1. I.V.Fluids
Presented by
Dr.JATINDER CHHABRA

2. Introduction Can You Imagine life without water?
Of course not, because water is essential to sustain life. Likewise, body fluids are vital to maintain normal body functioning
Total body fluid (TBW), accounts for approximately 60% of total body weight (this can be 70% or higher in a newborn down to 50–55% in a mature woman).
Total Body Fluid can be divided into Intracellular and Extracellular

3. Normal Water Balance 2/3rd 1/3rd I.C.F. E.C.F.
Food Oxidation = 300ml
2/3rd
1/3rd
Lungs = 400ml
Skin = 500ml
Intestine = 100ml
I.C.F.
E.C.F.
1000ml
Kidney - Urine Excertion
E.C.F = 75% interstial fluid + 25% plasma

4. Insensible fluid loss Insensible fluid input – 300 ml oxidation
Insensible fluid loss – skin+lung+stool=1000ml
Normal daily insensible fluid loss = 700 ml
Daily fluid requirement = UO + insensible losses

5. Water requirements increase with:
Fever Sweating
Burns Tachypnea
Surgical drains Polyuria
Gastrointestinal losses through Vomiting or diarrhea
Water requirements increase by 100 to 150 mL/day for each C degree of body temperature elevation.

6. Electrolyte Composition of fluid Compartments

7. INTRODUCTION TO IV FLUID THERAPY:
Must know……….
- illness first and its patho physiology including stage of illness
- Vital organs (Liver,Heart and Kidney) functioning
- Etiology of fluid deficit and type of electrolyte imbalance
Associated illness (DM, HTN, IHD etc.)
Clinical status (hydration, vital data, urine output etc.)

8. Based on above Information , Calculate/Plan
- To give fluid or no
If Yes - Amount
- type of fluid
- rate
- Electrolyte correction
- Contraindication
- Specific fluid

9. Intravenous fluid therapy
Indications
Coma, anaesthesia, Severe vomiting and diarrhoea,
Dehydration and shock
Hypoglycemia
Vehicle for – antibiotics, chemotherapy agents
TPN
Critical problems – anaphylaxis, pancreatitis , forced diuresis in drug overdose, poisoning

10. Advantages
Accurate , controlled and predictable way of administration
Immediate response due to direct infusion
Prompt correction of electrolyte disturbances

11. Disadvantages
More expensive, need asepsis, and under skilled supervision
Improper selection of type, volume , rate and technique can lead to serious problems
Contra indications
Avoided if patient can take oral fluids
CHF, pulmonary edema

12. Complications
Local : hematoma , infusion phlebitis
systemic :
Large volume can lead to circulatory overload
Rigors, air embolism
Septicemia
others – fluid contamination, mixing of incompatible drugs

13. Classification of iv fluids
1. Maintenance fluids : replaces insensible fluid losses
5 % dextrose, dextrose with 0.45 % NS
2. Replacement fluids : correct body fluid deficit
gastric drainage, vomiting,diarrhoea, infection , trauma, burns
3. Special fluids :
Hypoglycemia – 25 % dextrose
Hypokalemia – inj Kcl
Metabolic acidosis – inj soda bicarb

14. ISOTONIC
Osmolality of mOsm/L
No shifting of fluid
Only serves to increase the ECF
HYPOTONIC
Osmolarity of >250 mOsm/L
Shifting of fluid from intravascular to both intracellular and interstitial spaces
Hydrate the cells causing them to swell.
HYPERTONIC
Osmolarity of 375 mOsm/L or higher
Water moves out of the intracellular space increasing ECF( volume expanders)
Dehydrate the cells causing shrinkage.

