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Intravenous Fluid
TOTAL BODY WATER
 Approx. 60% Body weight
Varies with age, gender and body
habitus
 50% BW in females
 80% BW in infan...
Body Water Compartments
 Intracellular volume : 2/3 of TBW
 Extracellular volume : 1/3 of TBW
- Intravascular : Plasma v...
Preoperative Evaluation of Fluid
Status
- Mental status
- H/O intake and output
- Blood pressure: supine and standing
- He...
Orthostatic Hypotension
• Systolic blood pressure decrease of greater than
20mmHg from supine to standing
• Indicates flui...
 Osmoles :unit for conc. Of osmotically
active particles
 Osmolality: osmotic active solute per
volume of solution ( mOs...
Intravenous Fluids
Therapy
Intravenous fluid therapy may consist of infusions ofIntravenous fluid therapy may consist of i...
Types
• Crystalloids
• Colloids
Crystalloids
 Clear fluids made up of water and electrolyte
solutions; Will cross a semi-permeable membrane
 Grouped as ...
Crystalloids
0.9% Normal Saline
 Contains: Na+ 154 mmol/l, Cl-
- 154 mmol/l
 Osm : 308mosm/l, pH 6.0
 IsoOsmolar compar...
 Distribution:
 Stays almost entirely in the extracellular space.
Of 1 litre - 750ml extra vascular fluid; 250ml
intrava...
3.0 % Saline = HYPERtonic saline
 3% contain 513 mmol/l of Na+ and Cl-
each,
 osmol of 1026 mOsm/l; pH 5.0
 Indications...
Must be administered slowly and
preferably with CV line because it
carries risk of causing phlebitis,
necrosis, hemolysis...
Dextrose
5% Dextrose (often written D5W)
 50g/l of glucose, 252mOsm/l, pH 4.5
 Regarded as ‘electrolyte free’ – contains...
 Indication :
 To maintain water balance in patients
who are not able to take anything by
mouth;
 Used post-operatively...
 Less than 10% stays in the intravascular space
therefore it is of limited use in fluid resuscitation.
 Side effects:
I...
Ringer Lactate
 Most physiological solution
 Electrolyte composition similar to ECF
 One litre of lactated Ringer's sol...
 Lactate is converted to bicarbonate in liver
 Indications :
 Deficit ,Intraoperative fluid loss
 Severe hypovolemia
...
DNS
 0.9% saline & 5% dextrose
 Na+ 154, Cl- 154, 5 gm. Glucose
 Osm : 432 mosm/L
 Indication :
Maintenance solution
...
IsoLyte -P
Multiple electrolyte & dextrose solution
Na+ : 26
K+ : 20
Mg++ : 03
Cl- : 21
Acetate : 23
Ph+ : 03
Isotonic
Ind...
Colloids
 Particles which do not readily cross semi-
permeable membranes
 Stays (initially) almost entirely within the
i...
 However they leak out of the intravascular space
when the capillary permeability significantly changes
e.g. Severe traum...
ALBUMIN
 Principal natural colloid comprising of 50-60% of all plasma
proteins.
 Synthesized only in liver and has a hal...
 Side effects :
 pruritis, anaphylactoid reactions and coagulation
abnormalities as compared to synthetic colloids.
 Di...
DEXTRAN
 Highly branched polysaccharide molecules
 Produced by synthesis using the bacterial enzyme
dextran sucrase from...
 Used mainly to improve microcirculatory flow
in microsurgical re-implantation .
 Also used in extracorporeal circulatio...
GELATINS
 Large mol. wt. proteins formed from
hydrolysis of collagen.
 Produced by thermal degradation of cattle-
bone g...
 Advantage :
cost effectiveness and no effect of renal
impairment ,does not affect coagulation
 Disadvantage :
Hyperse...
HYDROXYETHYL
STARCHES
 Derivatives of amylopectin, which is a highly
branched compound of starch.
 6% HES soln are isoon...
 Advantage
Cost effective: cheaper and comparable vol of
expansion to albumin.
 Disadvantage: assoc. with 1st
& 2nd
gen...
Colloid or Crystalloid Resuscitation
Recommendations:
 Colloid should NOT be used as the sole fluid
replacement in resusc...
