IV FLUIDS

Dr.Unnikrishnan.C.P
 Topics of Discussion
Introduction
Crystalloids-Types
Colloids-Types
Fluid therapy in different situations
- Hypovolemic Shock
- Sepsis
- Congestive Cardiac Failure
- Accute Kidney Failure
- Hepatic Failure
- Burns
- Vomiting
- Trauma
- Neuro Surgery cases
 INTRODUCTION
• In 1861 Thomas Graham’s investigated and classified substances as crystalloids
and colloids depending on their ability to diffuse through a parchment membrane.

• Intravenous fluids are similarly classified based on their ability to pass through
capillary walls that separate the intravascular and interstitial fluid compartments

• Crystalloid fluids are electrolyte solutions with small molecules that can diffuse
freely from intravascular to interstitial fluid compartments

• Colloid fluid is a saline solution with large solute molecules that do not pass
readily from plasma to interstitial fluid. The retained molecules in a colloid fluid
create an osmotic force called the colloid osmotic pressure or oncotic pressure that
holds water in the vascular compartment
 COMPOSITION OF BODY FLUIDS

• Water is the most abundant constituent in the body, comprising approximately

50% of body weight in women and 60% in men

• 55–75% is intracellular [ICF] and 25–45% is extracellular [ECF]

• The ECF is further subdivided into intravascular (plasma water) and

extravascular (interstitial) spaces in a ratio of 1:3

• Fluid movement between the intravascular and interstitial spaces occurs across
the capillary wall and is determined by Starling forces, i.e., capillary hydraulic
pressure and colloid osmotic pressure
 Distribution of Fluid Volume
Fluid Total ICF ECF Interstitial Plasma
Type
% of 60% 40% 20% 15% 5%
Body
Weight
Volume 42L 28L 14L 10.5L 3.5L
for 70 kg
Weight
• Principal component of extracellular
fluid is Sodium  responsible for
much of extracellular fluid
osmolality

• Principal component of intracellular

fluid is Potassium key role in the
maintenance of transmembrane
potentials
The aims of IV fluid administration should be to

• Avoid dehydration

• Maintain an effective circulating volume

• Prevent inadequate tissue perfusion during a period when the patient is

unable to achieve these goals through normal oral fluid intake

“Intravenous fluids have a range of physiologic effects and should be

considered to be drugs with indications, dose ranges, cautions, and side
effects.”
 INSENSIBLE AND SENSIBLE LOSS OF WATER

 Oral or IV fluid intake and urine output are important

parameters of body fluid balance
Insensible fluid input Insensible fluid loss
300 ml water due to oxidation 500 ml through skin
400ml through lung
100 ml through stool

 Normal daily insensible fluid loss:

Fluid loss – Fluid input = 1000-300 = 700 ml.
 Daily fluid requirement = urine output + insensible loss
URINE OUT PUT IS
= 1.5ml/kg/hr
For a person of 70kg
Urine out put = 70 x 1.5x24=2.5lit/day
For a normal adult fluid requirement is
= Urine out put +insensible loses
= 2.5 lit + 0.7 lit
= 3.2 lit/day
THE REQUIREMENT OF AN INDIVIDUAL DAILY
For an adult- 2ml/kg/hr
Children - 4ml/kg/hr
 Classification of IV Fluids
Can be broadly classified into 3 groups
1. Maintenance Fluids
Replaces fluids lost from skin,lungs,urine & faeces.These loses are
poor in salt so the maintenance fluid should be hypotonic to plasma
sodium. Eg.5%D, D1/2 NS

2. Replacement Fluids
Replaces losses such as gastric drainage,vomiting,diarrhoea,fistula
drains,oozing from trauma,burns etc. Eg.NS,DNS,RL,Isolyte M,P,G.

3. Special Fluids
For special indications such as hypoglycemia,hypokalemia and
metabolic acidosis. Eg.25%D,Inj.Sodabicarb,Inj.KCl
CLASSIFICATION BASED UPON COMPONENTS
I V Fluids

Blood and Products Non blood I V Fluids

Crystalloids Colloids

•Glucose Containing Proteinous Non proteinous

•Electrolyte
solutions
•Mixed Albumin Starch Dextrans
Gelatins 20% & 5%
• Haemaccel
• Gelofusin  Hydroxy
Ethyl Starch
 PentaStarch
 Tetrastarch
CRYSTALLOIDS
 CRYSTALLOIDS
Crystalloid are electrolyte solutions with small molecules that can diffuse freely from
intravascular to interstitial fluid compartments
• The principal component of crystalloid fluids is sodium chloride. Sodium is the
principal determinant of extracellular volume, and is distributed uniformly in the
extracellular fluid
• Because the plasma volume is only 25% of the interstitial fluid volume only 25% of an
infused crystalloid fluid will expand the plasma volume, while 75% of the infused
volume will expand the interstitial fluid.
• Thus, the predominant effect is only 25% of transfused crystalloids remains in the
intravascular space and 75% diffuses into interstitial space
The effects of selected colloid and crystalloid fluids on the plasma volume
and interstitial fluid volume
General characteristics of
Crystalloid

