Intravenous fluids: Types, Indications, Contraindications, Administration, Resuscitation.

1. INTRAVENOUS
FLUIDS
Usheem Syed

2. Fluid Compartments

3. Fluid Balance

5. Physical exam for assessing volume
• Physical exam in general is not sensitive or specific
• Acute weight loss; however, obtaining an accurate weight over time may be difficult
• Decreased skin turgor - if you pinch it stays put
• Dry skin, particularly axilla
• Dry mucus membranes
• Low arterial blood pressure (or relative to patient's usual BP)
• Orthostatic hypotension can occur with significant hypovolemia; but it is also common in
euvolemic elderly subjects.
• Decreased intensity of both the Korotkoff sounds (when the blood pressure is being
measured with a sphygmomanometer) and the radial pulse ("thready") due to peripheral
vasoconstriction.
• Decreased Jugular Venous Pressure
• The normal venous pressure is 1 to 8 cmH2O, thus, a low value alone may be normal and does
not establish the diagnosis of hypovolemia.

6. SIGNS & SYMPTOMS OF Fluid Volume
Excess
• SOB & orthopnea
• Edema & weight gain
• Distended neck veins & tachycardia
• Increased blood pressure
• Crackles & wheezes
• Pleural effusion

8. Fluid Therapy
• Indications:
• Coma, anesthesia, severe vomiting and diarrhoea
• Dehydration
• Shock
• Hypoglycemia (where orals are not possible)
• Vehicle for: antibiotics, chemotherapy agents
• TPN
• Critical problems: anaphylaxis, pancreatitis, forced diuresis in drug overdose,
poisoning.

9. Disadvantages
• More expensive
• Needs asepsis, under skilled supervision
• Improper selection of type, volume, rate and technique can lead to
serious problems.
Contraindications:
• Avoided in patients who can take oral fluids
• CHF, Pulmonary edema

10. Types of I.V Fluids
• Crystalloids
• Colloids
• Blood and Blood Products

11. Crystalloid vs Colloid
Type of particles (large or small)
• Fluids with small “crystallizable” particles like NaCl are called
crystalloids
• Fluids with large particles like albumin are called colloids, these
don’t (quickly) fit through vascular pores, so they stay in the
circulation and much smaller amounts can be used for same
volume expansion. (250ml Albumin = 4 L NS)
• Edema resulting from these also tends to stick around longer for same
reason.
• Albumin can also trigger anaphylaxis.

13. CRYSTALLOIDS

14. Osmolality

15. Plasma Osmolality(285-295)

20. NORMAL
SALINE

21. NORMAL SALINE
• Composition: Na: 154 mEq , Cl: 154 mEq
• Pharmacological Basis:
• Provides major extracellular electrolytes
• Corrects both water and electrolyte deficit
• Increases the intravascular volume substantially
• Contraindications:
• Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis
• Dehydration with severe hypokalemia: Deficit of intracellular potassium
• Large volume may lead to hyperchloremic acidosis

22. INDICATIONS
• Water and salt depletion: Diarrhea, vomiting, excessive diuresis
• Hypovolemic shock
• Alkalosis with dehydration
• Severe salt depletion and hyponatremia
• Initial fluid therapy in DKA
• Hypercalcemia
• Fluid challenge in prerenal AKI
• Irrigation of body fluids

23. Other NaCl %

25. RINGER’
S
LACTATE

26. Ringer’s Lactate

27. Ringer’s Lactate
• Pharmacological Basis:
• Most physiological fluid, rapidly expands intravascular
volume.
• Lactate metabolized in liver to bicarbonate providing
buffering capacity
• Acetate instead of lactate advantageous in severe shock.

