Clinical session

for
4th year students

IntraVenous Fluids (IVF)

Dr.Ali M.Ali Andaleeb

Consultant Surgeon
Osmosis
Movement of fluid from an area of low concentration solute to an area of high
conc. solute to balance the osmolarity.
Molality is the no. of moles of particles of solutes in each 1 kg of solution
Molarity is the no. of moles of particles of solutes in each 1 litre of solution

• When the particles are osmotically active that can drive osmosis, it can be
measured by osmoles

 Osmotic gradient is the difference in osmotic conc. Between two solutions

• Osmotic press. is the pressure that drive the process of osmosis
 Tonicity (ROA) is the effective osmotic gradient(related to the size of molecules
or solutes) ,that is only the pressure exerted by large particles that does not
cross the semipermeable membrane
• Oncotic pressure is the effective osmotic pressure that is exerted by large
particles
Total Body Water ( TBW ) : approximately 60% of body weight
It varies with age, gender and body habitus (50% BW in females ,80% BW in
infants) ,Less in obese as fat contain little water

 Body Fluid Compartments :

Intracellular comp. ( IC ) : 2/3 of TBW
Extracellular comp. ( EC ) : 1/3 of TBW
- Intravascular ( IV ) : Plasma volume (1/4)
- Extravascular: Interstitial fluid ( IS) - (3/4)
Third space comp. : negligible ?
Preoperative Evaluation of Fluid Status
Mental status - H/O intake and output - Blood pressure: supine and standing -
Heart rate - Skin turgor - Urinary output - CVP
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

Electrolytes are substances that become charged when it be in water

 Types of Intravenous Fluids Therapy :
 Crystalloids
 Colloids
 Blood and blood products

 Crystalloids : Clear fluids made up of water and electrolyte ( electrolyte containg

fluids) that can cross a semi-permeable membrane
May be : Isotonic, Hypertonic, and Hypotonic
Ex:
• Normal saline (NS) 0.9% , ½ NS(0.45) , 3 % NS ,
• Dextrose solutions 5 %,10%,20%,25%
• Ringer’s lactate
• DextroSaline (DNS)
 0.9% Normal Saline :
Contains: Na+ 154 mmol/l, Cl- 154 mmol/l ,Osm : 308mosm/l, No buffer
IsoOsmolar compared to normal plasm ,stays almost entirely in the extracellular space.
Indications : Intravascular resuscitation and replacement of salt loss e.g. diarrhoea and
vomiting.
In large amounts, may cause acidosis
 3.0 % Saline :
Contains 513 mmol/l of Na+ and Cl- each, Osm of 1026 mOsm/l;
Hypertonic compared to normal plasm
Indications : Treatment of severe symptomatic hyponatremia (coma, seizure) , and
increased ICP( cytogenic brain edema)
Must be administered slowly and preferably with CV line because it carries risk of
causing phlebitis, necrosis, hemolysis.
Precaution in pt. with CHF , severe renal insufficiency, edema with Na retention.
 ½ NS (0.45%) : hypernatremia
hypertonic extracellular dehydration
.
 Dextrose 5% (D5W) :‘electrolyte free’
Contains 50g/l of glucose, Osm 252mosm/l,
Indications : maintain blood glucose levels , maintain water balance in patients
who are not able to take anything by mouth; may be used post-operatively,
Hypernatremia treatment
Hypotonic compared to normal plasma
May cause Iatrogenic hyponatraemia in surgical patient ,Hyperglycemia ,Not
compatible with blood ( hemolysis)
 Ringer Lactate :
Most physiological solution , Electrolytes composition similar to ECF (ballanced
fluiud)
Contains: Sodium ion= 130 mmol/L. Chloride ion = 109 mmol/L. Lactate = 28
mmol/L. , Potassium ion = 4 mmol/L. ,Calcium ion = 3 mmol/L ,Osm 274 ,
Indications : Intraoperative fluid loss ,Severe hypovolemia (Resuscitation)
May cause severe metabolic acidosis ( impaired lactate conversion).

 DNS (5%dextrose in ½ NS plus 20meq KCL )

Contains Na+ 77, Cl- 97, K+ 20 , Glucose 5 gm ,Osm : 446 mosm/L
Indications : Maintenance solution ,Correction of fluid deficit with supply of
energy .
Fluid Management
The following factors must be taken into
account:
• Maintenance fluid
• Deficit
• Ongoing fluid loss
 Maintenance Fluid Requirements
• “4-2-1 Rule”

 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 , the deficit = ?
half in first hr and one fourth each in next two hr .

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.
 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.

Amount of replaced third Space Losses as follow:

• Minimal Surgical Trauma (herniorrhaphy) : 0-2 ml/kg/hr
• Moderate Surgical Trauma (cholecystectomy) : 2-4 ml/kg/hr
• Severe surgical trauma (major bowel resection): 4-6 ml/kg/hr (or even more)
 Ex: Fluid management 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 = Half of deficit + maintenance + loss+ third space loss
440 + 110 + ? + 420
Second hr = one fourth of deficit + maintenance + loss+ third space loss
220 + 110 + ? + 420
Third hr = one fourth of deficit + maintenance + loss+ third space loss
220 + 110 + ? + 420
Fourth hr = Maintenance + loss+ third space loss
110 + ? + 420
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.
• In elective surgical patients ,replace fluid loss with ‘physiological Ringer’s
solutions.
• Blood products and colloid may be needed to replace intravascular volume
acutely.