This document discusses common intravenous fluids used in anesthetic practice and fluid therapy. It begins by defining intravenous fluids as chemically prepared solutions tailored to the body's needs that are used to replace lost fluids and aid in drug delivery. Safe IV fluid prescribing requires understanding physiology and fluid/electrolyte homeostasis. The document then covers the classifications, compositions and indications for various IV fluid types - crystalloids like normal saline and lactated ringer's, colloids like albumin and hetastarch, and blood/blood products. It discusses concepts of fluid therapy including distribution in body compartments, osmolarity, and goals of fluid management. Guidelines are provided for fluid rate calculations and assessing dehydration severity

1. COMMON FLUIDS USED IN
ANAESTHETIC
PRACTICE/FLUID THERAPYIN
ANAESTHESIA
BY
AROWOJOLU BOLUWAJI SAMUEL

2. INTRODUCTION
Intravenous (IV) fluids are chemically prepared
solutions that are tailored to the body’s needs and
used to replace lost fluid and/or aid in the delivery of
intravenous medications (Perel, 2012)
Safe and effective prescribing of intravenous fluids
requires understanding of the physiology of fluid
and electrolyte homeostasis, physiological responses
to injury and disease, as well as knowledge of the
properties of intravenous fluids

3. INTRODUCTION CONT’D
Starvation, surgery and anaesthesia cause
stress and alter body physiology
Intravenous fluids are administered perioperatively to
maintain homeostasis during this period

4. • Explain the distribution of fluids in various body
compartments
• Explain the concept of intravenous fluid therapy
• Explain the principles and protocols involved in
fluid therapy
• Describe the forms of intravenous fluids and
their compositions

5. Distributionof Fluidsin DifferentBody Compartments
Total Body Water =60% of body
weight (42 litres)
Plasma component =
5% (3 litres)
Extracellular Compartment =
20% (14 litres)
It is rich in Na+ and CI-
Intracellular compartment =
40% (28 litres). high in
KPO4
3-
Interstitial Fluid
component = 15% (11
litres)

6. ECF is high in Na+ and Cl- while ICF is high
in KPO4
3-.
Water without sodium expands the TBW
All infused Na+ remains in the ECF via the
Na+ pump. Hence, normal saline expands the
ECF only
There is a fine balance between input,
controlled by the thirst mechanisms and output
that is controlled mainly by the renals (ADH
system)

7. BasicfluidHomeostasis
Routes Average Daily Volume (ml) Total intake
H2O intake:
Sensible
2500
Oral fluids 800 – 1500
Solid foods 500 – 700
Insensible:
Water of metabolism 250
H2O loss
Sensible:
2500
Urine 800 – 1500
Intestinal 150 – 400
Sweat 150
Insensible:
Lungs and skin 600

8. DailyElectrolyte Requirements
Electrolyte Daily requirement For 70Kg adult For 10Kg Child
Sodium 1 – 2 meq/kg 70 – 140 meq/day 10 – 20 meq/day
Potassium 0.5 – 1.0 meq/kg 35 – 70 meq/day 5 – 10 meq/day
Calcium 0.2 – 0.3 meq/kg 1.4 – 2.1 meq/day 2.0 – 3.0 meq/day
Magnesium 0.35 – 0.45meq/kg 24.5 – 31.5
meq/day
3.5 – 4.5 meq/day
Chloride Equal to sodium Equal to sodium Equal to sodium
Bicarbonate/Acetate Use with chloride to
balance cations and
help PH
Use with chloride to
balance cations and
help PH
Use with chloride to
balance cations and
help PH

9. Concepts of Intravenous Fluid Therapy
There are 3 key concepts namely:
1. Cell membrane permeability
2. Osmolarity. Concentration of sodium is the major
determinant of osmolarity. Normal serum
osmolarity ranges from about 280 to 295 mOsm
3. Electroneutrality

10. Goals of FluidManagement
Principle goals:
Maintain intravascular
volume
Maintain cardiac
preload
Maintain adequate
blood pressure
Replace insensible
and surgical losses
Ultimate goal is
optimizing oxygen
delivery