• Contains water and electrolytes

• Non ionic solutions expands all the compartments i.e intracellular and
extracellular space

• Sodium cannot gain access into the intracellular space. Hence all sodium will
remain in the extracellular space thus expanding it
 CRYSTALLOIDS

HYPOTONIC ISOTONIC HYPERTONIC IONIC NON-IONIC

• NS
• D5W • 5% Dextrose
• RL • Hypertonic • NS
• ½NS(0.45%) • 25% Dextrose
• Plasmalyte saline • Dextrose saline
• 10%, 25% & (DNS)
50% dextrose. • Ringer’s lactate
 NORMAL SALINE
• One of the most commonly administered crystalloids

• Using in vitro red cell lysis experiments, Hamburger ascertained that 0.9%
was the NaCl concentration that was isotonic with human plasma. It was not
initially developed with the aim of in vivo administration, yet has entered
widespread clinical use despite having a Na+ and Cl− concentration far in
excess of that of plasma.

• 0.9% saline also known as normal saline, physiological saline, isotonic

saline - but none of these names are appropriate as chemically it is not
normal because the concentration of a one-normal (1 N) NaCL solution is
58 grams per liter (the combined molecular weights of sodium and
chloride), while 0.9% NaCL contains only 9 grams of NaCL per litre)
• Composition
Na-154 meq/l
Cl- 154 meq/l
pH- 5.7
hence it affects the acid base balance of the body

• Pharmacological basis

1. Provide major extracellular electrolytes.

2. Corrects both water and electrolyte deficit.
3. Increase the intravascular volume substantially.
 Volume effects of NS
• Infusion of one liter of 0.9% NaCL adds 275 mL to the plasma volume and 825 mL to
the interstitial volume
• One unexpected finding; i.e., the total increase in extracellular volume (1,100 mL) is
slightly greater than the infused volume. This is the result of a fluid shift from the
intracellular to extracellular fluid, which occurs because 0.9% NaCL is slightly
hypertonic in relation to Extracellular fluid

Acid-Base Effect
• Large-volume infusions of 0.9% NaCL produce a metabolic acidosis
• The saline-induced metabolic acidosis is a hyperchloremic acidosis, and is caused by
the high concentration of chloride in 0.9% saline relative to plasma (154 versus 103
mEq/L)
 Interstitial edema

Promote interstitial edema more than other crystalloid fluids with a

lower sodium content (e.g., Ringer’s lactate, Plasma-Lyte)
through
1. Increased sodium load from 0.9% NaCL, which increases the
“tonicity” of the interstitial fluid
2. Sodium retention by the action of renin-angiotensin-aldosterone
axis
3. Decreases in renal perfusion have also been observed after
infusion of 0.9% NaCL,presumably as a result of chloride-
mediated renal vasoconstriction.
 Indications of Normal Saline

• To maintain effective blood volume and blood pressure in emergencies

• Water and salt depletion –diarrhoea, vomiting, excessive diuresis or excessive
perspiration
• Hypovolemic shock- distributed in extracellular space expanding the intravascular
volume. Ideal fluid to increase blood pressure.
• Preferred in case of brain injury, hypochloraemic metabolic alkalosis , hyponatraemia
• Initial fluid therapy in DKA
• In patients with hyperkalemia like renal failure
• Hypercalcaemia
• Fluid challenge in prerenal ARF
• Irrigation for washing of body fluids
• Vehicle for certain drugs
 Limitations/ Contraindications

• Avoid in Hypertension, Preeclamsia and in patient with edema due to

CCF, renal failure and cirrhosis
• In dehydration with severe hypokalaemia – deficit of intracellular potassium
– infusion of NS without additional K+ supplementation can aggravate
electrolyte imbalance
• Large volumes or too rapid administration can cause sodium accumulation
and pulmonary edema.
• Increased chloride content in relation to plasma can cause
hyperchloremic metabolic acidosis in large volume administration
 RINGER'S FLUIDS
• In 1880, Sydney Ringer , a British physician studied the contraction of
isolated frog heart

• He introduced a solution that contained calcium and potassium in sodium

chloride solution to promote cardiac contraction and cell viability. This is
known as Ringer`s injection

• In early 1930, an American pediatrician named Alex Hartmann added

sodium lactate to Ringer`s solution as a buffer to metabolic acidosis.

• This is known as Hartmann`s solution or Ringer`s lactate

 Composition

Ion concentration RL
Sodium-131meq/l Chloride - 111meq/L
Potassium -5meq/L Calcium - 2meq/L
Bicarbonate - 29 meq/L
Each 100 ml contains
• Sodium lactate - 320mg
• NaCl - 600mg,
• KCl- 40mg CaCl- 27mg
 Advantage :
• Lack of significant effect on acid base balance

Disadvantage:
• Presence of ionized calcium in ringer’s lactate can bind to citrated
anticoagulant in stored blood and promote formation of clots.

