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Fluid Therapy Fluid Therapy
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RESUSCITATION
MAINTENANCE
NUTRITION
Crystalloid
1. Replace acute loss
(hemorrhage, GI loss,
3
rd
space etc)
1. Replace normal loss
(IWL + urine+ faecal)
2. Nutrition support
ELECTROLYTES
FLUID THERAPY FLUID THERAPY
Colloid
Volume of Distribution of Water
60%-Males
50%-Females
Solids
/////////////////////
H
2
O
Solids 40% of Wt
H
2
O H
2
O
Na
Intracellular
(2/3)
Extracellular
(1/3)
E.C.F. COMPARTMENTS
H
2
O
Na
Colloids
& RBC
Intra-
vascular
1/4
Interstitial 3/4
H
2
O
Na
Third Space
Acute sequestration in a body compartment
that is not in equilibrium with ECF
Examples:
Intestinal obstruction
Severe pancreatitis
Peritonitis
Major venous obstruction
Capillary leak syndrome
Burns
Daily Fluid Balance
Urine: 1.0 to 1.5L
Insensible Loss
-Lungs 0.3L
-Sweat 0.1 L
Intake:
1-1.5L
Body Water and Fluid Body Water and Fluid
Compartments Compartments
TBW = 0.6 or 0.5 x kg
TBW = ECF + ICF
(1/3) (2/3)
ECF = extracellular, ICF = intracellular
ECF = Interstitial + Plasma
(3/4) (1/4)
Fluid spaces are iso-osmolar due to water
movement
70 kg male
Total body water=60% body wt
=0.6X70=42 liters
ICF=2/3
0.6 X42=25 liters
ECF=1/3
0.3X42=13 liters
Blood=1/4 (ECF)
0.25X13=3. 3 liters
Monitoring Fluid Therapy
Serial exams: vascular fullness, skin turgor,
auscultation,, pulse quality, HR, RR
Urine: specific gravity, volume
Blood pressure
Body weight
Labs: electrolytes, BUN, Creatinine, lactate
(tissue perfusion)
CVP
Why give fluids? Why give fluids?
Replace intravascular volume
Improve tissue perfusion
Replace fluid deficits (dehydration)
Meet maintenance in NPO patient
Replace ongoing losses (burns, etc.)
Fluid diuresis to eliminate toxins
Anesthetic and surgical support
Replacement of specific components (blood,
plasma)
Nutritional support (TPN, PPN)
Clinical Diagnosis
Intravascular depletion
MAP= CO x SVR
Hemodynamic effects
BP HR JVP
Cool extremities
Reduced sweating
Dry mucus membranes
E.C.F. depletion
Skin turgor, sunken eyeballs
Weight
Hemodynamic effects
Water Depletion
Thirst
Hypernatremia
Electrolyte composition Electrolyte composition
mEq/L ICF ECF
Plasma Interstitial
15 142 144
150 4 4
2 5 2.5
27 3 1.5
1 103 114
10 27 30
100 2 2
20 1 1
- 5 5
63 16 6
Na
+
K
+
Ca
2+
Mg
2+
Cl
-
HCO
3
-
HPO
4
2-
SO
4
2-
Organic acid
Protein
142
150
144
.
COMPARTMENT CATION ANION Suitable solution
ICF K
+
Mg
++
HPO4
-
, Prot containing K
+
Mg
+
and HPO4
-
ECF PLASMA Na
+
Cl
-,
HCO3
-
Prot. High Na
+
and Cl
-
ISF Na
+
Cl
-
HCO3
-
COMPARTMENT CATION ANION Suitable solution
ICF K
+
Mg
++
HPO4
-
, Prot containing K
+
Mg
+
and HPO4
-
ECF PLASMA Na
+
Cl
-,
HCO3
-
Prot. High Na
+
and Cl
-
ISF Na
+
Cl
-
HCO3
-
Ion Distribution Ion Distribution
Volume Deficit-Clinical Types
Total body water:
Water loss (diabetes insipidus, osmotic diarrhea)
Extracellular:
Salt and water loss (secretory diarrhea, ascites, edema)
Third spacing
Intravascular:
Acute hemorrhage
Dehydration Dehydration
Hypovolemia Hypovolemia
* thirst
* urine output
headache
nausea
syncope
hypotonic
electrolytes
isotonic
electrolytes
5% Dextrose 5% Dextrose
Ringers acetate
Ringers lactate
Normal saline
Ringers acetate
Ringers lactate
Normal saline
..
