1. Intravenous Fluid
Therapy
Dr. Ahmed Abbas Elsaid
King Khalid Hospital – Najran
February,2014

3. How to prescribe the proper IV fluid
for your patient ?
Understanding the physiology of fluid and
electrolyte balance in patients with normal
physiology and during illness.
Assessing patients’ fluid and electrolyte
needs.
Understanding the nature and composition
of the common IV fluids.

4. About 60% of a 70 kg (42 litres) human
adult is water.
two-thirds is intracellular (28 litres) and
one third is extracellular.
The latter comprises the interstitial fluid
(10.5 litres) and plasma (4.5 litres). Minor
components include CSF, synovial fluid
and vitreous humour

6. Approximate daily water balance
in health

7. Average Daily Intake
Water
:25-35 ml/kg/day
Sodium
:Approx.1 mmol/kg/day
Potassium :Approx. 1 mmol/kg/day

8. ICF (mmol/l)
ECF (mmol/l)
Cations
K+ = 150 (main
Cation)
Na+ = 10
Na+ = 150 (main
cation)
K+ = 4-5
Anions
Organic Po4= 25
(main anion)
C HCO3 = 10
Cl - = 110 (main
anion)
HCO3 = 25
Osmolality 280- 295
280-295

9. Osmolarity

10. Expected osmolarity of plasma can be
calculated according to the following
formula:
Osmolarity (mOsm/kg) = 2×[mmol/L Na+]
+ glucose+ BUN
Concentration of sodium is the major
determinant. „
Normal serum osmolarity ranges from
about 280 - 295 mOsm /kg.

13. IV fluids
A.
B.
C.
D.
Crystaloids.
Colloids.
Free water solutions.
Blood products.

14. Crystalloid
Normal slaine (0.9% Na Cl)
Hypertonic saline (3% Na Cl) considered
plasma expanders.
Hypotonic saline (0.45% and 0.225%)
Ringers

15. Isotonic Saline
Expand blood volume by only a quarter to a third of the
volume infused.
The normal daily requirements of sodium are only 70100mmol but one litre of NS contains 154mmol.
Produces a degree of hyperchloraemia due to its high
chloride content compared with plasma. lead to
significant reductions in renal blood flow and glomerular
filtration as well as hyperchloraemic acidosis,
gastrointestinal mucosal acidosis and ileus.
Some GI fluid losses and occasionally renal losses are
very high in sodium chloride and hence sodium chloride
0.9% use may be appropriate.

16. Balanced Crystalloid Solutions
similar efficacy to Na Cl 0.9% in plasma volume
expansion.
They contain somewhat less sodium and significantly
less chloride, and they have some potassium, calcium
and magnesium content.
Less likely to cause the possible problems linked to NaCl
0.9% use for resuscitation or routine maintenance,
particularly some of the more modern preparations which
come in more specialized ‘resuscitation’ and
‘maintenance’ versions with their content more tailored to
meet theoretical requirements for these different
circumstances.

17. Colloids
A. Synthetic colloid: hydroxyethyl starch,
succinylated gelatin (Gelofusine), urea-linked
gelatin (Haemaccel), penta- and hexastarches.
B. Albumin: 4-5% and 20-25%
C. Human plasma protein fraction (HPPF): 5 g
selected plasma proteins (approximately 88%
normal human albumin, 12% alpha and beta
globulins and not more than 1% gamma
globulin )

18. Colloids
Theoretically better in resuscitation, but
actually there is no evidence of better
outcome.
renal dysfunction, disturbances of
coagulation, allergy or other colloidinduced physiological disturbance.
hydroxyethyl starch, succinylated gelatin
(Gelofusine), urea-linked gelatin
(Haemaccel) are commonly used

19. Colloids
Albumin
Intravascular volume expansion + solve
fluid redistribution problems
Used in some patients with hepatic failure
and ascites
Expensive

20. Free Water Solutions
D5W (5% dextrose in water), D10W,
D20W, D50W
Dextrose/crystalloid mixes (D5 NS, ….)

21. Composition of Some Common IV
Fluid

24. Provide intravenous (IV) fluid therapy
only for patients whose needs cannot
be met by oral or enteral routes and
stop as soon as possible

25. “NICE” IV Fluid Therapy
Algorithms. (NICE- December
2013)

26. Standard principles
1. When prescribing IV fluids, remember
the 5 Rs:
Resuscitation
Routine maintenance
Replacement
Redistribution
Reassessment.