• In critically ill patients with impaired lactate clearance due to circulatory

shock or hepatic insufficiency, Ringer’s lactate infusion can increase
serum lactate levels
 Pharmacological basis

• Ringer`s lactate is the most physiological fluid as the electrolyte content

is similar to that of plasma . Larger volumes can be infused without the
risk of electrolyte imbalance

• Due to high Na ( 130mEq/L) content RL rapidly expands intravascular

volume effective in treatment of hypovolemia

• Sodium lactate in RL is metabolized to bicarbonate in the liver -- useful

in correction of metabolic acidosis
 Indications :

• Correction in severe hypovolaemia

• Replacing fluid in post operative patients, burns , fractures.
• Diarrhoea induced electrolyte imbalance and hypovolemia.
• Fluid of choice in diarrhoea induced dehydration in paediatric patients.
• In DKA ,provides glucose free water, correct metabolic acidosis and supplies
potassium
• Maintainance fluid during surgery
 Contraindications
• Severe liver disease, severe hypoxia , shock – impaired lactate
metabolism –lactic acidosis.
• Severe CHF -lactic acidosis takes place.
• Addison’s disease
• In vomiting or continuous nasogastric aspiration, hypovolemia is
associated with metabolic alkalosis - as RL provides HCO3-
worsens alkalosis.
• Simultaneous infusion of RL and blood- inactivation of anticoagulant by
binding with calcium in RL – clots in donor blood.
• Certain drugs – amphotericin, thiopental, ampicillin, doxycycline
should not be mixed with RL – calcium binds with these drugs and
reduces bioavailability and efficiency
 DEXTROSE SOLUTIONS
• D5 water (5%D)
• Dextrose with 0.9% NS ( DNS ).
• Dextrose with 0.45% NS (D 1/2NS )
• 10% dextrose
• 25% dextrose

EFFECT OF DEXTROSE IN FLUID :

 Protein sparing effects
 Volume effect
 Lactate production.
 Effect of hyperglycemia
 Protein sparing effect

• Earlier it was used to provide calories in patients who were unable to eat.

• 50 grams of dextrose per liter provides 170 kcal

• Infusion of 3 liters of a D5 solution daily (125 mL/min) provides 3 x

170 = 510 kcal/day, which is enough nonprotein calories to limit the
breakdown of endogenous proteins to provide calories (i.e., protein-
sparing effect).

• It is no longer used frequently as most patients with long-term NPO

orders have enteral tube feedings or TPN.
 Volume Effects
5%D
• 50 g of dextrose adds 278 mOsm/L to IV fluids
• For a 5% dextrose the added dextrose brings the osmolality close to that of plasma.
However, dextrose is taken up by cells and metabolized, this osmolality effect rapidly
wanes, and the added water then moves into cells.
• The infusion of one liter of 5D results in an increase in ECF (plasma plus interstitial
fluid) of about 350 mL, which means the remaining 650 ml (two-thirds of the infused
volume) has moved intracellularly. Therefore, the predominant effect of D5W is cellular
swelling.
DNS
• Total osmolality of DNS fluid is 560 mOsm/L (278 of dextrose and 308 0f 0.9 NaCl)
which is almost twice the normal osmolality of the extracellular fluid. If glucose
utilization is impaired (as is common in critically ill patients), large-volume infusions
of D5W can result in cellular dehydration.
Enhanced lactate production
• In healthy individuals 5% of infused glucose is directed towards lactate
formation.
• In critically ill patients 85% of glucose is diverted to lactate production.
• when circulatory flow is compromised, infusion of 5% dextrose solutions can
result in lactic acid production and significant elevations of serum lactate

Hyperglycemia
It has several deleterious effects in critically ill patients including –
• Immune suppression .
• Increased risk of infection .
• Aggravation of ischemic brain injury
Considering the high risk of hyperglycemia in ICU patients, and the numerous
adverse consequences of hyperglycemia, infusion of dextrose containing fluids
should be avoided whenever possible.
 5 % DEXTROSE
Composition : Glucose 50 gms/L + free water

Pharmacological Basis
•Corrects Dehydration And Supplies Energy ( 70kcal/L)
•Administered safely at the rate of 0.5gm/kg/hr without causing glycosuria

Metabolism
 Dextrose is metabolised leaving free water  distributed in all
compartments of the body.
 A proportion of dextrose load contributes to lactate formation –
 5% in healthy subjects
 85% in critically ill patients ----hence not the preferred fluid.
 Indications of 5%D

• Prevention and treatment of intracellular dehydration

• Cheapest fluid to provide adequate calories to body
• For pre and post operative fluid management
• IV administration of various drugs
• Treatment and Prevention of ketosis in starvation, vomiting, diarrhoea
• Adequate glucose infusion protects liver against toxic substances.
• Correction of hypernatraemia due to pure water loss ( Diabetes insipidus)
 Limitations of 5D
1. Neurosurgical procedures - can aggravate Cerebral oedema and increase ICT
2. Acute ischaemic stroke-
• Hyperglycemia aggravates cerebral ischaemic brain damage.
• Dextrose metabolism aggravates tissue acidosis in ischaemic areas-
anerobic oxidation of glucose produces more lactic acid and free radicals
3. Hypovolemic shock
• Poor expansion of intravascular volume.
• Faster rate of infusion causes osmotic diuresis  worsens shock and false
impression of the hydration status  reduced fluid replacement.
4. Hyponatremia & water intoxication - 5%D worsens both conditions
 Limitations of 5D
5. Hypernatremia – fast infusion of 5D rapidly corrects hypernatremia but
correction occurs slowly in brain cells, so swelling of brain cells can lead
to permanent neurological damage. Moreover rapid infusion of 5D induces
osmotic diuresis which aggravates hypernatremia.