Deficit Deficit
The IV Fluid Supermarket
Colloids
Albumin
5% in NS
20% (Salt Poor)
Dextrans
Hetastarch
Blood
Crystalloids
Dextrose in water
D5W
D10W
D50W
Saline
Isotonic (0.9% or normal)
Hypotonic (0.45%, 0.25%)
Hypertonic
Combo
D51/2NS
D5NS
D10NS
Ringers lactate physiologic.
(K, HCO3, Mg, Ca)
COMPOSITION OF
PARENTERAL FLUIDS
Parenteral fluids are generally classified
based on molecular weight and oncotic
pressure.
Colloids have a molecular weight of
>8000 and have high oncotic pressure.
Crystalloids have a molecular weight of
<8000 and have low oncotic pressure.
Nacl 5%
Na 850 mmol/L
CL 850 mmol/L
1700 mosm/L
Kcl 15%
K 2000mmol/L
Cl 2000mmol/L
2000 mosm/L
NaHco3 7.5%
Na 1000mmol/L
Hco3 1000mmol/L
2000mos/L
NaHco3 HCL H2co3 Nacl
H2co3 co2 H20
Dextrose Hyper Tonic
D25% 1180 mos/L
D50% 2770 mos/L
Dextran solutions (dextran 40 and dextran
70): Similar osmotic pressure to plasma. Dextrans
interfere with normal coagulation partly by
hemodilution of clotting factors and partly by
coating platelets and the vascular endothelium.
May promote renal failure.
20% Human serum albumin: Protein based
solution, falling out of favor in some circles secondary
to reports of increased mortality in the critically ill
adult population, and some debate still lays in its use
outside of the neonatal arena.
Colloids
Colloid refers to a liquid that exerts osmotic
pressure due to large MW (greater than
30,000) particles in solution. A variety of
colloid solutions are seen for in hospital use:
Hydroxyethyl starch (Hespan): hetastarch can
cause a coagulopathy, through hemodilution of
clotting factors, inhibition of platelet function and
reduction of the activity of factor VIII
Pentastarch (Pentaspan):Pentastarch differs from
hetastarch in that it has a lower mean MW.
Preliminary studies also suggest that pentastarch
may have fewer adverse effects on coagulation than
hetastarch.25. No clear pediatric value yet.
Colloids
Fluids can be described as being
from three categories
Fluids can be described as being
from three categories
.
Isotonic - Fluid has the same osmolarity as plasma
Normal Saline (N/S or 0.9% NaCl),
Ringers Acetate(RA), Ringers lactate (RL)
Hypotonic -Fluid has fewer solutes than plasma
Water, 1/2 N/S (0.45% NaCl), and D5W
(5% dextrose in water) after the sugar is
used up
Hypertonic-Fluid has more solutes than plasma
7.5% Hco3Na/ 15% kcl
3% saline solution, 5%salin solution
.
Isotonic - Fluid has the same osmolarity as plasma
Normal Saline (N/S or 0.9% NaCl),
Ringers Acetate(RA), Ringers lactate (RL)
Hypotonic -Fluid has fewer solutes than plasma
Water, 1/2 N/S (0.45% NaCl), and D5W
(5% dextrose in water) after the sugar is
used up
Hypertonic-Fluid has more solutes than plasma
7.5% Hco3Na/ 15% kcl
3% saline solution, 5%salin solution
Most Common form of Dehydration
Occurs when fluids and electrolytes are lost in
even amounts
There are no intercellular fluid shifts in
isotonic dehydration
Common Causes
diuretic therapy
excessive vomiting
excessive urine loss
hemorrhage
decreased fluid intake
Most Common form of Dehydration
Occurs when fluids and electrolytes are lost in
even amounts
There are no intercellular fluid shifts in
isotonic dehydration
Common Causes
diuretic therapy
excessive vomiting
excessive urine loss
hemorrhage
decreased fluid intake
Isotonic Dehydration
Hypertonic Dehydration
Second most common type of dehydration.
Occurs when water loss from ECF is greater than
solute loss
hyperventilation, pure water loss with high fevers,
and watery diarrhea.
Diabetic Ketoacidosis and Diabetes Insipidus
Iatrogenic Causes
prolonged NPO, excessive hypertonic fluids, sodium
bicarbonate,
Second most common type of dehydration.
Occurs when water loss from ECF is greater than
solute loss
hyperventilation, pure water loss with high fevers,
and watery diarrhea.
Diabetic Ketoacidosis and Diabetes Insipidus
Iatrogenic Causes
prolonged NPO, excessive hypertonic fluids, sodium
bicarbonate,
Hypotonic Dehydration
Relatively Uncommon - Loss of more solute
(usually sodium) than water.
