This document discusses fluid balance and fluid therapy. It begins by defining fluid balance as when water intake equals water loss each day. It then discusses total body water content and its compartments. Key points include that intravenous fluids can be classified as crystalloids or colloids. Common crystalloid fluids discussed include normal saline, Ringer's lactate, dextrose 5%, and Isolyte solutions. Albumin and dextran are presented as examples of colloid fluids. Indications, contraindications, and complications of various intravenous fluids are provided.

1. Presented by: Nesar Ahmad
(JR1)
Moderator: Dr Simeen Usmani

2. Fluid Balance
When the water coming into the body precisely
equals the water being lost by the body each day.

3. • Body is formed with solids & fluids.
• In human body water content is 45-75% of body weight.
Importance of Body fluids :
1. In homeostasis
2. In transport Mechanism
3. In metabolic reactions
4. In maintenance of tissue texture
5. In temperature regulation

4. • TBW varies with age, gender and body habitus .
• In adult males= 60-65% of body weight, average = 60%
• In adult female=50-55% of body weight, average = 50%
• In infant = 80% of body weight
• Obese patients have less TBW per Kg than lean body adult.

6. 1= Intracellular fluid (ICF)= 70% TBW or 30%(F) - 40% (M) BW
2= Extracellular fluid (ECF) = 30%TBW or 20% BW
 Interstitial fluid = 15% of body weight
 Intravascular fluid or plasma volume = 5% of body weight
 Other ECF – lymph, cerebrospinal fluid, eye humors, synovial fluid,
serous fluid, and gastrointestinal secretions
Body fluids compartments

7. Distribution of fluid volume in a 70 kg man is summarized below:

8. Organic Inorganic
Glucose
Amino acids
Proteins
Fatty acid
Lipid
Hormones
Enzymes
Oxygen
electrolytes

9. Normal water balance

10. Daily water input and output
Daily fluid input = 2500ml
1. Water from beverages – 1,200 ml
2. Water from solid food – 1,000 ml
3. Water from oxidation – 300 ml
Daily water output = 2500 ml
1. Urine – 1,500 ml
2. Insensible loss from skin & lungs – 900 ml
through skin – 500 ml
through lungs – 400 ml
1. Faeces – 100 ml

11. 11
Daily fluid replacement = 700 + urine output

12. Excess fluid loss
• Fever : 100 ml / degree fever / day
• Tracheostomy (unhumidified air) : >1.5 L / day
• Exercise
• Burns
• Abnormal perspiration

13. Volume Changes : Hypovolemia
Hypervolemia

14. Hypovolemia
• ECF volume deficit is most common fluid loss in surgical
patients, and aggravated by General Anesthesia.
• Most common causes of ECF volume deficit are: GI losses
from vomiting, nasogastric suction, diarrhoea, and fistulae
drainage
• Other common causes: soft-tissue injuries and infections,
peritonitis, obstruction and burns.

15. Signs
• Diminished skin turgor
• Dry oral mucus membrane
• Dry axilla
• Oliguria
- <500ml/day (normal:
0.5~1ml/kg/h)
• Flat neck veins
• Tachycardia
• Orthostatic Hypotension
• Hypoperfusion  cyanosis
(hypothermia)
• Sunken eye
• Altered mental status
Clinical Diagnosis
• Thorough history taking:
poor intake, GI bleeding…etc
• glucocorticoid therapy
• BUN : Creatinine > 20 : 1
• Increased specific gravity
• Increased hematocrit
• Electrolytes imbalance
• Acid-base disorder

16. Hypervolemia
• Iatrogenic or Secondary to renal insufficiency, cirrhosis, or CHF.
Signs
• CNS: none
• CVS: elevated JVP, venous
distension – pulmonary edema,
S3, confusion, restlessness,
convulsions and coma
• Respiratory : shortness of
breath even in rest.
• GI: edema of bowel
• Tissue: pitting edema –
anasarca, ascites, weight gain
Clinical Diagnosis
• through history and physical
examination
• Electrolytes imbalance
• Decreased specific gravity
• Decreased hematocrit

