basic principles of fluid therapy

1. FLUID
THERAPY
DR MUKESH SHUKLA , MD
SENIOR RESIDENT
MEDICINE, KGMU
LUCKNOW

2. Body Water Compartments
• Intracellular water: 2/ 3 (40%)of TBW
• Extracellular water: 1/3 (20%)of TBW
- Extravascular water[interstitial]: 3/4 (15%)of extracellular water
- Intravascular water[plasma]: 1/4 (5%)of extracellular water

4. Why patients need
intravenous fluid therapy
?
Patient needs IV fluid therapy for
Maintenance ( to supply daily needs ) ,
Replacement ( to replace deficit and on-going losses )
Resuscitation ( to correct an IV or extracellular deficit )

7. Practical Fluid
Balance
H2
O H2
O H2
O
Rule 1
Water without Na expands the TBW (enter both ICF &
ECF in proportion to their initial volume)
ECFICF

8. Practical Fluid
Balance
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Rule 2
All infused Na+ can not gain access to the ICF Because of
the Sodium Pump
ECFICF
Isotonic = NO Water Exchange

10. Total body water
ECF=1 liter ICF=0
Intravascular
=1/4 ECF=250 ml
1 Liter 0.9% saline
Interstitial=3/4 of
ECF=750ml

11. Hypotonic = Water Exchange
a. Hypotonic saline (¼ NS)
H2
O
Rule 3
Change in tonicity of Na solutions (relative to Plasma)
causes water exchange
Practical Fluid Balance

13. 1 liter 5% Dextose
Total body water=1 liter
ECF=1/3 = 300ml ICF=2/3 = 700ml
Intravascular
=1/4 of ECF~75ml

14. Hypertonic = water exchange
b. Hypertonic solution
H2
O

16. 1 liter 5% Albumin
Intravascular=1 liter

18. Clinical characteristic of iv fluids
 Ringer lactate is the most physiological iv fluid
 Isotonic saline and DNS have maximum sodium
 Isotonic saline ,DNS and ISO-G have maximum chloride
 ISO – E,P,M directly correct acidosis
 ISO-G only iv fluid which directly correct metabolic
alkalosis.
 ISO-M,P,G,E and Ringer lactate are usually avoided in renal
failure.
 ISO-G and Ringer lactate are avoided in patients with liver
failure.

19. • Isotonic saline and Ringer Lactate do not contain
glucose so preferred fluid for diabetic patients.
• 5,10 and 20 D are only fluids which do not contain
Na and Cl. Iso-M and P have low Na and Cl.
• NS , DNS and dextrose containing fluids do not
contain potassium and they do not correct
metabolic acidosis and alkalosis directly.

20. Clinical characteristic of iv
fluids
DEXT Na k Cl ACE LACT NH4
CL
CA MG HPO
4
CITR
ATE
mOs
m/l
5D 50
NS 154 154 278
DNS 50 154 154 432
RL 130 4 109 28 3 586
ISO-
G
50 63 17 150 70 274
ISO-
M
50 40 35 40 20 15 580
ISO-P 50 25 20 22 23 3 3 410
ISO-E 50 140 10 103 47 5 3 8 368

21. Characteristics of
intravenous fluids
Characteristic Intravenous fluids Characteristic Intravenous fluids
Most physiological RL Glucose free Saline, RL
Rich in sodium NS,DNS,RL Sodium free Dextrose solutions
Rich in chloride NS,DNS,Iso-G Potassium free NS/DNS,dextrose solution
Rich in potassium Iso-M,P and G Avoid in liver failure RL, Iso-G, 5% D
Corrects acidosis RL, all isolyte Except Iso-G Avoid in renal failure NS, RL, all isolyte
Corrects alkalosis Isolyte-G, NS Provides phosphorous Isolyte-M

22. SUMMARY
CHARACTERISTIC TYPE OF FLUID
Most physiological Ringers lactate (RL)
Rich in sodium NS, DNS
Rich in Chloride NS, DNS,ISO - G
Rich in potassium Isolyte - M, P, G
Correct Acidosis Ringers Lactate, Iso-E,P,M
Correct alkalosis Isolyte-G
Caution in renal failure Ringer lactate , Isolyte-M,G,P and E
Avoided in liver failure Ringer lactate , Isolyte-G
Glucose free NS, Ringers lactate
Sodium free 5,10,20 and 25 D
Potassium free NS, DNS and Dextrose fluids