28. Lactated Ringer’s

29. Indications
• Correction in severe hypovolemia
• Replacing fluid in post op patients, burns
• Diarrhea induced hypokalemic metabolic acidosis
• Fluid of choice in diarrhea induced dehydration
• DKA, provides water, corrects metabolic acidosis and supplies
potassium
• Maintaining normal ECF fluid and electrolyte balance

30. Contraindications
• Liver disease, severe hypoxia and shock
• Severe CHF : may lead to lactic acidosis
• Addison disease
• Vomiting pr NGT induced alkalosis
• Simultaneous infusion of RL and blood
• Certain drugs: Amphotericin, Thiopental, Ampicillin, Doxycycline

31. D5

32. 5% Dextrose
• Composition: Glucose 50 g
• Pharmacological basis: Corrects dehydration and supplies energy
(170 kCal/L)
• Indications:
• Pre and post of fluid replacement
• I.V administration of various drugs
• Prevention of ketosis in starvation
• Adequate glucose infusion protects liver against toxic
substances
• Correction of hypernatremia
• Avoid fast infusions as this may lead to swelling of hypotonic
brain cells.

34. Contraindications:
• Cerebral edema, Neuro surgical procedures
• Acute ischemic stroke
• Hypovolemic shock
• Hyponatremia, Water intoxication
• Same I.V line, blood transfusion: Hemolysis, clumping
• Uncontrolled DM: Severe hyperglycemia
• Rate of administration:
• 0.5 g/kg bwt/hr

35. • D5W is not the right choice for patients with renal failure or CHF
since it could cause fluid overload.
• Patients at risk for intracranial hypertension should not receive
D5Wsince it could precipitate cerebral edema.
• D5W should not be used in isolation to replace fluid deficit because
it dilutes plasma electrolytes.
• Never mix blood with dextrose as that can lead to hemolysis
• Not used for resuscitation as it does not remain in the intravascular
space.
• Not used in the early post operative period, because the body’s
reaction to surgical stress may cause an increase in ADH.

36. ISOLYTE FLUIDS

37. • ISOLYTE G
• Vomiting or NGT induced hypochloremic, hypokalemic metabolic
alkalosis
• NH4+ gets converted to H+ and urea in the liver
• Treatment of metabolic alkalosis
• Contraindications: Hepatic/Renal Failure, metabolic acidosis
• ISOLYTE M
• Richest source of potassium (35 mEq)
• Ideal fluid for maintenance
• Correction of hypokalemia
• Contraindications: Renal failure, Burns, Adrenocortical
insufficiency

38. COLLOIDS
Colloids: Large molecular weight substances that largely
remain in the intravascular compartment thereby generating
oncotic pressure
3 times more potent
1 mL blood loss = 1 mL colloid = 3 mL crystalloids

41. Albumin
Pharmacological basis:
• 5% albumin: COP of 20 mmHg
• 25% albumin: COP of 70 mmHg, expands
plasma volume to 4-5 times the volume
infused
Rate of infusion:
• Adults: initial infusion of 25 g
• 1 to 2 mL/min - 5% albumin
• 1mL/min – 25 %

43. Indications:
• Plasma volume expansion in acute hypovolemic shock, burns,
severe hypoalbuminemia
• Hypoproteinemia: Liver disease, diuretic resistant nephrotic
syndrome
• In therapeutic plasmapheresis as an exchange fluid
• Contraindications:
• Severe anemia, Cardiac failure
• Hypersensitivity reaction

44. Dextran
• Dextrans are glucose polymers produced by bacteria (Leuconostoc)
• 2 forms:
• Dextran 70 (Mol wt: 70,000)
• Dextran 40 (Mol wt: 40,000)
• Pharmacological basis:
• Effectively expands intravascular volume
• Dextran 40 as 10% solution: Greater expansion, Short duration (6 hr)
– Rapid renal excretion
• Anti thrombotic: Inhibits platelet aggregation
• Improves micro circulatory flow

45. Indications:
• Hypovolemia correction
• Prophylaxis of DVT and post operative thromboembolism
• Improves blood flow and micro circulation in threatedned
vascular gangrene
• Myocardial ischemia, Cerebral ischemia, PVD and
maintaining vascular graft patency
• Priming in ECC
Adverse Effects
• Acute Kidney injury
• Interferes with blood grouping and cross matching
• Hypersensitivity reaction

46. Precautions:
• Severe oligo/anuria
• CHF, Circulatory overload
• Bleeding disorders
• Severe dehydration
• Anticoagulant effect of heparin increased
• Hypersensitivity to Dextran
Administration
• Adult atient in shock: Rapid 500 ml infusion
• First 24h: Dose should not exceed 20 mL/kg
• Next 5 days: 10 mL/kg/day

47. Gelatin polymers (Haemaccel)
• 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:
NaCl: 145 mEq
Ca: 12.5 mEq
K: 5.1 mEq
• Indications
• Rapid plasma volume expansion in hypovolemia
• Volume pre loading in regional anesthesia
• Priming of heart lung machines.