17. Regulating Body Fluids
The primary methods of body water regulation are:
1. Regulating the volume of liquid ingested: when the
extracellular fluid volume reduces, the thirst centre in
the hypothalamus is stimulated which encourages the
person to ingest more water.
2. Regulating the volume of urine excreted: this is
regulated by plasma ADH. A reduction in plasma
volume releases ADH from the posterior pituitary
which in turn acts on the ADH receptors in the
collecting tubules of the kidney.this result in increased
reabsorption of water and reduced production of urine.

19. Fig52-8
Antidiuretichormone(ADH)regulateswaterexcretionfromthekidneys

20. Basic principles of Fluid Therapy
For proper fluid therapy
Should have knowledge of
1. Etiology of fluid deficit
2. Type of electrolyte
imbalance
3. Associated illness (i.e. DM,
HTN, IHD, Renal or Hepatic
disorders etc)
4. Clinical status (hydration,
vital data, urine output etc)
For Rational & Adequate fluid
therapy should have answer of
1. When to give or avoid
2. Which fluid & Why
3. How much & How calculate
4. Drop rate calculation
5. Contraindication of specific fluid
6. How to correct the imbalance
7. How & when to use specific
fluids

21. • Oral route is always preferred over I.V. route
• Intravenous therapy should be started in critical situations.
indications
Oral intake is not possible e.g. coma, anaesthesia, surgery
Severe vomiting, diarrhoea, Dehydration & shock
Hypoglycemia -> 25% dextrose is life saving
Vehicle for some medication e.g. antibiotics, chemotherapeutic
agents, insulin
Total parenteral nutrition
Treatment of critical problems: shock, anaphylaxis, severe asthma,
cardiac arrest and forced diuresis in drug overdose, poisoning,
urinary stone

22. complications
Local : hematoma, infiltration & infusion phlebitis
Systemic : circulation overload, rigors, septicemia, air embolism
Others : fluid contamination, fungus in I.V. fluids, I.V. set &
catheter related problems and human error related problems
contraindications
Ability to take oral fluid
Avoid in CHF & volume overload

23. I.V. fluids
Based on use
Maintenance fluids Replacement fluids Special fluids
5% Dext.
5% Dext. with 0.45%
NaCl
NS,
DNS,
RL,
ISOLYTE -G,
ISOLYTE-E,
ISOLYTE-M,
ISOLYTE-P
Inj.
Sod.bicarbonate,
mannitol,
Inj. KCl
25% Dextrose

24. I.V. fluids
Based on property
Crystalloids
(solution of
electrolytes)
Colloids
(solution of large
molecules)
Life saving
RL
NS
DNS
D-5%
ISOLYTES
5% Albumin
25% Albumin
10% Pentastarch
10% Dextran -40
6% Dextran -70
10% Hetastarch

25. Ringer’s lactate (RL)
Pharmacological basis :
• Most physiological fluid , rapidly expands iv volume..
• Lactate metabolised in liver to bicarbonate providing buffering
capacity
• Acetate instead of lactate advantageous in severe shock.

26. Indications
• Correction in severe hypovolemia
• Replacing fluid in post op patients, burns
• Diarrhoea induced hypokalemic metabolic acidosis
• Fluid of choice in diarrhoea induced dehydration in paediatrics
• In Diabetic ketoacidosis RL provides glucose free water, correct
metabolic acidosis and supplies potassium
• Maintaining normal ECF fluid and electrolyte balance in surgery
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 product in one I.V.line
• Calcium in RL binds with certain drugs – amphotericin, thiopental,
ampicillin, doxycycline) and reduces their efficiency.

