FLUID THERAPY

By: Omar Ahmed Shakir

Under supervision of:
Dr. ALAA H.ALWAN
• Water forms about 60% of total body weight in men and
55% in women

• Distribution
• two-thirds is intracellular
• one-third extracellular
Fluid balance

“The basic principle of fluid and electrolyte

balance is that which is lost must be
replaced”
Osmolarity and tonicity

Osmolarity refers to the number of solute particles per 1 L of solvent

“normal serum
Osmolarity is
280-300
mOsmol/L ”
solutes
Osmosis refers to the movement of fluid
across a membrane in response to
differing concentrations of solutes on the
two sides of the membrane.
tonicity: The ability of an extracellular
solution to make water move into or out of
a cell by osmosis
 Types of IV fluid

Crystalloids Colloids

Natural Synthetic
Isotonic Hypertonic
Hypotonic

Normal D10W, Albumin HES

saline D5W ½NS D25W

Ringer
3% NaCl FFP Dextran
lactate

Gelatin

HES=hydroxyethyl starch
Crystalloids
• Crystalloids contain organic or inorganic salts dissolved in
sterile water

• have a relatively low tendency to cross plasma membranes but

can cross capillaries -- it distributed evenly in ECF

• compared to colloids, have low plasma expansion efficacy.

Colloids are rapid plasma expanders.

• They are the fluid of choice because they are less expensive
than colloids.
Isotonic crystalloids

Normal saline
• Composition: Na+: 154 mEq/L Cl-: 154 mEq/L
Osmolarity: 308 mOsm/L

• Increase ECF, no change on ICF

• Clinical uses:
• Resuscitiation
• Maintenance therapy
• Hypontremia
• Cautions:
• Fluid overload
• Hyperchloremic acidosis
Lactated ringer solution

• the most physiologically adaptable fluid, as it has most closely related

electrolyte contents
• Increase ECF with minimal increment on ICF
• Clinical uses :
• Resuscitation
• Dehydration (replace GI losses)
• Burns
• Cautions:
• Liver diseases ( cannot metabolize lactate, so lead to lactic
acidosis)
• Renal impairment ( risk of hyperkalemia )
Hypotonic solutions
• Examples are: 0.45% NS and D5W
• 0.45% NS :
• Composition: Na+: 77 mEq/L, Cl-: 77 mEq/L, Osmolarity:
154 mOsm/L
• D5W:
• Composition : Glucose 5 g/dl , osmolarity: 252 mOsm/L
• When administerd, glucose is rapidly metabolized leaving
free water that distribute widely in body fluid compartments
• Provide 170 kcal/L
• Clinical uses :
• Correction of free water deficit
• Maintenance
• Caution:
• Renal & cardiac failure ( fluid overload )
• Cerebral edema
Hypertonic solutions

3% NS
• Composition: Na+: 513 mEq/L, Cl-: 513 mEq/L,
Osmolarity: 1027 mOsm/L

• Increase in ECF but decrease in ICF

• Clinical uses:
• Severe hyponatremia (seizure, coma)
• Cerebral edema
• Hemorhagic shock
• Cautions:
• central pontine myelinosis
• thrombophlebitis, extravasation
Dextrose in saline solutions
Na Cl Glucose osmolarity
5% dextrose in 0.9% 154 154 5g/dl 560 mOsm/L
NaCl (D5NS) mEq/L mEq/L
5% dextrose in 77 mEq/L 77 5 g/dl 406 mOsm/L
0.45% NaCl mEq/L
(D5½NS)

• Clinical applications
• replacement of losses
• maintenance therapy
 Colloids
Colloids
Natural Synthetic
• These are the electrolyte solutions, which have a
relatively high tendency to stay intravascular.
Albumin HES
• They contain large proteins that generally do not cross
capillary walls. FFP Dextran

• have a greater effect on intravascular volume than Gelatin

crystalloids.

• it requires administration of less total volume and have

a longer duration of action because the molecules
remain within the intravascular space longer.
• Colloids are used as plasma expanders and are
indicated in conditions such as
• Burns
• hypovolemic shock
• Trauma
• Cautions :
• Allergic reaction (HES is the least allergic)
• Coagulation abnormalities
• Fluid overload
 In acute fluid loss conditions like hemorrhage, diarrhea, and
vomiting, there is a decrease in ECF Volume and no change
in body osmolality and ICF Volume

NS, LR
3%NS
Colloids

So we use isotonic and /or hypertonic to replace ECF

Fluid therapy principle

Resuscitation

Maintenance

Replacement
Resuscitation
• Possible indicators include:
• systolic BP <100mmHg
• heart rate >90bpm
• capillary refill >2s or peripheries cold to touch
• respiratory rate >20 breaths per min

• Rx:
crystalloids (NS or LR) with a bolus of 500 ml over less than
15 minutes
Resuscitation

“ No evidence that resuscitation with colloids reduces the

risk of death, compared with crystalloids in patients with
trauma or burns or 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
000567, 2004
Maintenance

• Methods of calculation:
• 100-50-20 rule : • 35 ml/kg/day
- 100 ml/kg/ 24hr for 1st 10 kg
- 50 ml/ kg/24hr for 2nd 10 kg • 1.5 L /m2 of surface
- 20 ml/kg/24hr for each kg > 20kg area/ 24hr
• 4-2-1 rule
Replacement of ongoing losses

• For examples, losses from NG tube or other drains

• replaced with solutions whose electrolyte composition

closely mirror that of the fluid lost
• NG tube losses - NS + KCl
• Intestinal & biliary losses  RL

• Fever increases water loss from the skin by approximately

200 mL/day for each 1°C rise in temperature
 Post-operative fluid replacement

Day 0: D5W
diminishes the protein degradation that would
occur if the patient received no calories

Day1: D5W+ NS or LR
since RAAS is activated as a part of metabolic
response to trauma, there is a net sodium gain and
thus usually no need to give sodium in the first day
after surgery

Day 2: same as above in addition to

KCL 1mmol/kg
tissue damage with release of
intracellular K,
Assessment of fluid balance

• Clinical :
• Conscious status
• Weight
• Skin turgor • Laboratory
• Mucus membrane • PCV
• Capillary refill • Urea & Creatinine
• Pulse rate • Electrolytes
• BP ( assess for orthostatic
hypotension)
• Urine output
 Rx:
-Fluid and sodium
restriction
Rx: - Diuretics in severe
cases
- Fluid therapy
Take home messages

• The fluid of choice for :

• Initial resuscitation  NS or LR
• Burn LR
• Maintenance  Dextrose in saline solutions

• Assess carefully for fluid balance