 In elective surgical patients
Replace fluid loss with ‘physiological
Ringer’s solutions.
Blood products and colloid ma...
Peri- operative Fluid
Requirements
• The following factors must be taken into
account:
• C V E
• Maintenance fluid
• Defic...
COMPENSATORY INTRAVASCULAR VOLUME
EXPANSION
Fluid must be adm. to expand the blood vol to
compensate for venodilation (GA...
Maintenance Fluid Requirements
• “4-2-1 Rule”
- 4 ml/kg/hr for the first 10 kg of body
weight
- 2 ml/kg/hr for the second ...
Deficit
• Deficit = number of hours NPO x maintenance
fluid requirement.
• Measurable fluid losses, e.g. NG suctioning,
vo...
Third Space Losses
• Isotonic transfer of ECF from functional body
fluid compartments to non-functional
compartments.
• De...
Replacing Third Space Losses
Minimal Surgical Trauma: 0-2 ml/kg/hr
- e.g. herniorrhaphy
Moderate Surgical Trauma: 2-4 ml/k...
Blood Loss
• Replace 4 cc of crystalloid solution per cc of blood
loss (crystalloid solutions leave the intravascular
spac...
Fluid management, starting with a hemoglobin level of 15 g/dL,
for a 70-kg patient undergoing gastrectomy who has been fas...
Summary
 Most physiological :RL
 Rich in sodium : NS,DNS
 Rich in potassium :ISo –p
 Glucose free: ?RL,NS,3% saline
 ...
Thank you
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intravenous fluid

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intravenous fluid

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intravenous fluid

  1. 1. Intravenous Fluid
  2. 2. TOTAL BODY WATER  Approx. 60% Body weight Varies with age, gender and body habitus  50% BW in females  80% BW in infants Less in obese : fat contain little water
  3. 3. Body Water Compartments  Intracellular volume : 2/3 of TBW  Extracellular volume : 1/3 of TBW - Intravascular : Plasma volume (1/4) - Extravascular: Interstitial fluid & others(3/4)
  4. 4. Preoperative Evaluation of Fluid Status - Mental status - H/O intake and output - Blood pressure: supine and standing - Heart rate - Skin turgor - Urinary output - CVP
  5. 5. Orthostatic Hypotension • Systolic blood pressure decrease of greater than 20mmHg from supine to standing • Indicates fluid deficit of 6-8% body weight - Heart rate should increase as a compensatory measure - If no increase in heart rate, may indicate autonomic dysfunction or antihypertensive drug therapy
  6. 6.  Osmoles :unit for conc. Of osmotically active particles  Osmolality: osmotic active solute per volume of solution ( mOsm/L)  Osmolarity : mOsm/Kg  Plasma osmolarity : 290 mOsm/kg  Tonicity ( relative osmotic activity )  Isotonic/ hypotonic/hypertonic BASICS
  7. 7. Intravenous Fluids Therapy Intravenous fluid therapy may consist of infusions ofIntravenous fluid therapy may consist of infusions of crystalloids, colloids, or a combination of both.crystalloids, colloids, or a combination of both. IndicationsIndications  Volume resuscitationVolume resuscitation  Vehicle for i/v drugsVehicle for i/v drugs  KVOKVO
  8. 8. Types • Crystalloids • Colloids
  9. 9. Crystalloids  Clear fluids made up of water and electrolyte solutions; Will cross a semi-permeable membrane  Grouped as isotonic, hypertonic, and hypotonic  Eg:  Normal saline 0.9%,3 %  Dextrose solutions 5 %,10%,20%,25% DNS Ringer’s lactate  Isolyte P
  10. 10. Crystalloids 0.9% Normal Saline  Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l  Osm : 308mosm/l, pH 6.0  IsoOsmolar compared to normal plasma.  Indication :  Intravascular resuscitation and replacement of salt loss e.g. diarrhoea and vomiting.  Also for diluting packed RBCs prior to transfusion  Used for diluting Drugs
  11. 11.  Distribution:  Stays almost entirely in the extracellular space. Of 1 litre - 750ml extra vascular fluid; 250ml intravascular fluid.  Complications:  When given in large volume can produces Hyperchloremic metabolic acidosis because of high Na+ and Cl- content.
