COLLOIDS AND CRYSTALLOIDS

JCCA JAKARTA 2018

Physiology
• A solution is a product of a chemical reaction that
completely incorporates a solute into a solvent.
• The size of the dissolved molecules determines their
ability to cross the capillary membrane.
• The capillary membrane acts as a semi-permeable
membrane and by measuring the amount of solute present,
in terms of osmolarity and osmolality, we can describe fluids
as hypotonic, isotonic and hypertonic.
• Fluid is distributed across the intracellular and
extracellular compartments.
• Total body water accounts for 55-60% of a 75-kg
male’s body weight, which is the equivalent of 45 litres of
water.
• The intracellular compartment contains 30 litres, with
the extracellular compartment holding the remaining 15
litres.
• This extracellular compartment is further subdivided
into the interstitial and transcellular space comprising of
11.5 litres and the plasma only accounting for 3.5 litres,
which is 8% of total body water.
Colloid Solutions.
• Are IV fluids that contain solutes in the form of large proteins
or other similarly sized molecules.
• The proteins and molecules are so large that they cannot pass
through the walls of the capillaries and onto the cells.
• Colloids remain in the blood vessels for long periods of time
and can significantly increase the intravascular volume.
• Also have the ability to attract water from the cells into the
blood vessels.
• The movement of water from the cells into the bloodstream
may be beneficial in the short term, continual movement in this
direction can cause the cells to lose too much water and
become dehydrated.
• Colloids are expensive, have specific storage
requirements, and have a short shelf life.
• This makes their use more suitable in the hospital
setting.
• The EMT may be required to assist with the
administration of colloids either in a field hospital or
during the transport of critically injured patients.
• Colloids maybe natural or synthetic compounds.
• Natural colloids include whole blood, plasma, or
packed red cells.
• Commonly used colloid solutions include plasma
protein fraction, salt poor albumin, dextran, gelatin
and hetastarch.
Albumin

• a purified single polypeptide derived from pooled

donor plasma.
• Most common human plasma protein (60%)
• Synthesized in the liver
• Responsible for 80% osmotic pressure
• It has an average MW of 65-69 kDa.
• It comes in isotonic and concentrated formulations
and being purified can be considered free from the risk
of transmitting infection.
• Available:
 Iso – oncotic (4 – 5%)
 Hyper – oncotic (20 – 25%)
Dextrans

• formed from lactic acid-producing bacteria, most

commonly Leuconostoc mesenteroides.
• a high-molecularweight branched polysaccharide and
preparations average between 40 and 70 kDa.
• In clinical practice dextran is used for its colloidal,
anticoagulant and hypo-viscosity effects on the plasma.
• The high molecular weight of dextran exerts a large
oncotic pressure thus expanding intravascular volume.
• its anticoagulant effects by reducing platelet and
erythrocyte aggregation.
• It also reduces levels of von WiIlebrand factor
further decreasing platelet function.
• Acts as a plasminogen activator providing
thrombolytic properties.
• Anticoagulant and antithrombotic effects reduce
clot production and sustainability and dextran’s
oncotic effects reduce plasma haematocrit and thus
viscosity.
• The combination of these two effects achieves an
improvement in blood flow.
• Dextran use has however been linked to direct
nephrotoxicity causing acute kidney injury (AKI).
• There is also a recognized incidence of
anaphylaxis and it has been shown to interfere with
blood cross-matching.
Gelatins