Hypotonic Dehydration causes fluid to shift from the
blood stream into the cells, leading to decreased
vascular volume and eventual shock
Seen in Heat Exhaustion
Increased cellular swelling -causes increased
intracrainial pressure - Confusion.
Seen in Heat Stroke
Relatively Uncommon - Loss of more solute
(usually sodium) than water.
Hypotonic Dehydration causes fluid to shift from the
blood stream into the cells, leading to decreased
vascular volume and eventual shock
Seen in Heat Exhaustion
Increased cellular swelling -causes increased
intracrainial pressure - Confusion.
Seen in Heat Stroke
increases ECF increases ECF
ICF ISF Plasma ICF ISF Plasma
Replace acute/
abnormal
loss
Replace acute/
abnormal
loss
Isotonic infusion Isotonic infusion
700 ml 300 ml
Ringers acetate
Ringers lactate
Normal saline
Ringers acetate
Ringers lactate
Normal saline
increases ICF > ECF increases ICF > ECF
ICF ISF Plasma ICF ISF Plasma
Replace Normal
loss (IWL + urine)
Replace Normal
loss (IWL + urine)
Hypotonic infusion Hypotonic infusion
5% dextrose 5% dextrose
70 ml 70 ml 270 ml 270 ml 660 ml 660 ml
Replacement
Maintenance
Repair deficit
Replacement
Maintenance
Repair deficit
Fluid Therapy Fluid Therapy
BACIC PRINCIPLES BACIC PRINCIPLES
Replace Replace
Maintain Maintain
Repair Repair
Abnormal loss: GIT, 3
rd
space,
Ongoing loss, septic and
Hypovolemic shock
Abnormal loss: GIT, 3
rd
space,
Ongoing loss, septic and
Hypovolemic shock
IWL + urine IWL + urine
Acid base, electrolyte imbalances Acid base, electrolyte imbalances
FLUID SELECTION FLUID SELECTION
Replace : RA, RL, NS
Maintain: N/2 + D (adult)
Repair : NaHCO3 8,4%
KCl 15%
NaCl 3%
Replace : RA, RL, NS
Maintain: N/2 + D (adult)
Repair : NaHCO3 8,4%
KCl 15%
NaCl 3%
Maintenance Maintenance
IWL + urine
Adults/children : 4:2:1
eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 =
100ml/hr
IWL + urine
Adults/children : 4:2:1
eg 60 kg 4 x 10 + 2 x 10 + 1 x 40 =
100ml/hr
Requirements Requirements
Fever
Restless/delirium
Warm ambient temperature
Hyperventilation
Fever
Restless/delirium
Warm ambient temperature
Hyperventilation
Requirements Requirements
Hypothermia
High humidity
Oliguria/anuria
Reduced consciousness
Retention/oedema
Increased intracranial pressure
Hypothermia
High humidity
Oliguria/anuria
Reduced consciousness
Retention/oedema
Increased intracranial pressure
Rationale of maintenance
solutions
Rationale of maintenance
solutions
Fluid redistribution
Basal requirement of potassium &
sodium
electrolyte concentration in
infusion solutions
Fluid redistribution
Basal requirement of potassium &
sodium
electrolyte concentration in
infusion solutions
Electrolyte solutions Electrolyte solutions
Plasma
Isotonic
solutions
Hypotonic solutions
Normal
saline
Ringers
acetate/ lactate
KAEN 3B*
290
308 273
278
D5
290 278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol
Cl-, 20 mmol lactate, 27 g dextrose per L.
Electrolyte Requirements:
70-kg adult
Sodium (as NaCl): 80-150 mEq (mmol)/d
(Pediatric patients, 3-4 mEq/kg/ 24 h
[mmol/kg/24 h])
Chloride: 80-150 mEq (mmol)/d, as NaCl
Potassium: 50-100 mEq/d (mmol/d)
(Pediatric patients, 2-3 mEq/kg/24 h
[mmol/kg/24 h]).
Calcium: 1-3 gr/d,
Magnesium: 20 mEq/d (mmol/d).
Sodium Physiology
1. Sodium and its anions make up about 90% of
the total extracellular osmotically active
solute.
2. Serum osmolality (mOsm/kg H20) = 2 X
[Na+] + [glucose]/18 + [BUN]/2.8
3. For practical purposes, twice the Na+
concentration equals serum osmolality
because urea and glucose ordinarily are
responsible for less than 5% of the osmotic
pressure.
Hyponatremia
(Na+ <136 mEq/L
[mmol/L])
Low osmolality. Further classified based on clinical assessment of
extracellular volume status
Isovolemic.