27. 5 % Dextrose
Composition : one litre of fluid contains:
Glucose 50 gms
Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L)
Indications :
• Prevention and treatment of dehydration
• Pre and post op fluid replacement
• for IV administration of various drugs
• Prevention of ketosis in starvation, vomiting, diarrhea and high grade
fever
• Adequate glucose infusion protects liver against toxic substances
• Correction of hypernatremia due to pure water loss (e.g. diabetes
insipidus

28. Contra indications:
• Cerebral edema: due to its hypotonic nature
• Neuro surgical procedures: it increases intracranial pressure so it can
cause damage during neurosurgery
• Acute ischaemic stroke: because hyperglycemia aggravates cerebral
ischaemic brain damage.
• Hypovolemic shock
• Hyponatremia and water intoxication
• Same iv line blood transfusion and Dext.solution administeration–
hemolysis , clumping occurs
• Uncontrolled DM , severe hyperglycemia
Precautions: I.V. Dext. may cause local pain, vein irritation &
thrombophlebitis
Prolonged I.V. 5%dext. can cause hypokalemia, hypomagnesaemia and
hypophosphatemia.
Rate of adminstration – 0.5 gm/kgBW/hr or 666ml/hr 5 % D or 333ml/hr
10 %D

29. INVERTED SUGAR SOLUTION
Composition : inverted sugar 100 gms
Pharmacological basis :
equimolar mixture which contains half dextrose + half fructose
Indications :
• Treatment of nausea and vomiting (specially of pregnancy)
• Liver diseases (provides glucoise & prevents glycogen depletion)
Adverse effects :
1. Lactic acidosis
2. Hyperuricemia
3. hypophosphatemia
Contra indications
• hereditary fructose intolerance
• Cautions in renal & hepatic impairment
• >25gm fructose/day should be avoided
• more expensive fluid

30. Isotonic saline(0.9 % NS)
• Composition : Na+ 154 mEq, Cl- 154 meq
each 100ml contains: sodium chloride 0.90 gm
• Pharmacological basis : provide major ECF electrolytes..
corrects both water and electrolyte deficit.
increase the iv volume substantially
Indications
• Water and salt depletion – diarrhoea, vomiting, excessive diuresis
• Hypovolemic shock
• Alkalosis with dehydration
• Severe salt depletion and hyponatremia
• Initial fluid therapy in Diabetic ketoacidosis
• Treatment of Hypercalcemia

31. • Fluid challenge in prerenal ARF
• Irrigation – washing of body fluids
• Vehicle for certain drugs and can be given safely with blood
Contra indications
• Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis
• Dehydration with severe hypokalemia – deficit of ICF potassium
• Large volume may lead to hyperchloremic acidosis.

32. DNS
Pharmacological basis :
• Supply major EC electrolytes, energy and fluid to correct dehydration
Indications :
• Correction of salt depletion and hypovolemia
• Correction of vomiting or NGT aspiration induced alkalosis and
hypochloremia
• Compatible with blood transfusion
Contra indications :
• Anasarca – cardiac, hepatic or renal
• Severe hypovolemic shock when rapid replacement with larger volume of
fluid is required as it causeshyperglycemia andosmotic diuresis

33. DNS with
half strength saline
Pharmacological basis :
• Supply major EC electrolytes, energy and fluid to correct dehydration
• more water with less salt.
Indications :
• paediatric & very elderly
• Maintenance fluid in early post operative periods
• Treatment of hypernatremia
• Compatible with blood transfusion
Contra indications :
• hyponatremia
• Severe dehydration

34. 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

35. Isolyte G :
• Vomiting or NGT induced hypochloremic, hypokalemic
metabolic alkalosis
• NH4 gets converted to H+ and urea in liver
• Treatment of metabolic alkalosis and in vomiting and continuous
gastric aspiration
• Contraindications : Hepatic failure, renal failure, metabolic
acidosis
Isolyte M: (maintenance solution with 5% Dextrose)
• Richest source of potassium (35 mEq)
• Ideal fluid for maintenance
• Correction of hypokalemia
• Contraindications : Renal failure, burns, adrenocortical
insufficiency

36. 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, it has double the concentration
of K and acetate (47mEq)
• Only iv fluid to correct Mg deficiency
• Treatment of diarrhoea, metabolic acidosis
• Contraindications – metabolic alkalosis

37. 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..