• Gelatins use polypeptide molecules derived primarily

from bovine collagen.
• They undergo modification to reduce their viscosity in
one of two ways:
• hydroxylation and succinylation, as in Gelofusine,
Isoplex and Volplex
• degradation and modification with nitrogen, as in
Haemaccel.
• Gelatins have a mean molecular weight of about 35
kDa.
• enables to exert a greater oncotic pressure across the
basement membrane resulting, with a half-life of
approximately 4 hours, in greater plasma volume
expansion.
• Gelatins can cause mild urticarial reactions and severe
anaphylactic reactions.
Starches
• Synthetic polymers of glucose derived from the
breakdown of amyloid peptin by amylase.
• There are multiple preparations that can be differentiated
by three characteristics, which influence the length of time
taken to metabolize the starch molecules and hence a
solution’s effect on plasma expansion.
• Molecularweight (MW): Within a given solution starch
molecules vary in weight.
• A solution is therefore defined by its average molecular
weight and can be subdivided as low (70e130 kDa), medium
(200e260 kDa) and high MW (>450 kDa) groups.
• After intravenous administration the molecules are
metabolized and at a MW of less than 50 kDa the
molecules can be excreted in the urine.
• Degree of substitution: within a starch solution there
are a mixture of glucose polymers with hydroxyl group
substitutions and those without.
• The ratio of the two within a solution is called the
substitution ratio (SR).
• A fluid with higher SR takes longer to metabolize and
increases the duration of plasma expansion.
• C2/C6 ratio: the hydroxyl group substitutions occur at
the C2, C3 and C6 positions of the glucose polymer.
• Substitution at C2 increases the time taken to metabolise
the molecule compared to C6 substitution.
• Hence a high C2/C6 ration (>8) has an increased
duration of plasma expansion.
• Initial starches contained high MW (e.g. 480) and high SR
(0.6), written as 480/0.6, these solutions were shown to
provide a plasma expansion of up to 24 hours.
• The development of coagulopathies secondary to a
reduction in factor VIII and von Willebrand factor as well as
increased incidence of AKI.
• On this basis most physicians switched to low weight
starches (130/0.4).
• However two large trials have demonstrated direct
harm from their infusion when compared to crystalloid
administration.
• The Scandinavian Starch for Severe Sepsis/Septic
shock trial demonstrated an increased mortality and
requirement for dialysis in those patients with sepsis
who received low molecular weight starch.
Crystalloids Solutions

• The primary fluid used for prehospital IV therapy.

• Crystalloids contain solutes of a low molecular weight
dissolved in water.
• Contain electrolytes (e.g., sodium, potassium, calcium,
chloride)
• Are classified according to their “tonicity.”
• Tonicity describes the concentration of electrolytes
(solutes) dissolved in the water, as compared with that of
body plasma.
• One that contains ions or molecules that are difficult to
metabolize will initially remain in the extracellular space.
• The end result is a temporary expansion of the
intravascular volume but ultimately a redistribution of
free water into all compartments.
• Small sugar solutions will quickly undergo this
process rapidly leaving behind free water to be re-
distributed.
1. Isotonic.

• Have a tonicity equal to the body plasma.

• Isotonic crystalloids do not cause a significant shift,
When administered to a normally hydrated patient.
• Thus, there is no (or minimal) osmosis occurring.
• LR and 0,9% NS
• Only 25% remain intravascularly
2. Hypertonic.

• have a tonicity higher than the body plasma.

• A hypertonic crystalloid causes water to shift from
the extravascular spaces into the bloodstream,
increasing the intravascular volume.
• This osmotic shift occurs as the body attempts to
dilute the higher concentration of electrolytes
contained within the IV fluid by moving water into the
intravascular space.
• Ie : 3% NS
3. Hypotonic.

• Have a tonicity lower than the body plasma.

• A hypotonic crystalloid causes water to shift from the
intravascular space to the extravascular space, and
eventually into the tissue cells.
• It creates an environment where the extravascular spaces
have higher concentrations of electrolytes.
• The osmotic change results in the body moving water
from the intravascular space to the cells in an attempt to
dilute the electrolytes.
• Ie : D5W, 0,45% NS
• Less than 10% remain intravascularly.
The most common isotonic solutions used in
prehospital
• Lactated Ringer’s. Lactated Ringer’s (LR) is an isotonic
crystalloid that contains sodium chloride, potassium chloride,
calcium chloride, and sodium lactate in sterile water.
• Normal saline solution. Normal saline solution (NSS) is an
isotonic crystalloid that contains 0.9% sodium chloride (salt) in
sterile water.
• 5% Dextrose in water. 5% Dextrose in water (D5W) is packaged
as an isotonic carbohydrate (sugar solution) that contains
glucose (sugar) as the solute.
• D5W is useful in keeping a vein open by delivering a
small amount of the fluid over a long period of time
and/or supplying sugar, which is used by the cells to
create energy.
• However, once D5W enters the body, the cells rapidly
consume the glucose.
• This leaves primarily water and causes IV fluid to
become hypotonic in relation to the plasma surrounding
the cells.
• Accordingly, the now hypotonic solution causes an
osmotic shift of water to and from the bloodstream and
into the cells
• In the prehospital setting, LR and NSS are commonly used
for fluid replacement because of their immediate ability to
expand the volume of circulating blood.
• After the course of about 1 hour, approximately two-
thirds of these IV fluids eventually leave the blood vessels
and move into the cells.
• Some authorities recommend that for every 1 liter of
blood lost, 3 liters of an isotonic crystalloid be
administered for replacement.
• The volume of IV fluid administered should be based on
medical direction or local protocol, as well as the patient’s
clinical response to fluid administration
Normal Saline