6. Can cause Hypokalemia, hypomagnesemia and hypophosphatemia

7. Blood and dextrose solutions should not be administered in same IV
line – haemolysis ,clumping seen due to hypotonicity of the solution.
8. Uncontrolled DM , severe hyperglycemia
 DEXTROSE SALINE (DNS)
Composition
Na+ 154mEq/L
CI - 154mEq/L
Glucose- 50 gm/L

Pharmacological basis
• Supply major extracellular electrolytes, energy and fluid to correct
dehydration
• In presence of incompletely or partially corrected shock patient will have
increased urine output (due to diuresis)
• Unlike 5D, DNS is not hypotonic (due to Nacl) and hence it is compatible
with blood transfusion
Indications .
Conditions with salt depletion and hypovolaemia with supply of energy-
Fluid compatible with blood transfusion
Correction of vomiting or nasogastric aspiration induced alkalosis and
hypochloremia along with supply of calories

Limitations
• Anasarca – cardiac, hepatic or renal cause
• Severe hypovolemic shock – rapid correction is needed. Faster
infusion can cause osmotic diuresis and worsen the condition.
 DEXTROSE WITH HALF STRENGTH SALINE
Composition : 5% dextrose with 0.45% NS,NaCl -77 meq/Leach,glucose 50 gm/L
Contains 50% salt as compared to DNS /NS and used when there is need for
calories , more water and less salt.
Indications
1. Fluid therapy in paediatric – In paediatric group ratio of requirement of water :
NaCl is double as compared to adults
2. Treatment of severe hypernatremia – It corrects hypernatremia gently, it avoids
cerebral edema
3. Maintenance fluid therapy and in early post operative period.
Limitations
1. Hyponatremia
2. Severe dehydration where larger salt replacement is needed
 10% DEXTROSE & 25% DEXTROSE

Composition
1 litre of 10% D has 100 gms glucose
1 litre of 25%D has 250 gms glucose

Pharmacological basis:
• It is hypertonic crystalloid fluid
• Supplies energy and prevents catabolism -useful when faster replacement of
glucose is needed like in Hypoglycemic coma
• In patients with fluid restriction- CCF, Cirrhosis and Renal failure
Indications
• Rapid correction of hypoglycaemia .
• In liver disease, if given as first drip, it inhibits glycogenolysis and
gluconeogenesis
• Nutrition to patients on maintainance fluid therapy.
• Treatment of hyperkalemia with Insulin
Limitations
• In patients with dehydration, anuria, intracranial hemorrhage and in
delirium tremens
• Avoided in patients with diabetes unless there is hypoglycemia.
• Rapid infusion of 25D can cause glycosuria.Hence in the absence of
hypoglycemia it should be infused slowly over 45 - 60 min
 HYPEROSMOLAR FLUIDS

MANNITOL
HYPERTONIC SALINE
 MANNITOL

• Mannitol is an osmotic diuretic that is metabolically inert in humans

• Mannitol elevates blood plasma osmolality, resulting in enhanced flow of
water from tissues, including the brain and cerebrospinal fluid, into
interstitial fluid and plasma
• Benificial effects are due to the reduction in blood viscosity
• Complications associated are
• Rebound edema
• Dehydration due to osmotic diuresis
• Renal failure
 Limitations

• Anuria due to severe renal disease

• Cannot be used in patients with hypotension
• Severe pulmonary congestion or frank pulmonary edema
• Active intracranial bleeding except during craniotomy.
• Severe dehydration
• Progressive renal damage or dysfunction after institution of mannitol
therapy, including increasing oliguria and azotemia.
 HYPERTONIC SALINE
• Available as 1.8%, 3% , 5%, and 7.5%
 PHARMACOLOGICAL PROPERTIES
The hypertonic nature of these solutions draws water out of the
intracellular compartment into the extracellular compartment
USES
• Plasma volume expansion: The hypertonic nature of these solutions
draws water out of the intracellular compartment and into the
extracellular (including plasma) volume and may therefore achieve
plasma volume expansion while minimizing the volume of fluid
administered. However, clinical trials have not shown any benefits.
• Correction of hypo osmolar hyponatremia
• Treatment of raised ICT - superior to mannitol
• 7.5% - endothelial injury  used as sclerosant
 Isolyte G,M,P,E
ISOLYTE G ISOLYTE M ISOLYTE P ISOLYTE E
DEXTROSE 50 50 50 50
Na 63 40 25 140
K 17 35 20 10
Cl 150 40 22 103
Acetate --- 20 23 47
Lactate --- --- --- ---
NH4CL 70 --- --- ---
Ca --- --- --- 5
Mg --- --- --- 3
HPo4 --- 15 3 ---
Citrate --- --- 3 8
Mosm/L 580 410 368 595
 INDICATIONS AND LIMITATIONS
Isolyte G :
Vomiting / NGT induced hypochloremic , hypokalemic metabolic alkalosis.
NH4 gets converted to H+ and urea in the liver.
Treatment of metabolic alkalosis.
Limitations : hepatic failure , renal failure , metabolic acidosis