  12. 12. 3.0 % Saline = HYPERtonic saline  3% contain 513 mmol/l of Na+ and Cl- each,  osmol of 1026 mOsm/l; pH 5.0  Indications : Treatment of severe symptomatic hyponatremia (coma, seizure) To resuscitate hypovolemic shock
  13. 13. Must be administered slowly and preferably with CV line because it carries risk of causing phlebitis, necrosis, hemolysis. Complications :  Precaution in pt. with CHF  severe renal insufficiency, edema with sod. retention.
  14. 14. Dextrose 5% Dextrose (often written D5W)  50g/l of glucose, 252mOsm/l, pH 4.5  Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium, Chloride or Calcium
  15. 15.  Indication :  To maintain water balance in patients who are not able to take anything by mouth;  Used post-operatively in conjunction with salt retaining fluids ie saline  Hypernatremia treatment
  16. 16.  Less than 10% stays in the intravascular space therefore it is of limited use in fluid resuscitation.  Side effects: Iatrogenic hyponatraemia in surgical patient  Hyperglycemia  Not compatible with blood ,cause hemolysis conc 5% 10% 20% 25% plasma Osmolarity 252 505 1010 1262 290
  17. 17. Ringer Lactate  Most physiological solution  Electrolyte composition similar to ECF  One litre of lactated Ringer's solution contains:  Sodium ion= 130 mmol/L.  Chloride ion = 109 mmol/L.  Lactate = 28 mmol/L.  Potassium ion = 4 mmol/L.  Calcium ion = 1.5 mmol/L  Osmolarity of 273 , pH of 6.5
  18. 18.  Lactate is converted to bicarbonate in liver  Indications :  Deficit ,Intraoperative fluid loss  Severe hypovolemia  Precautions:  Severe metabolic acidosis ( impaired lactate conversion)  Don’t give with blood product ( Ca bind with citrate  reduced anticoagulant activity )
  19. 19. DNS  0.9% saline & 5% dextrose  Na+ 154, Cl- 154, 5 gm. Glucose  Osm : 432 mosm/L  Indication : Maintenance solution Correction of fluid deficit with supply of energy Compatible with blood
  20. 20. IsoLyte -P Multiple electrolyte & dextrose solution Na+ : 26 K+ : 20 Mg++ : 03 Cl- : 21 Acetate : 23 Ph+ : 03 Isotonic Indication :Pediatric maintenance fluid
  21. 21. Colloids  Particles which do not readily cross semi- permeable membranes  Stays (initially) almost entirely within the intravascular space .  Stay intravascular for a prolonged period compared to crystalloids.
  22. 22.  However they leak out of the intravascular space when the capillary permeability significantly changes e.g. Severe trauma or sepsis.  Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) – thus they can cause significant coagulopathy in large volumes.  Natural : Albumin  Artificial : Gelatin and Dextran , HES
  23. 23. ALBUMIN  Principal natural colloid comprising of 50-60% of all plasma proteins.  Synthesized only in liver and has a half life of app. 20 days.  5% soln is iso oncotic and leads to 80% initial vol expansion 25% soln leads to 200-400% increase in vol.  Used  For emergency treatment of shock especially due to loss of plasma  acute management of burns  Fluid resuscitation in ICU  Hypoalbumineamia.
  24. 24.  Side effects :  pruritis, anaphylactoid reactions and coagulation abnormalities as compared to synthetic colloids.  Disadvantages  cost effectiveness  volume overload (in septic shock pt albumin add to interstitial edema)
  25. 25. DEXTRAN  Highly branched polysaccharide molecules  Produced by synthesis using the bacterial enzyme dextran sucrase from the bacterium Leuconostoc mesenteroids.  Most widely used are 6%(dextran 70) and 10% (dextran 40) soln.  Excreted via kidney primarily.
  26. 26.  Used mainly to improve microcirculatory flow in microsurgical re-implantation .  Also used in extracorporeal circulation during cardiopulmnary bypass.  Side effects: Anaphylactic reactions, Coagulation abn, Interference with cross match, Ppt of ARF.