48. • Advantages:
• Does not interfere with coagulation, blood grouping.
• Remains in the blood for 4 to 5 hours
• Infusion of 1000 mL expands plasma volume by 300 to 350 mL
• Side Effects:
• Hypersensitivity reaction
• Should not be mixed with citrated blood

49. Hydroxyethyl Starch
It is composed of more than 90% esterified
amylopectin.
Esterification retards degradation leading to longer
plasma expansion.
6% Hetastarch: Mol wt: 4,50,000
Pharmacological basis:
Osmolality: 310 mOsm/L
Higher colloidal osmotic pressure

50. • Advantages:
• Non antigenic
• Does not interfere with blood grouping
• Greater plasma volume expansion
• Preserves intestinal micro vascular perfusion in endotoxemia
• Duration: 24 hours
• Disadvantages:
• Increase in serum amylase concentration up to 5 days after
discontinuation
• Affects coagulation by prolongation of PT, PTT and bleeding
time by lowering fibrinogen
• Decreases platelet aggregation, vWF, Factor VIII

52. Fluid Therapy
There are two components to fluid therapy:
• Maintenance therapy replaces normal ongoing losses, and
• Replacement therapy corrects any existing water and electrolyte
deficits.

53. Fluids for Resuscitation
• Intravenous fluids are an essential component of resuscitation in a
patient with shock.
• In these case, I.V fluids are given as boluses, and crystalloids are
always preferred over colloids.
• The rate of correction depends on the type of shock and on the
response of the patient to fluid replacement.

60. Maintenance therapy
• Maintenance therapy is usually undertaken when the individual is
not expected to eat or drink normally for a longer time (eg,
perioperatively or on a ventilator).
• Big picture: Most people are “NPO” for 12 hours each day.
(8hours for us)
• Patients who won’t eat for one to two weeks should be considered
for parenteral or enteral
nutrition.

61. • Water requirements increase with:
Fever, sweating, burns, tachypnea, surgical drains, polyuria, or
ongoing significant gastrointestinal losses.
• For example, water requirements increase by 100 to 150 mL/day for
each C degree of body temperature elevation.

62. Holiday Segar Method

64. 4/2/1 rule
4 ml/kg/hr for first 10 kg (=40ml/hr)
then 2 ml/kg/hr for next 10 kg (=20ml/hr)
then 1 ml/kg/hr for any kgs over that
This always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kg
This comes down to: Weight in kg + 40 = Maintenance IV rate/hour.
For any person weighing more than 20kg

67. Drop Rate

68. Drops and mL
• 1 Drop= 4 Microdrops
• 1 mL Equals:
1. Normal drip set=15 drops
2. Micro Drip set= 60 Drops
3. Blood set= 10 Drops

73. PARAMETER CONVENTIONAL TO SI UNITS SI
TO CONVENTIONAL UNITS
To convert units, multiply the reported value by the appropriate conversion
factor.
• Sodium × 1 = mmol/L × 1 = mEq/L
• Potassium × 1 = mmol/L × 1 = mEq/L
• Chloride × 1 = mmol/L × 1 = mEq/L
• Bicarbonate × 1 = mmol/L × 1 = mEq/L
• Calcium × 0.25 = mmol/L × 4.0 = mg/dL
• Urea × 0.36 = mmol/L × 2.8 = mg/dL
• Creatinine × 88.4 = μmol/L × 0.0113 = mg/dL
• Glucose × 0.055 = mmol/L × 18 = mg/dL
• Albumin × 10 = g/L × 0.1 = mg/dL