ISOLYTE M:
Richest source of potassium (35mEq)
correction of hypokalaemia.
LIMITATIONS : Renal failure ,burns, adrenocortical insufficiency.
ISOLYTE P:
Maintenance fluid for children.
Excessive water loss or inability to concentrate urine .
LIMITATIONS : hyponatremia , renal failure.

ISOLYTE E:
Extracellular replacement fluid, additional potassium and acetate.
Corrects Mg deficiency.
Treatment of diarrhoea and metabolic acidosis.
LIMITATIONS : metabolic alkalosis.
 PLASMA-LYTE
• Ionic concentration of 1 litre
Na+ - 140 mEq , K+ - 5 mEq ,Mg2+ - 3 mEq,
Cl- - 98 mEq ,27 mEq acetate, and 23 mEq gluconate with a pH of 7.4.
• The caloric content is 21 kcal/L.
• Each 100 mL contains - 526 mg of NaCl; 502 mg of Sodium Gluconate;
368 mg of Sodium Acetate Trihydrate; 37 mg of KCl and 30 mg of
Magnesium Chloride.
• Osmolarity - 295 mOsmol/L .
• Acetate and gluconate ions are metabolized ultimately to carbon dioxide
and water, which requires the consumption of hydrogen cations -
alkalinizing effect.
• Caution : in patients with hyperkalemia, severe renal failure, and in
conditions in which potassium retention is present.
COLLOIDS
 COLLOIDS
• The term colloid is derived from Greek word “Glue”.
• These solutions are also called suspensions.
• Colloid fluid is a saline fluid with large solute molecules that do not
readily pass from plasma to interstitial fluid.
• Colloids have large molecular weight >30000 Daltons that largely
remain in intravascular compartment.
• The retained molecules create an osmotic force called colloidal osmotic
pressure or oncotic pressure.
• In normal plasma the plasma proteins are the major colloids present.
 General characteristics of colloids

This characteristic determines their behaviour in the intravascular compartment

1. Molecular weight.
2. Colloid molecular size.
3. Plasma volume expansion- determined by the molecular weight.
4. Osmolality.
5. Colloid osmotic pressure - determines the volume of expansion.
6. Plasma Half Life - depends on the molecular weight and the route of
elimination.
7. Acid base composition - albumin and gelatin have physiologic pH, others
are acidic
 Capillary fluid Exchange

• The direction and rate of fluid exchange (Q) between capillary blood and
interstitial fluid is determined, in part, by the balance between the hydrostatic
pressure in the capillaries (Pc), which promotes the movement of fluid out of
capillaries, and the colloid osmotic pressure of plasma (COP), which favors
the movement of fluid into capillaries.
Q ≈ PC – COP
• Normal Pc averages about 20 mm Hg (30 mm Hg at the arterial end of the
capillaries and 10 mm Hg at the venous end of the capillaries); the normal
COP of plasma is about 28 mm Hg, so the net forces normally favor the
movement of fluid into capillaries (which preserves the plasma volume)
• About 80% of the plasma COP is due to the albumin fraction of plasma
proteins
 Resuscitation Fluids

• Crystalloid fluids reduce the plasma COP (dilutional effect),which

favors the movement of these fluids out of the bloodstream.

• Colloid fluids can preserve the normal COP (iso-oncotic fluids), which
holds these fluids in the bloodstream, or they can increase the plasma
COP (hyperoncotic colloid fluids), which pulls interstitial fluid into
the bloodstream.
 COLLOIDS

Natural Artificial
colloids colloids

Fresh Frozen
Plasma Dextrans

Albumin 5%,20%
Gelatins
25%
Hydroxy Ethyl
Plasma proteins
Starch
4% 5%
CHARACTERISTICS OF I.V. COLLOIDS FLUIDS PER 100ML INFUSION