No evidence of edema, normal BP. Caused by water intoxication
(urinary osmolality <80 mOsm), SIADH, hypothyroidism,
hypoadrenalism, thiazide diuretics, beer potomania
Hypovolemic.
Evidence of decreased skin turgor and an increase in heart rate and
decrease in BP after going from lying to standing. Due to renal loss
(urinary sodium >20 mEq/L) from diuretics, postobstructive diuresis,
mineralocorticoid deficiency (Addison disease, hypoaldosteronism) or
extrarenal losses (urinary sodium <10mEq/L) from sweating, vomiting,
diarrhea, third spacing fluids (burns, pancreatitis, peritonitis, bowel
obstruction, muscle trauma)
Hypervolemic.
Evidence of edema. urinary sodium <10 mEq/L). Seen with CHF,
nephrosis, renal failure, and liver disease
severity of symptoms correlates with
the rate of decrease in Na+.
?Lethargy, confusion, coma
?Muscle twitches and irritability,
seizures
?Nausea, vomiting
Signs:
Hyporeflexia, mental status changes
Symptoms: Usually with Na+
<125 mEq/L (mmol/L)
Life-Threatening. (Seizures, coma) 3-5% NS can be given in the
ICU setting. Attempt to raise the sodium to about 125 mEq/L
with 3-5% NS.
Isovolemic Hyponatremia. (SIADH)
Restrict fluids (1000-1500 mL/d).
Demeclocycline can be used in chronic SIADH.
Hypervolemic Hyponatremia
Restrict sodium and fluids (1000-1500 mL/d).
Treat underlying disorder. CHF may respond to a combination of
ACE inhibitor and furosemide.
Hypovolemic Hyponatremia
Give D5NS or NS.
Treatment: Based on
determination of volume status.
Mechanisms: Most frequently, a deficit
of total body water.
(Hypovolemic hypernatremia).
(Isovolemic hypernatremia).
(Hypervolemic hypernatremia).
Hypernatremia (Na+ >144 mEq/L
[mmol/L])
[mmol/L])
Mechanisms: Most frequently, a deficit of
total body water.
Combined Sodium and Water Losses
Water loss in excess of sodium loss
results in low total body sodium.
Due to renal (diuretics, osmotic diuresis
due to glycosuria, mannitol, etc) or
extrarenal (sweating, GI, respiratory)
losses
[mmol/L])
Excess Sodium (Hypervolemic
hypernatremia).
Total body sodium increased, caused by
iatrogenic sodium administration (ie,
hypertonic dialysis, sodium-containing
medications) or adrenal hyperfunction
(Cushings syndrome,
hyperaldosteronism).
[mmol/L])
Excess Water Loss (Isovolemic
hypernatremia).
Total body sodium remains normal,
but total body water is decreased.
Caused by diabetes insipidus
,excess skin losses, respiratory
loss, others.
[mmol/L])
Mechanisms: Most frequently, a deficit of
total body water.
Combined Sodium and Water Losses
Water loss in excess of sodium loss
results in low total body sodium.
Due to renal (diuretics, osmotic diuresis
due to glycosuria, mannitol, etc) or
extrarenal (sweating, GI, respiratory)
losses
Hypernatremia
Symptoms:
Depend on how rapidly the sodium level
has changed
Confusion, lethargy, stupor, coma
Muscle tremors, seizures
Signs:
Hyperreflexia, mental status changes
Hypernatremia:
Treatment:
Euvolemic/Isovolemic. (No orthostatic
hypotension) calculate the volume of free
water needed to correct the Na+ to normal
as follows:
Body water deficit = Normal TBW - Current
TBW
Where Normal TBW = 0.6 x Body weight in kg
And Current TBW =Normal serum sodium x
TBW / Measured serum sodium
Hypervolemic
Hypernatremia
Avoid medications that contain
excessive sodium
(carbenicillin, etc).
Use furosemide along with D5W.
Hypernatremia:
Treatment:
Hypovolemic Hypernatremia.
Determine if the patient volume is
depleted by determining if orthostatic
hypotension is present;
if volume is depleted, rehydrate with
NS until hemodynamically stable,
then administer hypotonic saline (1/2
NS).
Treatment of hypernatremia
Hypotonic fluid loss is the most common form
of hypernatremia.
It is caused by gastroenteritis, osmotic
diuresis.
Signs of intravascular depletion are evident.