23. Daily Electrolyte Requirements
• - Sodium: 100-250meq (western diet)
– mostly excreted in urine
• - Potassium: 50-100meq
– mostly excreted in urine, 5% in feces
• - Chloride: 60-150meq
– Example: 1/2NS @ 100cc/hr provides ~180mEq of sodium and chloride/day!
- this is why NS should not be used for maintenance fluid in patients with
normal renal function- risk of hyperchloremic metabolic acidosis
• - Bicarb: 1 meq/kg/day

24. Crystalloids
 Combination of water and electrolytes
Balanced salt solution: electrolyte composition and osmolality similar to
plasma; example: lactated Ringer’s, Plasmlyte, Normosol.
- Hypotonic salt solution: electrolyte composition lower than that of plasma;
example: D5W.
 True solution, No particulate
 Expands IVC adequately (less than colloids), however Small increase in
plasma volume
 Replenishes interstitial compartment
 It leaves IVC faster ( t/2 20-30 minutes)
 Cheap
 Increase GFR
 No risk of allergic reaction

25.  Suspension of particle rather than a solution
 High Molecular Weight: Unable to pass through semi permeable
membrane
 Remains confined to intra-vascular compartment (at least initially)
 Do not correct water and electrolyte deficiencies
 Examples: hetastarch (Hespan), albumin, dextran
Colloids

26.  Antigenicity & Anaphylactic Reaction
 Blood typing
 Coagulopathy
 Never exceed 1 – 1.5 liter/day (20 ml/kg/day)
Colloids

27. colloids
Colloids
 Most logical choice for intravascular expansion
 Since greater portion remains in IVC & for longer time
( t/2 3-6 hours)
 Less volume is required& initial resuscitation is rapid
 500 ml of colloids expands plasma by 500ml

28.  Blood-derived: Albumin 5%( Heated,
Antigenic)
 Dextran: Dextran 70, Dextran 40
 Gelfusine (Anaphylaxis)
 Hydroxy ethyl ether
Hetastarch 6%
MW = 450 000
Effective Plasma Expander
Least Antigenicity
&Effect on Coagulation
Colloids
(Types)

29. colloid
• Advantages : Smaller infused
volume.
Prolonged increase in plasma
volume.
Less cerebral edema.
• Disadvantages :Greater cost
Coagulopathy(dextran>HES).
Pulmonary edema (capillary leak
states).
Decreased GFR.
Osmotic diuresis (low molecular
weight dextran)
crystalloid
• Advantages : Lower cost. Greater
urinary flow. Replaces interstitial
fluid.
• Disadvantages :Transient
hemodynamic improvement.
Peripheral edema(protein
dilution). Pulmonary
edema (protein dilution plus high
PAOP)

30. CRYSTALOID CLASSIFICATION
1. Maintenance
fluid
2. Replacement
fluid
3. Special fluid
5% DEXTROSE NORMAL SALINE 25% DEXTROSE
DEXTROSE WITH .45%
NORMAL SALINE
DNS SODIUM BICARBONATE
RINGER LACTATE POTASSIUM CHLORIDE
ISOLYTE – M,P,G

31. 5% DEXTROSE
COMPOSITION –
 One litre of fluid contains 50 gram of glucose .
 PHARMACOLOGICAL BASIS –
 Correct dehydration and supplies energy
 Best agent to correct intracellular dehydration
 Used where there is need of water but not electrolytes
 INDICATIONS –
 Dehydration due to inadequate water intake or excessive water loss
 Pre and post operative fluid management
 IV administration of various drugs
 Prevention of ketosis in starvation , diarrhea , vomiting and high grade fever
 Correction of hyperntremia due to pure water loss
 Hypernatremia due to salt poisoning or excessive use of electrolyte solution

32. CONTRAINDICATIONS –
Cerebral oedema
Neurosurgical procedures
Acute ischemic stroke
Hypovolemic shock
Hyponatremia and water intoxication
Hypernatremia
Blood transfusion
Uncontrolled diabetes and severe hyperglycemia

33.  PRECAUTIONS –
 May cause local pain , irritation and
thrombophlebitis.
 Can cause hypokalemia, hypomagnesaemia and
hypophosphatemia
RATE OF ADMINISTRATION –
 Can be given .5gm/kg body weight/hour without
causing glycosuria .