38. Crystalloids …

39. Colloids
Colloids : large molecular wt substances that largely remains in
the intravascular compartment thereby generating oncotic
pressure
• 3 times more potent than crytalloid fluids for increasing
vascular volume and supporting the cardiac output
• 1 ml blood loss = 1ml colloid = 3ml crystalloids

40. colloids…

41. Characteristics of I.V. Colloid fluids
Type of fluid Effective plasma
volume
expansion/100ml
Duration of
expansion
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

42. Albumin
• Maintain plasma oncotic pressure – 75-80 %
• 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 within 4-5 min.
Rate of infusion :
• Adults – initial infusion of 25 gm
• 1 to 2 ml/min – 5% albumin
• 1 ml/min - 25% albumin

43. Indications :
• Plasma volume expansion in acute hypovolemic shock, burns,
severe hypoalbuminemia
• Hypo proteinemia – liver disease, Diuretic resistant in nephrotic
syndrome
• Oligourea
• In therapeutic plasmapheresis , as an exchange fluid
Contra indications :
• Severe anaemia, cardiac failure
• Hypersensitive reaction

44. 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, but not suitable for blood
transfusion.
• Dextran 40 as 10% sol greater expansion , short duration( 6hrs)
– rapid renal excretion
• Anti thrombotic , inhibits platelet aggregation
• Improves micro circulatory flow as preventing
thromboembolism.

45. Indications :
• Hypovolemia correction
• Prophylaxis of DVT and post operative thromboembolism
• Improves blood flow and micro circulation in threatened
vascular gangrene
• Myocardial ischemia, cerebral ischemia as maintaining
vascular graft patency
Adverse effects
• Acute renal failure
• Interfere with blood grouping and cross matching
• Hypersensitivity reaction

46. 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

47. Gelatin polymers( haemaccel)
• 500 ml 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 145 mEq, Cl 145 mEq, Ca 12.5 mEq,
potassium 5.1 mEq
Indications :
• Rapid plasma volume expansion in hypovolemia
• Volume pre loading in general anesthesia
• Priming of heart lung machines

48. Advantages :
• Does not interfere with coagulation, blood grouping
• Remains in blood for 4 to 5 hrs
• Infusion of 1000ml expands plasma volume by 50%
Side effects :
• Hypersensitivity reaction
• Bronchospasm, hypotension
• Should not be mixed with citrated blood

49. Hydroxyethyl starch
Hetastarch :
• Hetastarch is a synthetic colloid available as 6% solution in
Isotonic saline
• 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

50. Advantages :
• Non antigenic
• Does not interfere with blood grouping
• Greater plasma volume expansion
• Preserve intestinal micro vascular perfusion in endotoxaemia
• Expands plasma volume for a longer period, effect lasts for
about 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 , factor VIII (anti-haemophilic
factor)

51. Contra indications :
• Bleeding disorders , CHF
• Impaired renal function
Administration :
• Adult dose 6% solution – 500ml to 1 lit
• Total daily dose should not exceed 20ml/kg

52. Pentastarch :
• Low molecular weight derivative of Hetastarch that is
available as 3%, 6% and 10% solution in Isotonic saline
• Lower degree of esterification
• Lesser effect on coagulation
• 10% solution can increase plasma volume 1.5 times of infused
volume