15. ISOTONIC
0.9% Nacl
Lactated Ringer
Ringers’ Solution
5% Dextrose in water
HYPOTONIC
0.45% Nacl
0.33% Nacl
0.2 % Nacl
2.5% Dextrose water
HYPERTONIC
3% Nacl
5% Nacl
3%Nacl or 5% Nacl +D/W
>5% D/W example,D10W

16. Difference between NS and D5W in distribution
Free water
content
ICF
ECF
Interstitial
Intravascular
D5W
1000cc
660cc
340cc
226cc
114cc (11%) NS
330cc (33%)

18. 5 % dextrose Composition : Glucose 50 gms Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L)
Indications :
Pre and post op fluid replacement
IV administration of various drugs
Prevention of ketosis in starvation
Adequate glucose infusion protects liver against toxic substances
Correction of hypernatremia
Avoid fast infusion as this may lead to swelling of hypotonic brain cells

19. Contra indications
Cerebral edema, neuro surgical procedures
Acute ischaemic stroke
Hypovolemic shock
Hyponatremia , water intoxication
Same iv line blood transfusion – hemolysis , clumping occurs
Uncontrolled DM , severe hyperglycemia
Rate of adminstration – 0.5 gm/kgBW/hr or 666ml/hr % D or 333ml/hr 10 %D

20. Isotonic saline(0.9 % NS) Composition : Na 154 mEq, Cl 154 meq
Pharmacological basis : provide major EC electrolytes..
corrects both water and electrolyte deficit.
increase the iv volume substantially
Contra indications
Avoid in pre eclamptic patients, CHF, renal disease and cirrhosis
Dehydration with severe hypokalemia – deficit of IC potassium
Large volume may lead to hyperchloremic acidosis.

21. Indications
Water and salt depletion – diarrhoea, vomiting, excessive diuresis
Hypovolemic shock
Alkalosis with dehydration
Severe salt depletion and hyponatremia
Initial fluid therapy in DKA
Hypercalcemia
Fluid challenge in prerenal ARF
Irrigation – washing of body fluids
Vehicle for certain drugs

22. DNS Composition : Na Cl – 154 mEq, glucose 50 gm
Pharmacological basis :
Supply major EC electrolytes, energy and fluid to correct dehydration
Indications :
Conditions with salt depletion ,hypovolemia
Correction of vomiting or NGT aspiration induced alkalosis and hypochloremia
Contra indications :
Anasarca – cardiac, hepatic or renal
Severe hypovolemic shock

23. Ringer’s lactate Composition – Na, k , cl, lactate , ca
each 100 ml – sodium lactate 320 mg, Nacl -600mg, kcl-40mg, calcium chloride 27 mg
Pharmacological basis :
Most physiological fluid , rapidly expand s iv volume..
Lactate metabolised in liver to bicarbonate providing buffering capacity
Acetate instead of lactate advantageous in severe shock.

24. Indications
Correction in severe hypovolemia
Replacing fluid in post op patients, burns
Diarrhoea induced hypokalemic metabolic acidosis
Fluid of choice in diarrhoea induced dehydration
DKA , provides water, correct metabolic acidosis and supplies potassium
Maintaining normal ECF fluid and electrolyte balance

25. Contra indications
Liver disease, severe hypoxia and shock
Severe CHF , lactic acidosis takes place
Addison’s disease
Vomiting or NGT induced alkalosis
Simultaneous infusion of RL and blood
Certain drugs – amphotericin, thiopental, ampicillin, doxycycline

26. Isolyte fluids Isolyte G Isolyte M Isolyte P Isolyte E dextrose 50 NaK Cl 63 17
150 40 35 25 20 22
140 10
103
Acetate
Lactate
NH4Cl
--- 70 23 47 Ca Mg 5 3
HPO4 15
Citrate 8
Mosm/L
580
410
368
595

27. Isolyte G :
Vomiting or NGT induced hypochloremic, hypokalemic metabolic alkalosis
NH4 gets converted to H+ and urea in liver
Treatment of metabolic alkalosis
Contraindications : Hepatic failure, 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

28. Isolyte P
Maintenance fluid for children – as they require less electrolytes and more water
Excessive water loss or inability to concentrate urine
Contraindications : hyponatremia, renal failure
Isolyte E
Extracellular replacement solution, additional K and acetate (47mEq)
Only iv fluid to correct Mg deficiency
Treatment of diarrhoea, metabolic acidosis , losses of lower GI tract
Contraindications – metabolic alkalosis