FLUID TYPE ONCOTIC PRESSURE PLASMA VOLUME DURATION OF

(mmHg) EXPANSION EFFECT
5% Albumin 20 70-130 ml 12 h

25% albumin 70 400-500 ml 12 h

10% Dextran-40 40 100-150 ml 6h

6% Dextran-70 80 ml 12 h

6% Hetastarch 30 100-130 ml 24 h

10% Pentastarch 150 ml 8h

Colloid fluid is about 3 times more effective in expanding the plasma

volume than the crystalloid fluid
 ALBUMIN
• Albumin is a versatile plasma protein synthesized only in the liver and has a
half-life of approximately 20 days.
• Principal determinant of plasma colloid osmotic pressure COP(75% of the
oncotic pressure),principal transport protein in blood,has significant
antioxidant activity,and helps to maintain the fluidity of blood by inhibiting
platelet aggregation
• 5% albumin ( 50gm/L or 5gm /dl) has COP of 20 mmHg (similar to plasma) &
expands plasma volume to same as volume infused
• 25% albumin ( 250gm/L or 25gm /dl) has COP of 70 mmHg & expands
plasma volume by 4 to 5 times the infused volume
 Indications:
• Emergency treatment of shock specially due to the loss of plasma.
• Acute management of burns
• Fluid resuscitation in intensive care
• Clinical situations of hypo-albuminemia
i. Following paracentesis.
ii. Patients with liver cirrhosis.
iii. After liver transplantation.
• Spontaneous bacterial peritonitis
• Acute lung injury
• Correction of diuretic resistant nephrotic syndrome.
• In therapeutic plasmapheresis
 Precautions and contraindications
• Because it does not replace lost volume, but instead shifts fluid from
one compartment to another, 25% albumin should not be used for
volume resuscitation in patients with blood loss
• 5% albumin is safe to use as a resuscitation fluid, except possibly in
traumatic head injury
• Hyper oncotic (25%) albumin has been associated with an increased
risk of renal injury and death in patients with circulatory shock
• Fast infusion will rapidly increase circulatory volume with
resultant vascular overload and pulmonary oedema
• Contraindicated in severe anaemia and cardiac failure.
• Dehydrated patient may require additional fluids along with albumin
• Should not be used as parenteral nutrition
 Disadvantages

1.Cost : Albumin is expensive as compared to synthetic colloids

2.Volume overload: In septic shock the release of inflammatory

mediators has been implicated in increasing the ‘leakiness’ of the
vascular endothelium. The administration of exogenous albumin may
compound the problem by adding to the interstitial edema.
 GELATIN POLYMERS( HAEMACCEL)

• Gelatinis a large molecular weight protein formed from hydrolysis of

bovine collagen.
• Gelatin solutions were first used as colloids in man in 1915.
• The MW ranges from 5,000 to 50,000 with a weight average MW of
35,000.

3 types of gelatin solutions-

• Succinylated or modified fluid gelatins (e.g.,Gelofusine, Plasmagel,
Plasmion)
• Urea-crosslinked gelatins (e.g., Polygeline)
• Oxypolygelatins (e.g., Gelifundol)
 HYDROXYETHYL STARCH
• Hydroxyethyl starch (HES) is a chemically modified polysaccharide
composed of long chains of branched glucose polymers substituted
periodically by hydroxyl radicals(OH), which resist enzymatic degradation

• HES elimination involves hydrolysis by amylase enzymes in the

bloodstream, which cleave the parent molecule until it is small enough to
be cleared by the kidneys

• HES are derivatives of amylopectin, which is a highly branched

compound of starch.
 DEXTRAN
• Dextrans are highly branched polysaccharide molecules which are
available for use as an artificial colloid
• These glucose polymers are produced by bacterium (leuconostoc
mesenteroides) incubated in sucrose medium by bacterial dextran
sucrase

Physico chemical properties

• Two dextran solutions are now most widely used,
6% solution with an average molecular weight of 70,000 (dextran 70)
10% solution with an average weight of 40,000 (dextran 40, low-
molecular-weight dextran).
FLUIDS IN SPECIFIC CONDITIONS
 HYPOVOLEMIC SHOCK
 Isotonic saline (NS) is selected as an initial fluid because
 1 litre of NS will expand intravascular volume by 300ml
1 Litre FLUIDS ECF - Intravascular ECF- Interstitial ICF

NS 300 ml 700 ml NIL

5%D 83 ml ( 75-100) 260 670
COLLOIDS 1000 ml

 Unknown glycemic status (Dextrose solutions will rise glucose level rapidly)
 Unknown renal status – RL can cuase hyperkalemia or lactic acidosis
 Reaction free (compared to colloids), Least expensive and readily available
 RL is preferred IV fluid after urine output is established
 RL is most physiological fluid, so large volume can be infused without
electrolyte imbalance
 In shock hepatic conversion of lactate to bicarbonate is unpredictable
Colloids in Hypovolemic shock
More effective plasma expanders as these agents are restricted to
intravascular compartments
Lesser risk of pulmonary oedema
Primary indication is hypotension in protein losing state –burns
Although used in shock , they offer little or no advantages over
crystalloids

Blood in hypovolemic shock

In patients who are bleeding
Severe Anaemia
However with blood transfusion haematocrit should not be raised
over 35% - increase in blood viscosity lead to stasis
 SEPSIS
• Cardiovascular instability may be a particular problem, contributed by
• Endothelial dysfunction
• Intravascular fluid loss
• Vasodilation with fluid maldistribution
• Sympathetic redistribution of blood volume away from the peripheral
circulation, and
• Impairment of cardiac function