27. Assess patients’ fluid and electrolyte
needs following Algorithm 1:
Assessment.

28. How do I know someone needs
fluid?
Assess the patient’s likely fluid and
electrolyte needs from their history, clinical
examination, clinical monitoring and
laboratory investigations

29. History should include any previous limited
intake, the quantity and composition of
abnormal losses and any comorbidities

30. Clinical examination should include an
assessment of the patient's fluid status,
including:
- pulse, blood pressure, capillary refill and
jugular venous pressure
- presence of pulmonary or peripheral
oedema
- presence of postural hypotension.

31. Clinical monitoring should include current
status and trends in:
- NEWS
- Fluid balance charts
- Weight.

32. Laboratory investigations should include
current status and trends in:
- Full blood count
- Urea, creatinine and electrolytes

35. If patient need IV fluids for
resuscitation, follow Algorithm 2:
Resuscitation.

36. Indicators of urgent resuscitation
include
Systolic blood pressure is less than 100 mmHg
Heart rate is more than 90 beats per minute
Capillary refill time is more than 2 seconds or
peripheries are cold to touch
Respiratory rate is more than 20 breaths per
minute
National Early Warning Score (NEWS) is 5 or
more
Passive leg raising test is positive.

39. There is no evidence that colloids have
any benefit over crystalloids regarding the
outcome.
Use crystalloids that contain sodium in the
range 130–154 mmol/l, with a bolus of 500
ml over less than 15 minutes.
Consider human albumin solution 4–5%
only for resuscitation in patients with
severe sepsis. “NICE guidelines 2013”

40. A classification of haemorrhagic
shock(ATLS_2012)

41. Fluid Therapy in trauma “ATLS 2012” :
Fluid bolus: 1-2 liters for an adult and
20mL/kg for a pediatric patient
3:1 rule
39 ° C

42. 1.
2.
3.
4.
5.
Fluid warming is important to minimize:
Bradycardia and ↓COP.
Left shift of ODC.
Shivering & ↑ lactic acidosis
coagulopathy associated with massive
transfusion
Wound infection

44. If patients need IV fluids for routine
maintenance, follow Algorithm 3:
Routine maintenance.

45. Restrict the initial prescription to:
25–30 ml/kg/day of water
approximately 1 mmol/kg/day of
potassium, sodium and chloride and
approximately 50–100 g/day of glucose
to limit starvation ketosis (dextrose 5%
contains 5g/100ml)

46. Normal maintenance requirements
in infants (holiday & segar)
Wt (kg)
H2O(ml/kg/dy)
Na(mmol/kg/dy) K(mmol/kg/dy
First 10 kg
100
2
1.5-2
Second 10 kg
50
1-2
0.5-1.5
Subsequent kg
20
0.5-1
0.2-0.7

47. Normal maintenance requirements
in infants (holiday & segar)
1st 10 kg BW : 4ml/kg/h
2nd 10 kg BW: 2ml/kg/h
Each remaining kg: 1ml/kg/h

48. For patients who are obese, adjust the
IV fluid prescription to their ideal body
weight. Use lower range volumes per
kg (patients rarely need more than a
total of 3 litres of fluid per day)

49. IBW can be estimated from the formula:
IBW(KG)= Height (cm) – x
(where x = 100 for adult males and 105 for
adult females).

50. Consider prescribing less fluid (for
example, 25 ml/kg/day fluid) for
patients who:
Are older
Have renal impairment or cardiac
failure.

51. Consider delivering IV fluids for routine
maintenance during daytime hours, if
possible.

52. Include the following information in IV fluid
prescriptions:
 The type of fluid to be administered
 The rate and volume of fluid to be
administered

54. If patients need IV fluids to address
existing deficits or excesses, or
ongoing abnormal losses, follow
Algorithm 4: Replacement and
redistribution.

57. Preoperative fluid
D5 1/4 NS is used for neonates and
infant up to 1 year due to their limited
ability to handle Na+ loads.
D5 1/2 NS is used for children more than
1 year.
For adults D5 NS will be better to avoid
hypoglycemia

58. Central Venous Pressure
Monitoring
A central venous pressure is a useful tool
for assessment and treatment of more
complex patients.
Central lines are not the preferred way for
resuscitation in acute situations. Flow
rates of fluids increase with the diameter
of the cannula but decrease with
increasing length.

59. Questions ?????