11. Indications for fluid administration in anaesthetic practice
1. Preoperative fasting
2. Surgical blood loss
3. Urinary excretion
4. Vasodilation caused by anesthesia e.g during
epidural anesthesia
5. Transfer to third space
6. Transcapillary leak of albumin caused by
inflammatory mediators
7. Hypotension
8. Hypovolemia
9. Electrolyte, metabolic and acid base
disorders
10.Geriatric patients at risk of organ failure

12. Forms of Intravenous Fluids
Colloids Crystalloids
Blood and
blood
products
Oxygen
carrying
solutions

13. Colloids solutions
• Colloid solutions are IV fluids that contain solutes in
the form of large proteins or other similarly sized
molecules.
• Colloids remain in the blood vessels for long periods
of time and can significantly increase the intravascular
volume (volume of blood)
• Colloids are expensive and have a short shelf life.
Commonly used colloid solutions include salt poor
albumin, dextran and hetastarch (Hespan, Voluven)

14. Colloids are always administered along with crystalloids to restore
both intravascular and interstitial fluid volume.
Indications: hypoproteinemia, decreased oncotic pressure and
increased capillary pore size in conditions associated with sepsis or
systemic inflammatory response syndrome.
Whenever a colloid is administered with a crystalloid, reduce the
calculated crystalloid fluid requirements by 25% to 50% to avoid
volume overload
Types of colloids are : Natural colloids and synthetic colloids

15. Natural colloid solutions include whole blood and plasma
The Rule of Ones states that 1 ml fresh blood infused per 1 lb
body weight (2.2 ml/kg) will increase a patient's packed cell
volume (PCV) by 1%, provided no ongoing losses are present
A more accurate method to determine the volume of whole blood
to administer is as follows:
ml donor blood needed = [(Desired PCV – Actual Recipient PCV)
÷ Donor PCV] × ml recipient blood volume

16. Synthetic Colloids
Hydroxyethyl Starch (Hetastarch)
 It is synthesized from amylopectin
 It last in circulation for 36 hours
 Administer at 5 – 7 ml/kg as a bolus dose
 The total daily dose of hetastarch should not exceed 20 to
30 ml/kg/day
 Rapid hetastarch administration can cause histamine
release & vomiting, administer the bolus slowly over 15 to
20 minutes
 It may cause renal dysfunction

17. Synthetic Colloids cont’d
Dextran:
 It contains polymers of glucose with average molecular
weights of 40 and 70 daltons
 Dextran 70 is preferred to dextran 40 cos dextran 70's
larger particles contribute to the water-holding capacity of
blood
 It last between 4 – 9 hours
 Anaphylaxis and renal failure have been reported in people
that received dextran 40
 The dose is 10 to 20 ml/kg/day given intravenously

18. Polymerized bovine hemoglobin glutamer-200
 It contains bovine stoma-free hemoglobin that acts both as a potent
colloid and as an oxygen carrier in the face of thrombosis or
anemia
 Recommended doses are 20 to 30 ml/kg/day
 Administered as an intravenous bolus of 3 to 7 ml/kg

19. Human Serum Albumin
 It is a purified human protein gotten from plasma
 90% of it remains intravascular after about 2 hours of administration
 Albumin contributes 80% of the oncotic pressure of blood & acts as a
carrier for various essential compounds in the body
 It is effective in restoring serum & interstitial albumin in patients with
acute or chronic hypoalbuminemia
 Patients with conditions associated with increased capillary pore size,
such as sepsis, vasculitis & systemic inflammatory response syndrome
can benefit from maintaining the serum albumin concentration at or
ideally above 2 g/dl

21. Crystalloid Solutions
Crystalloid solutions are the primary fluid used for anaesthetic
IV therapy. They contain electrolytes but lack the large
proteins and molecules found in colloids.
They are classified based on their tonicity: Hypertonic,
Hypotonic & Isotonic
Examples are 0.9% normal saline, Lactated Ringer’s and
plasmalyte. For every 1 liter of blood lost, 3 liters of an
isotonic crystalloid be administered for replacement