  27. 27. GELATINS  Large mol. wt. proteins formed from hydrolysis of collagen.  Produced by thermal degradation of cattle- bone gelatin.  Gelatins lead to 70-80% of vol expansion  Indication : Rapid expansion of intravascular volume and correction of hypotension
  28. 28.  Advantage : cost effectiveness and no effect of renal impairment ,does not affect coagulation  Disadvantage : Hypersensitivity Anaphylactoid reactions
  29. 29. HYDROXYETHYL STARCHES  Derivatives of amylopectin, which is a highly branched compound of starch.  6% HES soln are isooncotic  10% soln are hyper oncotic , with a vol effect exceeding the infused vol .(about 145%)  Duration of vol expansion is usually 8-12 H.
  30. 30.  Advantage Cost effective: cheaper and comparable vol of expansion to albumin.  Disadvantage: assoc. with 1st & 2nd generation HES - Coagulation abn - Accumulation - Anaphylactoid reactions - Renal impairment - Increase in amylase level
  31. 31. Colloid or Crystalloid Resuscitation Recommendations:  Colloid should NOT be used as the sole fluid replacement in resuscitation ,volumes infused should be limited because of side effects and lack of evidence for their continued use in the acutely ill.  Colloid may be used in limited volume to reduce volume of fluids required or until blood products are available.
  32. 32.  In elective surgical patients Replace fluid loss with ‘physiological Ringer’s solutions. Blood products and colloid may be needed to replace intravascular volume acutely.
  33. 33. Peri- operative Fluid Requirements • The following factors must be taken into account: • C V E • Maintenance fluid • Deficit • Third space losses • Replacement of loss
  34. 34. COMPENSATORY INTRAVASCULAR VOLUME EXPANSION Fluid must be adm. to expand the blood vol to compensate for venodilation (GA,RA) Expansion with 5-7ml/kg of crystalloid must occur before or simultaneous with the onset of anaesthesia .
  35. 35. Maintenance Fluid Requirements • “4-2-1 Rule” - 4 ml/kg/hr for the first 10 kg of body weight - 2 ml/kg/hr for the second 10 kg body weight - 1 ml/kg/hr subsequent kg body weight Eg : 70 Kg pt Maintenance fluid : 40+20+50= 110 ml/hr
  36. 36. Deficit • Deficit = number of hours NPO x maintenance fluid requirement. • Measurable fluid losses, e.g. NG suctioning, vomiting, stoma output.  70 kg pt fasting for 8 hrs  Deficit : 8 X 110 = 880 ml  Half in first hr  One fourth each in next two hr .
  37. 37. Third Space Losses • Isotonic transfer of ECF from functional body fluid compartments to non-functional compartments. • Depends on location and duration of surgical procedure, amount of tissue trauma, ambient temperature, room ventilation.
  38. 38. Replacing Third Space Losses Minimal Surgical Trauma: 0-2 ml/kg/hr - e.g. herniorrhaphy Moderate Surgical Trauma: 2-4 ml/kg/hr - e.g. cholecystectomy Severe surgical trauma: 4-6 ml/kg/hr (or even more) - e.g. major bowel resection
  39. 39. Blood Loss • Replace 4 cc of crystalloid solution per cc of blood loss (crystalloid solutions leave the intravascular space) • When using blood products or colloids replace blood loss volume per volume.
  40. 40. Fluid management, starting with a hemoglobin level of 15 g/dL, for a 70-kg patient undergoing gastrectomy who has been fasting for 8 hours.  Maintenance rate is 110 mL/hr, Deficit of 880 mL First hr = CVE+ Half of deficit + maintenance + loss+ third space loss  350+440+110+50 + 420  Second hr = one fourth of deficit + maintenance + loss+ third space loss  220+ 110+ 250 + 420  Third hr = one fourth of deficit + maintenance + loss+ third space loss  220+ 110+ 250 + 420 Fourth hr = Maintenance + loss+ third space loss  110+ 50 + 420
  41. 41. Summary  Most physiological :RL  Rich in sodium : NS,DNS  Rich in potassium :ISo –p  Glucose free: ?RL,NS,3% saline  Sodium free: Dextrose  Potassium free: NS,DNS,Dextrose  Can correct acidosis directly : RL,ISo-p
  42. 42. Thank you

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