• Fluid resuscitation,with the goal of maintaining adequate end-organ

perfusion is therefore a key part of the first 6 hours of sepsis treatment.
• Targets suggested for patients with sepsis who have tissue hypoperfusion, defined by
blood lactate concentration >4 mmol/L or hypotension persisting after initial IV fluid
challenge:
• CVP 8 to 12 mm Hg (12 to 15 mm Hg in patients on ventilation)
• MAP 65 mm Hg or greater
• Urine output 0.5 mL/kg/hr or greater
• Scvo2 greater than 70%
• In the critical care setting, the use of colloids as resuscitation fluid has been the
subject of a number of important recent publications, which have led to the
withdrawal of Hydroxy Ethyl Starch.
• The crystalloid versus hydroxyethyl starch (CHEST) trial compared the use of
starches for resuscitation with crystalloids and showed not only no survival benefit
with the use of starch but also increased risk ofAKI.
• The use of expensive synthetic colloids is difficult to justify as there is a
failure to identify a mortality benefit associated with their use
• However, if the endothelial glycocalyx is impaired (as it is in severe sepsis),
then intravascular retention of any colloid may be no better than that of
crystalloid.

• In patients with established acute respiratory distress syndrome (ARDS)- the

focus of fluid therapy is the fine balance between avoiding an increase in
lung edema while maintaining adequate tissue perfusion.

• However, there is a lack of adequately powered studies on the choice of

colloid or crystalloid for intravascular volume replacement in patients with
ARDS.
 RECOMMENDATIONS

• Guidelines on IV fluid therapy published by the National Institute for

Health and Care Excellence (NICE) recommend the use of crystalloid
solutions containing a sodium concentration in the range of 130– 154
mmol litre for i.v. fluid resuscitation, and recommend against the use of
tetrastarch for this purpose

• Current recommendations are to use 30 mL/kg of crystalloid in a

protocolized fashion to achieve the described targets

• In patients requiring further fluid, albumin should be considered, along

with vasopressors, inotropes, and RBC transfusion to attain these goals.
 FLUID CHALLENGE
• The fluid challenge is considered the gold standard for diagnosis of fluid
responsiveness.
• The volume of fluid infused must be sufficient to increase right ventricular
diastolic volume and subsequently stroke volume (SV) as described by the
Frank-Starling law.
• Fluid responsiveness is conventionally defined as an increase of at least
10% to 15% in SV in response to a fluid challenge.
• Patients who reach this threshold are considered ‘fluid responders’.
 CONGESTIVE HEART FAILURE
Oedema in CCF is due to water and salt retention (water retention is more than
salt leads to hyponatremia)
Oral route always preferred – provides better nutrition and salt restriction
DON’T
Don’t correct hyponatremia with salt supplementation- because it is
dilutional
Don’t treat hyponatremia with sodium rich fluids -treat with ionotropes
Don’t chase urine output – diuretic induced
DO’S
Give less fluid
Restrict sodium
Correct potassim deficit induced by diuretic – oral route safer than IV fluid
 AKI
General principles of Fluid and electrolyte management
Fluid restriction in oedematous and oliguric patients
Fluid intake = urine output+ 500ml/day
Salt restriction – 2 to 3 gm per day
Avoid hyperkalemia

Acute renal failure (ARF) – Fluid management as per presentation

1. Prerenal azotemia
 In oliguric patients who are not volume overload and prerenal
azotemia is likely, fluid challenge is appropriate
 500-1000ml of NS over 30-60 min may results in increased urine
flow ,if no response add Frusemide
 I V fluid in hypotensive state is NS
2. Non oliguric ARF
 Due to septicemia, aminoglycosides, acute interstitial nephritis
 Carry risk of hyperkalemia and acidosis -K⁺ intake should be restricted

3. Oligiric ARF
 Due to acute tubular necrosis usually last for 1-3 week
 Urine output < 400 ml/day or < 0.5 ml/kg/hr
 Fluid, salt and K are restricted
 If patient needs preferred I V fluid is 5% dextrose or 10% dextrose

4. Diuretic phase of ARF

 Volume depletion and dehydration should be avoided
 Preferred IV fluid is Half strength saline (0.45%) with
K⁺ requirement
 HEPATIC FAILURE
ASCITIES IN CIRRHOSIS OF LIVER
Plasma volume expansion during paracentesis by colloids like albumin, plasma
proteins, blood transfusion prevents hypotension and permits large volume
paracentesis
6-8 gm of albumin for per litre of ascitic fluid removed
FFP for coagulation disorder and whole blood for anaemia