34. ISOTONIC SALINE
COMPOSITION –
One litre of normal saline contains 154 meq sodium
and 154 meq chloride
PHARMACOLOGICAL BASIS –
 Used to provide major extracellular electrolytes
Very useful to correct fluid and electrolyte deficit
Very useful to raise blood pressure in patient with
hupovolemic shock

35. INDICATIONS –
 Water and salt depletion as in diarrhoea, vomiting,excessive diuresis
or excessive persppiration
 Treatment of hypovolemic shock
 Treatment of alkalosis with dehydration
 Severe salt depletion and hyponatremia
 Inicial fluid therapy in DKA
 Treatment of hypercalcemia
 Fluid challenge in prerenal ARF
 Irrigation for washing of body fluids
 Vehicle for certain drugs

36.  Can be given safely with blood
 Hypertonic saline(3% nacl) is used in treatment of
hyponatremia due to SIADH or water intoxication
along with diuretic .

37. Contraindications :
 Hypertensive or preeclampsia patients
 Patient with edema due to CHF , renal disease and cirrhosis
 Very young and elderly patients
 Dehydration with severe hypokalemia

38. DEXTROSE SALINE (DNS)
COMPOSITION –
 One litre fluid contains 50gm glucose,154meq sodium and 154
meq chloride.
Pharmacological basis –
 useful to supply major extracellular electrolytes and
energy along with fluid to correct dehydration .
 Unlike 5D it is not hypotonic (due to Nacl) and hence it
is compatible with blood transfusion.

39. INDICATIONS –
 Correction of salt depletion and hypovolemia with supply
of energy
 Correction of vomiting and nasogastric aspiration induced
alkalosis and hypochlremia along with supply of energy
 Fluid compatible with blood transfusion
CONTRAINDICATIONS –
 Anasarca of cardiac, hepatic and renal disease
 Hypovolemic shock

40. RINGER LACTATE
 Most physiological fluid
 Rapidly expands intravascular volume so very effective in severe
hypovolemia
 Provide bicarbonate so useful in correction of metabolic acidisis
 INDICATIONS-
 Correction of severe hypovolemia
 Postoperative patients ,burns ,fracture and peritoneal irrigation
 Diarrhoea induced hypovolemia with hupokalemic metabolic acidosis
 Diabetic ketoacidosis
 For maintaing normal ECF fluid and elecrolyte balance during and
after surgery

41.  Contraindications –
 Liver disease , severe hypoxia and shock
 CHF
 Addison's disease
 Severe metabolic acidosis
 Vomiting and continuous nasogastric aspiration
 Infusion of RL and blood product in one IV line
contraindicated
 Calcium in RL binds with certain drugs like amphotercin and
reduces their bioavailability and efficiency

42. ISOLYTE -M
• ISO-M is the richest source of potassium.
• Also correct acidosis and supplies energy so ideal fluid for
maintenance fluid therapy
 INDICATIONS-
 For parenteral fluid therapy, it is the ideal maintenance fluid.
 To correct hypokalemia
 CONTRAINDICATIONS –
 Renal failure
 Hyponatremia and water intoxication
 Adrenocortical deficiency
 Burns

43. OTHER’s
ISOLYTE-G- only fluid to correct metabolic alkalosis.Used to
replace fluid loss due to vomiting or continuous nasogastri
aspiration .
ISOLYTE- P- Provide less electrolytes(half of isolyte –M)
and more water .Useful in pediatric patients.
ISOLYTE – E – Correct all ecf electrolytes, acidosis and
supplies glucose .

44. SODIUM
BICARBONATE
• Commonaly available preparation contains 7.5% , 25ml ampoule
• Each ampule contains 22.5 meq sodium and 22.5 meq bicarbonte
 INDICATIONS –
 Treatment of metabolic acidosis
 For cardiopulmonary resuscitation and shock
 Treatment of hyperkalemia
 Alkaline forced diuresis in treatment of acute poisoning of
barbiturate and salicylates

45.  When to use –
In severe metabolic acidosis
 How much to give –
 Always under corrected
 Amount in meq /l= .5xweight in kg x(desired bicarbonate – actual
bicarbonate )
 How to infuse –
 50% corrected in 4 hours and rest gradually over 24 hours
 To avoid irritation of vein and sudden sodium loading added to 5D
 Special precations –
 Should not be given in bolus except in emergency
 Establish proper IV line for infusion as it is very irritant

46.  Avoid overdose and alkalosis
 Never treat acidosis without treating etiology
 In renal failure bicarb correction may cause tetany and
pulmonary oedema so prefer dialysis if acidosis and renal
failure are severe
 Never correct acidosis without correcting assosiated
hypokalemia
 Never mix sodabicarb with injection calcium as
combination can precipitate calcium carbonate as white
crystals
 Avoid mixing of sodabicarb with ionotropes