22. ISOTONIC FLUIDS
Examples are
0.9%NS, Lactated
Ringer’s &
plasmalyte
Indications: to restore
fluid deficits, correct
electrolyte
abnormalities &
provide maintenance
fluid requirements.
Side effects: mild
hypernatremia
HYPERTONICFLUIDS
Examples are 1.8%,
3%, 5%, 7%, 7.5%,
10% saline
They are considered
as plasma expanders
as they act to
increase the
circulatory volume
via movement of
intracellular &
interstitial water into
the intravascular
space
Administering a low-
sodium crystalloid
fluid after a
hypertonic saline
solution can lead to
interstitial edema
HYPOTONICFLUIDS
Examples are
0.45%NaCl, 0.45%
NaCl+2.5% Dextrose
& 5% DW.
Indications: treating
patients with disease
processes that cause
Na & H2O retention,
namely, congestive
heart failure, hepatic
disease., severe
hypernatremia

23. The most common isotonic solutions used in
anesthetic management are:
Lactated Ringer’s: contains sodium chloride, potassium chloride,
calcium chloride, and sodium lactate in sterile water.
avoided if hyperkalemic or hypercalcemic as it tends to induce mild
alkalosis
Normal saline solution: contains 0.9% Nacl (salt) in sterile water.
It is useful if patient is hyperkalemic, hyponatremic,
hypochloremic or if slight hyperosmolarity is desired.
5% Dextrose in water: contains glucose (sugar) as the solute.
It is seldom used in anesthetic practice but very useful as a
background maintenance for diabetics on insulin, children and
adults undergoing long cases (> 6 – 8 hours)

24. 3. Blood and Blood Products
 Examples are platelets, packed red blood cells, whole blood & plasma
 Unlike colloids and crystalloids, the hemoglobin (in the red blood
cells) carries oxygen to the cells.
 Not only is the intravascular volume increased, but the fluid
administered can also transport oxygen to the cells
4. Oxygen-Carrying Solutions
 Oxygen-carrying solutions are synthetic fluids that carry and deliver
oxygen to the cells.
 These fluids, which remain experimental has showed promise for
anesthetic care of patients who have experienced severe blood loss or
are otherwise suffering from hypovolemia

25. Principles and protocols for intravenous fluidtherapy
4Rs
Fluid
resuscitation
Routine
maintenance
Replacement
Redistribution
Swollen… what’s
the big deal

26. Solution PH Na+ Cl- K+ Ca2+ Other
components
Comments
Ringers Lactate
(LR)
130 109 4 3 Lactate 28 meq/L Fluid choice for initial
resuscitation.
Normal Saline
(NS)
154 154 0 0 Alternative to LR; watch
for hyper-chloremic
acidosis
D5LR 5 130 109 4 3 Dextrose 50g,
Lactate 28 meq/L
Initial postoperative
maintenance; caution
blousing with dextrose
D5NS 4 154 154 0 0 Dextrose 50g Alternative to D5LR
D5,45NS 4 77 77 0 0 Dextrose 50g Hypotonic maintenance
D5,25NS 4 34 34 0 0 Dextrose 50g Hypotonic maintenance
7.5% NS 4 1283 1283 0 0 0 Hypertonic
D5W 4.5 0 0 0 0 Dextrose 50g Free water; no role in
resuscitation
6% hetastarch 3.5
–
7.0
154 154 0 0 30g hydroxyethyl
starch
Coagulation abnormalities
5% plasma protein
(250ml)
7.4 145 0 <2 0 12.5g protein Colloid expensive
Composition of common IV fluids