HEPATIC ENCEPHALOPATHY
Preferred fluid → 10% dextrose, 20% dextrose and DNS to prevent hypoglycemia
Avoid
 5% dextrose - hypotonic fluid aggravate cerebral edema
 Isolyte-G - contains ammonium chloride which precipitate hepatic precoma
 RL – contains lactate which gets converted into bicarbonate by liver →
alkalosis If lactate metabolism is impaired leads to lactic acidosis
 BURNS
• Extensive burns causes copious fluid loss from the circulation combined
with particular sensitivity to the effects of excess fluid administration.
• Local impairment of endothelial barrier function-loss of oncotically active
plasma constituents - increased capillary filtration into the interstitial
compartment and evaporative transcutaneous fluid loss due to loss of
skin integrity.
• Fluid administration is based on formulas such as the Parkland formula or
the Muir and Barclay versions.
• Fluids are down-titration of administered fluid volumes if urine output is
adequate (0.5 to 1 mL/kg/hr)
 FLUID THERAPY IN VOMITING
Vomiting and nasogastric aspiration
Commonly encountered problems are
Hypovolemia –dehydration due to loss of fluid
Hypokalemia↓
Loss in vomitus
Loss Na⁺ in gastric juice → ↑aldosterone → Na⁺ reabsorption and K excretion
Metabolic alkalosis
Upper GI loss of H⁺
Hypovolemia →↑reabsorption of HCO₃ in proximal tubules
High aldosteron will secrete H⁺ ion ( instead of K⁺ ) → Aciduria → metabolic
alkolosis
 Loss chloride lead increased HCO₃ reabsorption
Hypochloremia – loss in GIT → ↑ renal absorption of HCO₃ →alkalosis
Isotonic saline
Corrects fluid deficit → ↑ECF → ↓HCO3 absorption → Correction M.
Alkalosis
Correction of volume and Na⁺→ ↓ aldosteron → ↓ K⁺ and H
⁺secretion → Correction of hypokalemia and alkalosis
Corrects Hypochloremia → fovours HCO₃ secretion → correction of
M.alkalosis
Isotonic saline corrects all biochemical abnormalities except K⁺ deficit

Isolyte-G
Is the specific fluid for upper replacement of GI loss, it corrects H⁺, Cl⁺,
K⁺ and Na⁺
 TRAUMA

• Large volumes of IV crystalloids or colloids in early resuscitation will cause

hemodilution and dilute clotting factors, and saline-based fluids may aggravate the
acidosis associated with major blood loss

• Rather, packed RBCs (PBRCs), clotting factors (e.g., fresh frozen plasma [FFP])
and platelets should be replaced early

• Studies show that “high” ratios of FFP to PRBC (e.g., 1:1 to 1:2) are associated
with the best outcomes in massive transfusion.
 NEUROSURGICAL CASES

• Aim is to keep patient normovolemic and normo or slightly hyperosmolar with

normal sodium balance
• Safe I V fluids- NS, 5% albumin, 6% hetastarch are iso to hyperosmotic, so they
have minor effect on brain’s water content or ICP
• Cautious use – osmolarity of RL is 274 mOsm/L and 5%dextrose is 278 mOsm/L.
Both are hypotonic can cause cerebral edema and raised ICP
• Dextrose produces hyperglycemia and anaerobic oxidation of glucose produces
lactic acid which further damages brain
• Mannitol is the mainstay of therapy for raise ICP – Mannitol is impermeable to BBB
therefore drains water out of edenatous brain into plasma
• NS has 308 mOsm/L osmolality is ideal and cheap
 CRYSTALLOIDS COLLOIDS
Aqueous solution of low molecular weight ions High molecular weight substances similar to
with or without glucose plasma proteins
Readily pass through semi permeable membrane – Do not cross capillary membrane – intravascular
extravascular space expanders space expanders.

Intravascular t1/2 – 20-30 min 2-8 hrs

Reduces colloid oncotic pressure Maintain colloid oncotic pressure
Poor capillary perfusion Good
Risk of overhydration  tissue edema Insignificant.
No anaplylactic reactions More
In expensive Expensive
Readily available, well tolerated by patients Not so
 COLLOID–CRYSTALLOID CONUNDRUM

• There is a longstanding debate concerning the type of fluid that is most

appropriate for volume resuscitation, and each type of fluid has its loyalists
who passionately defend the merits of their chosen fluid.
• Crystalloid fluids were popularised for volume resuscitation for their ability
to expand interstitial volume than plasma volume.
• But recently, importance was given to promote cardiac output , systemic
oxygen delivery as the primary focus of volume resuscitation .Here ,colloids
have proven superior.
• Despite the superiority, crystalloids remain popular choice for volume
resuscitation because of
• Lower cost of crystalloid fluid.
• Lack of survival benefit with colloid resuscitation.

• The problem with crystalloid resuscitation – promotes edema ,positive fluid balance
 increasing morbidity and mortality.
• No clear consensus exists on which intravenously administered fluid is associated
with the best clinical outcomes in the perioperative setting.
• Comparisons of “balanced” with “unbalanced” and “crystalloid” with “colloid”
fluids are being studied in many clinical settings but definitive conclusions are
often lacking.
• The approach to fluid and electrolyte management may need adapting to
numerous patient and surgical factors.
• Hence ,a problem based approach is necessary .
 A problem-based approach
• The colloid-crystalloid controversy is fueled by the premise that one type of
fluid is optimal in all cases of hypovolemia.

• This seems unreasonable , since no single resuscitation fluid will perform

optimally in all conditions associated with hypovolemia.

• Example:
• life threatening hypovolemia due to blood loss – blood products / albumin
• Hypovolemia due to dehydration – crystalloid resuscitation

• Tailoring the type of resuscitation fluid to the specific cause and severity of
hypovolemia is a more reasoned approach than using the same type of fluid
for all cases of hypovolemia.