drop rate calculation for any parameter
Volume to be infused (in ml)
Duration of infusion in hours X 4
=
Drop rate / minute
2. FOR MICRO DRIP I.V. SET
A. For micro drip set 1 ml = 60 drops.
B.Number of micro drops per minute = Volume in ml / hour
Goals
• Maintenance of normovolemia and
hemodynamic stability
• Acceptable plasma colloid osmotic
pressure
• Correction of electrolyte imbalance
• Correction of acid base imbalance
• Adequate urine output( 0.5 to 1 ml/kg/hr)
Summary
Characteristics of I.V.fluids
Characteristic
Type of Fluid
Most physiological
Ringer's lactate (RL)
Rich in sodium
Isotonic saline , DNS
Rich in chloride
Isotonic saline , DNS , Isolyte - G
Rich in potassium
Isolyte - M , P and G
Corrects acidosis
Ringer's lactate , Isolyte - E , P and M
Corrects alkalosis
Isolyte - G
Cautions use in renal failure
Ringer's lactate , Isolyte - M , G, P and E
Avoided in liver failure
Ringer's lactate , Isolyte - G
Glucose free
Isotonic saline , Ringer's lactate
Sodium free
5% , 10% , 20% and 25% - Dextrose
Potassium free
Isotonic saline , DNS , Dextrose fluids
Tips & Take Home Message
1.Do not use DNS or any other Dx solution as first line I.V.fluid.
2.Calorie content of Dx/DNS is about 170/litre
Dx 10% about 340/litre.
3.About 20meq of potassium is lost in urine even in presence of
hypokalemia,this is even more in presence of hyponatremia.
4.Normal daily requirement of K is 60meq/day.
5.Assess patient every day for
- fluid status
- U.O
- BP/P/SPO2
- Electrocytes