27. The percentage of dehydration can be subjectively estimated
based on the presence and degree of loss of body weight,
mucous membrane dryness, decreased skin turgor, sunken
eyes, and altered mentation
Severe hypovolemia resulting in more than a 15% depletion
of effective circulating volume leads to a transcompartmental
fluid shift from the interstitial to the intravascular
compartments, which occurs within one hour of fluid loss
During states of normovolemia, baroreceptors in the carotid
body and aortic arch sense vascular wall tension and send
pulsatile continuous feedback via vagal afferent stimuli to
decrease heart rate
ClinicalAssessment of dehydration

28. • In the early stages of hypovolemic shock, the
baroreceptors sense a decrease in vascular wall stretch
or tension and blunt the tonic vagal stimulation
• This allows sympathetic tone to increase heart rate and
contractility in an attempt to normalize cardiac output
• Dehydration can be graded into mild, moderate, severe
and shock based on the percentage of fluid lost.
ClinicalAssessment of dehydration cont’d

29. Grade % of fluid lost Clinical Signs and Symptoms
Mild 5% Increased thirst, tears present, mucous membranes moist,
ext. jugular visible when supine, capillary refill > 2 seconds
centrally, urine specific gravity > 1.020
Moderate 10% Tacky to dry mucous membranes, decreased tears, pulse
rate may be elevated somewhat, fontanel may be sunken,
oliguria, capillary refill time between 2 and 4 seconds,
decreased skin turgor
Severe 15% Tears absent, mucous membranes dry, eyes sunken,
tachycardia, slow capillary refill, poor skin turgor, cool
extremities, orthostatic to shocky, apathy, somnolence
Shock >15% Physiologic decompensation: insufficient perfusion to meet
end- organ demand, poor oxygen delivery, decreased blood
pressure.

30. Combined water and electrolyte deficit is commonly associated with
GIT losses, diuretic therapy, adrenal insufficiency, excessive
diaphoresis, burns, stomas and third spacing following trauma or
surgery
Treatment involves replacement of enough water to restore plasma
[Na+] to normal
The excess sodium for which water must be provided can be estimated from
the equation: change in Na = (140 – Na plasma) x TBW
(Recall TBW = ECF + ICF = 50 to 70% body weight)
Pure water deficit is reflected biochemically by hypernatremia,
increase in plasma osmolality, concentrated urine and low urine
[Na+] (<15mEq/L)

31. Colloids versus Crystalloids for Resuscitation
• Controversy exists over the use of colloids and crystalloid
solutions as resuscitative fluids. The large volumes of
crystalloid sometimes necessary to stabilize patients may lead
to peripheral edema that may impair wound healing.
• Colloids offer the theoretical advantage of expanding the
intravascular space with less volume and have been shown to
increase blood pressure more rapidly than crystalloids
• 1litre of dextran increases intravascular volume by 800ml; 1 L
of hetastarch by 750ml; 1L 5% albumin by 500mls; and 1L
normal saline by 180 mls

32. Colloids may inhibit the coagulation system and cause
anaphylactoid reaction. Overall meta-analyses of IVF
therapy have not supported a benefit for colloids over
crystalloids.
Several meta-analyses have shown a trend toward increased
mortality in heterogeneous groups of critically ill patients
resuscitated with colloids.
crystalloids still remain the cornerstone of volume
resuscitation, although patients with profound volume
deficits may benefit from colloids in addition to crystalloids
Colloids versus Crystalloids for Resuscitation

33. FLUID RATE CALCULATIONS
3 elements to be considered include:
 Replacement
 Maintenance
 Ongoing losses
Replacement IVF: They are calculated based on the level of dehydration.
Amount required for replacement within a 24 hour period include:
Replacement = % Dehydration x Body Weight (kg) x 10

34. MaintenanceIVF:
 Holliday-Segar method (4-2-1) is the most commonly used.
 Fluid and electrolyte requirements are empirically based on caloric
needs of the average hospital patient.
 This caloric expenditure is approximated based on body weight.
For each kilogram in this
range
Hourly Maintenance Fluid
Requirements
1-10 kg (1st 10kg) 4ml/kg/hr
11-20 kg (2nd 10kg) 40ml + 2ml/kg/hr for each kg over 10
>20 kg 60ml + 1ml/kg/hr for each kg over 20