29. Effects of large volume crystalloid infusion.
Extravascular accumulation in skin, connective tissue , lungs and kidney
Inhibition of GI motility
Delayed healing of anastomosis
Large volume ,rapid infusion crystalloids causes hypercoagulability.. Due to reduction in AT 3
Ruttmann TG, James MF. Effects on coagulation due to intravenous crystalloid or colloid in patients undergoing vascular surgery.
Br J Anesth 2002 ; 89 :

30. Holiday Segar Method

31. Colloids
Colloids : large molecular wt substances that largely remains in the intravascular compartment thereby generating oncotic pressure
3 times more potent
1 ml blood loss = 1ml colloid = 3ml crystalloids

32. Type of fluid
Effective plasma volume expansion/100ml
duration
5% albumin
70 – 130 ml
16 hrs
25% albumin
400 – 500 ml
6% hetastarch
100 – 130 ml
24 hrs
10% pentastarch
150 ml
8 hrs
10% dextran 40
100 – 150 ml
6 hrs
6% dextran 70
80 ml
12 hrs

33. Albumin Maintain plasma oncotic pressure – 80 %
Heat treated preparation of albumin – 5%, 20% and 25% commercially available
Pharmacalogical basis :
5% albumin – COP of 20 mmHg
25% albumin – COP of 70mmHg ,expands plasma volume to 4-5 times the volume infused
Rate of infusion :
Adults – initial infusion of 25 gm
1 to 2 ml/min – 5% albumin
1 ml/min % albumin

34. Indications :
Plasma volume expansion in acute hypovolemic shock, burns, severe hypo albuminemia
Hypo proteinemia – liver disease, Diuretic resistant nephrotic syndrome
In therapeutic plasmapheresis , as an exchange fluid
Contra indications :
Severe anaemia, cardiac failure
Hypersensitive reaction

35. Dextran
Dextran are glucose polymers produced by bacteria(leuconostoc mesenteroides)
2 forms : dextran 70(MW 70,000) and dextran
40(40,000)
Pharmacological basis :
Effectively expand iv volume
Dextran 40 as 10% sol greater expansion , short duration( 6hrs) – rapid renal excretion
Anti thrombotic , inhibits platelet aggregation
Improves micro circulatory flow

36. Indications :
Hypovolemia correction
Prophylaxis of DVT and post operative thromboembolism
Improves blood flow and micro circulation in threatened vascular gangrene
Myocardial ischemia, cerebral ischemia, PVD and maintaining vacular graft patency
Priming in ECC
Adverse effects
Acute renal failure
Interfere with blood grouping and cross matching
Hypersensitive reaction

37. Precautions/CI :
Severe oligo-anuria
CHF, circulatory overload
Bleeding disorders like thrombocytopenia.
Severe dehydration
Anticoagulant effect of heparin enhanced
Hypersensitive to dextran
Administration :
Adult patient in shock – rapid 500 ml iv infusion
First 24 hrs – dose should not exceed 20ml/kg
Next 5 days – 10 ml/kg/ day

38. 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 : Na Cl 145 mEq, Ca 12.5 mEq,
potassium 5.1 mEq
Indications :
Rapid plasma volume expansion in hypovolemia
Volume pre loading in regional anesthesia
Priming of heart lung machines

39. Advantages :
Does not interfere with coagulation, blood grouping
Remains in blood for 4 to 5 hrs
Infusion of 1000ml expands plasma volume by to 350 ml
Side effects :
Hypersensitivity reaction
Should not be mixed with citrated blood

40. Hydroxyethyl starch Hetastarch :
It is composed of more than 90% esterified amylopectine.
Esterification retards degradation leading to longer plasma expansion
6% starch - MW 4,50,000
Pharmacological basis :
Osmolality – 310 mosm/L
Higher colloidal osmotic pressure
LMW substances excreted in urine in 24 hrs

41. Physiochemical characteristics :
Substitution of hydroxy ethyl groups at C2, C3 and C6
Concentration : low( 6%), high(10%)
MW : Low( <70kDa), med and high(>450kDa)
Degree of substitution : low(0.45 – 0.58),
high( 0.62 – 0.70)
C2/C6 : low(<8) , high(>8)
Metabolism :
Rapid amylase dependent breakdown and renal excretion upto 50% in 24 hrs