53. Special fluids
• Inj KCl 10 ml amp – 20mEq potassium
uses: treat hypokalemia
precautions: never give direct I.V. KCl injection
always use Inj.KCl diluted in infusion
never add more than 40 mEq potassium/litre
never infuse more than 10 mEq potassium/hour
• 25%D (25 ml amp or 100 ml infusion bottle)– in hypoglycemic shock
• Inj. Sodium bicarbonate (25 ml amp. 22.5mEq Na+ & 22.5mEq HCO3-)
dose = 10-15 mEq/L : in metabolic acidosis
uses: as an Alkalinising agent, to treat metabolic acidosis
and hyperkalemia
• Mannitol 10% & 20% : it is an osmotic diuretic
uses: reduce intracranial and intraocular pressure,

55. Fluid therapy in
surgical patients
• Fluid and electrolyte management is an important aspect for the
care of the surgical patient. Changes in both fluid volume and
electrolyte composition occur preoperatively, intraoperatively,
and post operatively, as well as in response to trauma and
sepsis.
• Proper fluid & electrolyte state is helpful in reducing morbidity
& mortality in certain surgical procedures, hence it is important.

56. 1. Acute stress : which increases sympathetic stimuli leads to
tachycardia & vasoconstriction, so it needs for correction
2. NPO require consideration & replacement.
3. Pre, intra & post operative blood / fluid loss require
consideration & replacement.
4. Hypovolemia should be corrected preoperatively 
hypotension intraoperatively
5. Surgical stress / direct damage can affect kidney, brain, lungs,
skin or GIT, should be considered as they play important role in
fluid & electrolyte balance, so fluid therapy in such surgical
patients needs special consideration.

57. Preoperative fluid therapy
• Very important for better outcome in surgical patients.
• 3 parameter are important
1. Correction of hypovolemia
2. Correction of anemia (48 hours prior to surgery)
3. Correction of other disorders (eg. Fluid overload hypo &
hyperkalemia)
For correction fluid deficit in pre operative period, needs proper fluid
replacement which depends on nature of loss, haemodynamic
status and compositional abnormality. 0.9% saline, RL, colloids
and whole blood are used.

58. Intraoperative fluid therapy
• A patient undergoing surgery should receive fluid deficit due to starvation +
maintenance fluids + third space losses + replacement of blood loss.
1. Correction of fluid deficit due to starvation :
2. Maintenance volume for intraop period :
3. Correction of intra op loss :
Duration of starvation (in hr) x 2 ml / kg
5% D is usually use for starvation fluid deficit
Duration of surgery (in hr) x 2 ml / kg
a. Suction container
b. Surgical sponge
c. Third space loss
Type of trauma Requirement of
fluid
Least trauma 2 ml /kg / hr
Minimal trauma 4 ml /kg / hr
Moderate trauma 6 ml /kg / hr
severetrauma 8 ml /kg / hr

59. 4. Blood loss is replaced by compatible blood
transfusion (homologous or autologous), if
haematocrit falls below 25%.
• Blood loss is replaced with an equal amount of
colloid or three times the volume with crystalloids if
haematocrit is > 25%

60. Postoperative fluid therapy
1. First 24 hrs of surgery (total = 2 L)
2. 2nd post op day (total = 3 L)
3. 3rd post op day (total = 3 L)
2L 5% D or 1.5 L 5% D + 500ml 0.9% NS
2L 5% D + 1L 0.9% NS
2L 5% D + 1L 0.9% NS + 40-60 mEq K+ / day

62. 1. Helen Giannakopoulos, Lee Carrasco, Jason Alabakoff, Peter D.
Quinn. Fluid and Electrolyte Management and Blood Product
Usage. Oral Maxillofacial Surg Clin N Am 18 (2006) 7 – 17.
2. Guyton & Hall textbook of medical physiology,11th edition.
3. K. Sembulingam Prema. K Sembulingam - Essentials of
Medical Physiology, 5th Edition
4. Concise Textbook of Surgery – S.Das, 7th ed.
5. Sanjay Pandya – Practical guidelines on fluid therapy, 2nd
edition
6. Davidson’s Principles & Practice of Medicine, 22nd edition.
7. K. Rajgopal Shenoy, Anitha Nileshwar – Manipal Manual of
Surgery, 3rd edition
References