Treatment involves replacement volume with
normal saline, followed by correction of the
free water deficit
Basal requirement of
Potassium
Basal requirement of
Potassium
K
+
intake ranges from 40-150 mEq daily
Homeostasis (minimum req) 20-30 mEq/day
Increased requirement in heart failure and
hypertension
K
+
intake ranges from 40-150 mEq daily
Homeostasis (minimum req) 20-30 mEq/day
Increased requirement in heart failure and
hypertension
-900 -600 -300 0 +300 -900 -600 -300 0 +300
K
+
deficit (meq) K
+
deficit (meq) K
+
excess (meq) K
+
excess (meq)
10 -
-
8 -
-
6 -
-
4 -
-
2 -
-
-
10 -
-
8 -
-
6 -
-
4 -
-
2 -
-
-
serum K
+
(meq/L)
serum K
+
(meq/L)
Relationship between serum K
+
serum and
TBK at various levels of deficit and excess
Relationship between serum K
+
serum and
TBK at various levels of deficit and excess
05 10 15 20 25 K
+
deficit (%) 05 10 15 20 25 K
+
deficit (%)
5 -
-
4 -
-
3 -
-
2 -
-
1 -
-
-
5 -
-
4 -
-
3 -
-
2 -
-
1 -
-
-
serum K
+
(meq/L)
serum K
+
(meq/L)
Decreased serum K
+
and deficit of TBK (%)
Decreased serum K
+
and deficit of TBK (%)
total body K
+
= 50 mEq/kg body weight total body K
+
= 50 mEq/kg body weight
A c i d o s i s A c i d o s i s
A l k a l o s i s A l k a l o s i s
Blood pH 7.2 7.3 7.4 7.5 7.6
5.0 4.5 4.0 3.5 3.0 0 mEq
4.5 4.0 3.5 3.0 2.5 100 mEq
4.0 3.5 3.0 2.5 2.0 200 mEq
3.2 3.0 2.5 2.0 1.5 400 mEq
cell
DCC
ECF
3 K
+
H
+
2 Na
+
3 K
+
H
+
2 Na
+
K
+
H
+
Urine
K
+
low urine K
+
H
+
acid urine
3 K
+
H
+
2 Na
+
3 K
+
H
+
2 Na
+
K
+
H
+
Urine Alkali
K
+
H
+
Urin
Cell Tubulus distal ECF
K
+
and acid-base status K
+
and acid-base status
Serum K
+
K
+
depletion
K
+
urin tinggi
Cnc: <40 mEq/L Cnc: <40 mEq/L 11
Rate of adm: <20 mEq/hr Rate of adm: <20 mEq/hr 22
daily dosage : <100 mEq/day daily dosage : <100 mEq/day 33
Monitor ECG and serum K
+
Monitor ECG and serum K
+
44
U r i n e output: >0.5 ml/kg/hr U r i n e output: >0.5 ml/kg/hr 55
< 40mEq/L < 40mEq/L
KCl KCl
Standard K
+
concentration in i.v.
solutions
Standard K
+
concentration in i.v.
solutions
KCl bolus KCl bolus
Serum Electrolytes Serum Electrolytes
MAGNESIUM
common electrolyte abnormality hospitalized
humans is hypomagnesimia
Primarily intracellular
Low Mg may be clinically silent but makes
hypocalcemia and hypokalemia refractory to
treatment
Vitamin D controls Mg absorption
May see high Mg in renal failure
Serum Electrolytes Serum Electrolytes
MAGNESIUM
Normosol and Plasmalyte contain Mg
Very low Mg may require treatment with IV
MgSO
4
Cofactor for NaK ATPase
Rate of administration of
Electrolyte & glucose
Rate of administration of
Electrolyte & glucose
Na
+ 100 mEq/hr
K
+ 20 mEq/hr
Ca
++ 20 mEq/hr
Mg
++ 20 mEq/hr
HCO
3
-
100 mEq/hr
Glucosa
0,5 gr/kg/hr ( 4 mg/kg/min)*
Na
+ 100 mEq/hr
K
+ 20 mEq/hr
Ca
++ 20 mEq/hr
Mg
++ 20 mEq/hr
HCO
3
-
100 mEq/hr
Glucosa
0,5 gr/kg/hr ( 4 mg/kg/min)*
* Neonates 6-8 mg/kg/min * Neonates 6-8 mg/kg/min
Conclusion
Maintenance fluid therapy : normal loss
(IWL + Urine)
Suitable in hypertonic dehydration
Minimized risk of potassium depletion in cases
of prolonged inadequate oral intake
Ready for use product associated with less
risk of contamination
Can be combined with amino acids
Maintenance fluid therapy : normal loss
(IWL + Urine)
Suitable in hypertonic dehydration
Minimized risk of potassium depletion in cases
of prolonged inadequate oral intake
Ready for use product associated with less
risk of contamination
Can be combined with amino acids

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