47.  Complications –
 Overshoot , post treatment metabolic alkalosis
 Hypokalemia
 Volume overload
 Hypocalcemia – tetany
 Contraindications –
 Respiratory alkalosis , metabolic alakalosis and hypokalemia
 Correct dehydration, hypokalemia and hypocalcemia prior to bicarb
treatment
 Cautious use in congestive heart failure , chronic renal failure
,cirrhosis of liver or hypertension

48. POTASSIUM CHLORIDE
 One amp of 10ml contains 1.5 gm or 20 meq potassium .
 INDICATION-
 Prevention and treatment of hypokalemia
 Added in potassium free peritoneal dialysis
 During cardiac bypass surgery
 PRECAUTIONS-
 Never give direct iv injection
 Never add more than 40 mEq potassium/litre
 Never infuse more than 10mEq potassim /hour
 Never add potassium chloride in ISO-M
 Monitor potassium level closely and if possible also monitor by ECG

49.  CONTRAINDICATIONS-
 Cautious use in renal failure
 Never use injection Kcl without knowing potassium
status

50. 25D
• 100 ml of 25D contains 25gm of glucose.
• Dextrose supplies energy and prevents , used when faster
replacement of glucose is needed like in hypoglycemic coma.
• In fluid restricted state like CHF provides larger glucose in smaller
volume.
INDICATIONS-
 Rapid correction of hypoglycemia
 Provide nutrition to the patient
 For treatment of hyperkalemia

51. CONTAINDICATIONS-
 Dehydrated patient with anuria
 Intracranial and intraspinal hemorrhage
 Delerium tremens
 Avoided in diabetic patients
CAUTION –
 Rapid infusion of 25D can cause glycosuria secondary
to hyperglycemia ,should be infused slowly

52. ALBUMIN
 Physiologic plasma protein
 Maintain plasma oncotic pressure
 Binding and transport of low molecular weight substances
 25% albumin expands the plasma volume by 4-5 times the
volume infused
 Plasma volume expansion occurs at the expense of
interstitial volume
 Oncotic pressure lasts for 12 to 18 hrs
 Preferred in case of hypoproteinemia with anasarca with
oedema

53.  INDICATIONS –
 Plasma volume expansion
 Correction of hypoproteinemia
 As an exchange fluid in therapeutic plasmapheresis
 Adverse effects –
 Nausea
 Vomiting
 Febrile reaction
 Allergic reaction including anaphylactic shock

54. Precautions and contraindications –
 Fast infusion may cause vascular overload and pulmonary
oedema
 Severe anemia and CHF
 Low cardiac reserve and cardiac insfficiency
 Dehydrated patients
 Should not be used for parenteral nutrition
 How much to give-
 Infusion of 25 gm of albumin is suggested at 1-2 ml /minute
(5% alba )and 1 ml /minute (25 % albumin)
 High rates may be needed in treatment of shock

55. HEMACCEL
• Sterile,pyrogen free,colloid plasma volume substitute
contain a polymer degraded gelatin and elecro
electrolytes
INDICATIONS-
Rapid expansion of intravascular volume
Prophylactic use in major surgery
Primig of heart lung machine

56. PRECAUTIONS –
 Contain no preservative so ensure clear solution before
infusion
 Contains calcium so should not be mixed with citrated
blood
 Monitor for adverse reactions
SIDE EFFECTS-
 Hypersensitivity reaction
 Bronchospasm and fall in blood pressure

57. MONITORING
 Weight
 Skin and tongue
 Sensorium
 Urine out put
 Pulse rate
 Blood pressure
 Hematocrit
 Metabolic acidosis
 CVP and PAWP

58. Calculation Of Fluid
Infusion
For routine IV set –
 15 drops = 1 ml
 Rule of ten for fluid calculation for 24 hours :
iv fluid in litre/24 hrsx10=Drop rate / minute
Drop rate per minute /10= IV fluid in litre in24 hrs
 Rule of Four for fluid calculation for one hour:
Volume in ml per hr/4= Drop rate per minute
Drop rate per min x4 = Volume in ml per hour

59. • Drop rate calculation by any parameter :
Volume to be infused in ml Drop rate
Duration of infusion in hours minute
For micro Drip set :
 For micro drip set 1 ml = 60 drops
 Number of micro drops /minute = volume in ml per
hr