42. Advantages :
Non antigenic
Does not interfere with blood grouping
Greater plasma volume expansion
Preserve intestinal micro vascular perfusion in endotoxaemia
Duration – 24 hrs
Disadvantages :
Increase in S amylase concentration upto 5 days after discontinuation
Affects coagulation by prolonging PTT, PT and bleeding time by lowering fibrinogen
Decrease platelet aggregation , VWF , factor VIII

43. Crystalloids or colloids…???
Crystalloids – recommended as the initial fluid of choice in resuscitating patients from hemorrhagic shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 :
COCHRANE Collaboration in critically ill patients –
“ No evidence from RCT that resuscitation with colloids reduces the risk of death, compared with crystalloids in patients with trauma or burns after surgery”
Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD , 2004

44. CAUTION : HYPERKALAEMIA
HYPOKALAEMIA
HYPERKALAEMIA
Inappropriate IV therapy is a significant cause of pt mortality and morbidity and may result from either too much or too little volume.
TOO MUCH!
Fluid overload has no precise definition but complications usually arise in the context of preexisting cardiorespiratory disease and severe acute illness.
TOO LITTLE!
Insufficient fluid administration is readily identified by signs and symptoms of inadequate circulation and decreased organ perfusion .
INFUSION OF WRONG TYPE OF FLUID!!!
This results in derangement of serum sodium concentration,which if severe,leads to changes in cell volume and function and may result in serious neurological injury.
PERIPHERAL EDEMA
HYPONATREMIA
HYPERNATREMIA
PULMONARY
EDEMA
HYPOVOLAEMIA

45. Calculation of fluid infusion
1. FOR ROUTINE I.V. SET
A. 15 drops = 1 ml
B. "RULE OF TEN" for fluid calculation for 24 hours.
I.V.fluid in litre / 24 hours X 10 = Drop rate / minute
Drop rate per minute / 10 =I.V.fluid in litre / 24 hours.
C."RULE OF FOUR'' for fluid calculation for one hour.
Volume in ml / hour / 4 = Drop rate / minute
Drop rate / minute X 4 = Volume in ml / hour
D.Drop rate calculation for any parameter
Volume to be infused (in ml)
= Drop rate / minute
Duration of infusion in hours X 4

46. 2. FOR MICRO DRIP I.V. SET
A. For micro drip set 1 ml = 60 drops.
B.Number of micro drops per minute = Volume in ml / hour

47. Goals Maintenance of normovolemia and hemodynamic stability
Acceptable plasma colloid osmotic pressure
Correction of electrolyte imbalance
Correction of acid base imbalance
Adequate urine output( 0.5 to 1 ml/kg/hr)

48. Characteristics of I.V.fluids
Summary
Characteristics of I.V.fluids
Characteristic
Type of Fluid
Most physiological
Ringer's lactate (RL)
Rich in sodium
Isotonic saline , DNS
Rich in chloride
Isotonic saline , DNS , Isolyte - G
Rich in potassium
Isolyte - M , P and G
Corrects acidosis
Ringer's lactate , Isolyte - E , P and M
Corrects alkalosis
Isolyte - G
Cautions use in renal failure
Ringer's lactate , Isolyte - M , G, P and E
Avoided in liver failure
Ringer's lactate , Isolyte - G
Glucose free
Isotonic saline , Ringer's lactate
Sodium free
5% , 10% , 20% and 25% - Dextrose
Potassium free
Isotonic saline , DNS , Dextrose fluids

49. Tips & Take Home Message
1.Do not use DNS or any other Dx solution as first line I.V.fluid.
2.Calorie content of Dx/DNS is about 170/litre
Dx 10% about 340/litre.
3.About 20meq of potassium is lost in urine even in presence of hypokalemia,this is even more in presence of hyponatremia.
4.Normal daily requirement of K is 60meq/day.
5.Assess patient every day for
- fluid status
- U.O
- BP/P/SPO2
- Electrocytes