35. Ongoing losses:
It is calculated based on a predicted amount of fluid lost by a patient
within a 24 hour period.
Ongoing losses = Amount per loss (ml/kg) x Body Weight (kg) x No. of
losses.
This is then further calculated depending on whether a drip pump is
used or fluid rate is adjusted manually as shown below.
Requirement per hour (ml/hr) = requirement per day (ml/24hr) ÷ 24

36. Special Consideration in Fluid Therapy
1. Shock
• Signs include tachycardia, pale mucous membrane,
prolonged/absent capillary refill time, hypotension,
reduced/absent peripheral pulses.
• Forms include: Hypovolemic, cardiogenic, Vascular:
Obstructive, distributive
• Choice of fluid in hypovolemic shock is isotonic
crystalloid fluid.
• Cardiogenic shock is diuretic cos the patient is already in
volume overload
• Obstructive shock is often treated by removal of the
obstruction.
is defined as decreased oxygen delivery or utilization
by tissues that may lead to irreversible cellular damage
if prolonged

37. 2. Anaesthesia
i. Pre-anaesthetic: Stabilize a patient fluid deficits & any electrolyte or
acid-base imbalances before anaesthesia. PCV & if possible urea,
creatinine, electrolyes and glucose should be balanced. Even if balanced,
place the patient on fluids as most anaesthetic agents will alter fluid
homeostasis.
ii. Intra-anaesthetic: normal homeostatic functions of the patient is
are altered during anesthesia & so fluid therapy should be initiated.
> Glucose levels should be closely monitored, especially patients
with diabetes, liver disease or pediatric patients.
> Some patients may develop an anaesthetic-induced hypotension
from the side-effects of anaesthetics. Hence, Fluids are given as a
preventative measure.
> Replace significant blood loss with either blood products or
appropriate fluid.
> Ensure fluid is warm before administration.

39. 3. Cardiac Disease
 Avoid fluid overload in cardiac patients who often have reduced cardiac
function.
 This means it is important to closely monitor fluid administration in these
patients as it may worsen the patient's condition.
4. Hepatic Disease
 Patients with hepatic disease often have alterations in protein levels due to
reduced production, as well as changes in clotting factors
 Hypoproteinemia will affect patients undergoing anaesthetics as many
agents are protein bound so the reduction in protein means that more of the
agent may be available
 If there are any clotting disorders then it may be necessary to give blood
products so that the missing clotting factors are available to the patient,
while the underlying cause is diagnosed and treated.

40. 5. Central Nervous System Disease
Patients with head trauma or increased intracranial pressure are
particularly susceptible to insufficient or excessive fluid loading
The choice of fluid is dependent on the other clinical signs of the patient
such as haemodynamics
The status of the blood brain barrier is an important consideration in any
patient and in the selection of fluid
However, fluids containing glucose should be avoided in these patients.

41. Intravenous Fluid Packaging
Most IV fluids are packaged in soft plastic or vinyl bags of various
sizes (10, 50, 100, 250, 500, 1,000, 2,000, and 3,000 milliliters)
Every IV fluid container must contain a label. The information on the
label include: Type of IV fluid (by name and by type of solutes
contained within), Amount of IV fluid (expressed in milliliters or
“mL”) and Expiration date
The IV fluid container contains a medication injection site and
administration set port. Both ports are located on the bottom of the
IV bag when holding it upright

42. Conclusion
IVF therapy is undoubtedly one of the mainstays of treatment of both acute and
chronic illnesses
Similar to choosing an antibiotic to treat the most likely bacterial infection, a
fluid should be chosen to treat a specific disease entity. The fluid should be
chosen after careful consideration of an individual’s acid-base, electrolyte,
dehydration, and oncotic pressure status.
However, having a combination of replacement and maintenance crystalloids
along with a colloid to choose from can decrease morbidity and mortality in
your most critically ill patients

43. SVWY
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References