• Normal Saline (0.9% Sodium Chloride) solution is a type

of isotonic fluid that when administered, helps to increase
intravascular volume.
• Because it is isotonic, Normal Saline does not move into
or out of the cells, but instead stays in the blood vessels in
which it was infused.
• Normal Saline contains water, sodium, and chloride, and
it is similar in concentration of sodium as what is already
found in the intravascular space.
• It is used as a volume expander for patients with
hypovolemia; and, also be ordered for other patients who
need extra volume in the extracellular space, including
those with shock or metabolic acidosis.
Lactated Ringer’s Solution

• Similar to Lactated Ringer’s (LR), Ringer’s solution

contains concentrations of the electrolytes sodium,
potassium, calcium, and chloride in measures similar to
that of blood plasma.
• It is also an isotonic solution that does not move fluid
between the intracellular space and the vessels, so it is
ideal for fluid volume replacement.
• Ringer’s solution and LR may be used among patients
for fluid resuscitation efforts and during maintenance
fluid therapy during surgery.
• Ringer’s solution does not contain lactate that is
found in LR, so it is not used among patients with lactic
acidosis.
• However, it may be used among a variety of other
patients who present with conditions such as burns or
dehydration.
D5W

• D5W is a combination of 5% dextrose in water.

• It is a fluid that is classified as either an isotonic or hypotonic
solution.
• It is isotonic in that the amount of dextrose contained in the
fluid is similar to that found in the blood vessels.
• The body quickly uses the dextrose found in D5W and so the
remaining water can pass through the semi-permeable
membranes and enter the interstitial and intracellular spaces.
• D5W is useful for providing calories, but it does not contain
electrolytes, and so is not useful for correcting electrolyte
imbalances.
• Typically not used as part of fluid resuscitation or to correct
severe hypovolemia because the fluid does not stay in the
intravascular space.
• It may be utilized as a form of maintenance fluid, although the
5% dextrose is not sufficient for calories or long-term nutrition.
Hypertonic sodium chloride solution

• sodium chloride concentrations greater than 0.9% are

available as 1.8, 3 and 30%.
• In these concentrations saline expands the circulating
volume by drawing water from the extravascular space when
administered intravenously.
• This is a direct result from its high tonicity.
• A Cochrane systematic review in 2004 showed no benefit
in using hypertonic solutions against near isotonic solutions
for the resuscitation of trauma and critically ill patients.
• There is growing evidence that hypertonic saline
solutions may be beneficial in the management of raised
intra-cranial pressure over mannitol.
• They are also used to correct hyponatraemia.
• The higher concentrations are irritant to smaller
vessels and large bore intravenous access, often via a
central line, may be required.
• In correcting hypernatraemia, care must be taken to
not cause a rapid rise in plasma sodium concentration
that can lead to disruption of osmotic gradients across
the blood–brain barrier and potentially result in osmotic
demyelination syndrome.
SUMMARY

• There are several different types of fluids used for IV

therapy.
• Depending on their specific type and makeup, IV fluids can
cause the shift and redistribution of body water between the
intracellular and extracellular compartments.
• It is important to have a basic understanding of the
different IV fluids and to choose the fluid most appropriate to
the patient’s needs.
• Because most IV fluids are packaged in similar-looking
plastic bags, it is imperative to carefully examine the label on
the bag to ensure the right fluid has been selected.
• Administering an inappropriate IV fluid can result in
undesirable complications, as well as a less than optimal
patient outcome.