TYPES OF INTRAVENOUS FLUIDS

The primary goal: Guarantee stable haemodynamics by

rapidly restoring the circulating plasma volume

Considerations
1. Type
2. Amount
3. Criteria for guiding vol therapy
4. Side effects
5. Costs
Parenteral solutions
Crystalloids
Colloids
Hypertonic Solutions

Products for fluid resuscitation - crystalloids

Hypotonic
Isotonic
Hypertonic
Only 25% - intravascular
Buffering anion lactate
or acetate
Acetate > lactate

Products for volume resuscitation

Colloids
-Natural
-Synthetic
Natural colloids
-Plasma
-Albumin

Ideal colloid:
-sustained iv OP.
No
-infection risks
-allergic reactions
-cross-matching
- Inexpensive

Plasma
Vol expansion < dextran or HES
Activate the cascade systems post -traumatic MOF

Albumin

Mol. wt. - 69kDa

Serum life 18hrs
Expensive
Altered vasc. endo.
integrity
interstitial vol. and
tissue perfusion
altered

The Cochrane Injuries Group Albumin Reviewers for albumin and

non-albumin (control) treated critically ill patients

Clinical
Mortality
Relative risk
condition
Albumin (n) Non-albumin (n) Albumin vs non-albumin
Hypovolaemia
38/256
26/278
1.46
Burns
19/81
8/82
2.40
Hypoalbuminaemia
41/259
24/248
1.69
All included patients
98/596
58/608
1.68

Choi et al: trauma patients

Composition of commonly used crystalloid solutions

Solution Dextrose
Na
Cl
Osm
pH
(gm/L) mEq/L mEq/L mosm/kg
5 DW
RL
0.9%NS
3%
saline

50
0
0
0

0
130
154
513

0
109
154
513

253
273
308
1026

4.5
6.5
6.0
6.0

Expansion
of PV/L
(ml)
100
194
190
560

Duration of
PV expansion
(hrs)
2
2
2
2

COMPOSITION OF COLLOIDS
Colloid

Vol. Mol Wt Osm C

Effec (kDa) (mOs O
t(%)
m/kg) P

pH

PV Duration
exp/ of action
L
(hr)

Half
life
(hr)

5% albumin

100

69

330

19 7.4

490

24-36

15

Dextran 40

120

41

255

40 4.0

600

4-6

3-12

Dextran 70

150

70

70 4.0

710

24

3-12

6% Hetastarch

100

69-200

310

30 5.9

710

24-36

17days

Pentastarch

140

120

308

40 3.56.5

500

18-24

8-12

Pentafraction

140

110

40

500

18-24

8-12

Gelofusine

80

22.6

Haemaccel

140

35

2-3
35 7.3

500

48

4-6

Advantages and disadvantages of crystalloids and

colloids in fluid resuscitation
Crystalloid

Colloid

Intravascular persistence

Poor

Good

Haemodynamic stablization

Transient

Prolonged

Required infusion volume

Large

Moderate

Plasma colloid osmotic pressure

Reduced

Maintained

Risk of overhydration/tissue oedema

Obvious

Insignificant

Enhancement of capillary perfusion

Poor

Good

Risk of anaphylactoid reactions

Non-existent

Low to moderate

Cost

Inexpensive

Expensive

Comparative costs of parenteral fluids

Solutions
Isotonic Crystalloids
0.9% NaCl (500ml)
Lactated Ringer's (500ml)
Human Albumin
5% albumin (1 U)
25% albumin (1 U)
Colloids (500ml)
3% Hetastarch
6% Hetastarch
Dextran 40
Gelofusine
Haemaccel

Rs. (INDIA)
17
17
2500-4000
2500-4000
175
315
400
165
165

Dextrans
~ 80% of a 1L infusion - intravasc space
Patency of microvascular or problematic
vascular anastomoses
Common preparations
6% dex 70 (avg Mol wt-70kDa)
3% dex 60 (avg Mol wt-60kDa)
10% dex 40 (avg Mol wt-40kDa)

in plasma vol 600 800ml

Dose < = 1.5g/kg body wt
Duration of plasma vol supp 24hrs

Dextrans
Dex 40 > dex 70 on
microcirculation
Resque flow Rx haemorrhagic
hypotension
Severe anaphylactic reactions
Hapten -dextran pretreatment
fibrin clot formation &
inhibition of factor VIII Ag

Gelatins

Polypeptides
Mol wt 30-35 kDa
Effect on i.v. volume is low
Renal function and haemostasis
- unimpaired.
Anaphylactoid reactions: direct
histamine liberation
Types
Cross linked(eg.Gelofundiol)
Urea linked (eg. Hemaccel)
Succinylated (eg.
Gelofusine)

Hydroxyethyl starch preparations (HES)

Amylopectin - rapidly hydrolysed
- renally excreted
Hydroxyethyl groups:
- @ C2&C6

met. degradation
Half life: 90% 17 days
10% -- 48 days
Stored in RES.

HES
Characteristics :
Concentration
The wt-averaged mean molecularwt[Mw]
The number- averaged mol wt [Mn]
Molar substitution [MS]
Degree of substitution

Conc : 3%, 6% and 10%

Mol wt :low, medium, high
MS
:low, moderate, high

The ratio of C2 : C6 hydroxyethylation pharmacokinetic behaviour, side effects

(eg.Accumulation)

Tetrastarch (Voluven)
6%HES (130/0.4) in isotonic saline sol,
Isooncotic, vol effect approximately 100%
I.V half life 3hrs, Vol stabilization 4-6hrs
blood loss during major surgery

Hypertonic saline
Haemorrhage, endotoxic
shock,trauma,and burn injury
vol.exp.cap.>crystalloids.
Inhibits oedema formation
Efficacy of small volumes and
rapidity of administration
Disadvantages
Na+ & Cl -, Osmolarity
Met.acd. & hypokalemia
Central pont.demyelination.

- intra cerebral bleeding

Side effects of volume replacement strategies

Coagulation
Dextrans negatively influence haemostasis
LMW-and MMW-HES preparations with a lower
MS[0.5] - detrimental to coagulation
Coagulopathy - HMW HES - PTT, BT,
factor VIII activity , thrombin and urokinase
activated clot lysis times and platelet count.
Pentastarch - less profound effect

 Storage, accumulation and pruritus

HES induced pruritus - long latency of onset
and persistence
Anaphylactic/anaphylactoid reactions:
Dextran induced - most common
Urea-linked gelatin preparations : incidence
Severe life-threatening - HES prep. rare
Renal function:
HES:Increased creatinine concentrations

Intravenous fluids in paediatric practice

Name
5% Dextrose

Dextrose Na K

Cl

Bicarbonate Cal

5%

10% Dextrose

10%

25% Dextrose

25%

DNS

5%

154 154

DNS 0.2%

5%

34

34

DNS 0.33%

5%

57

57

DNS 0.45%

5%

77

77

Normal Saline

154 154

Ringer Lactate

131

111

29

Isolyte-P

5%

26

21

21

Isolyte-M

5%

39

35

36

Isolyte-G

5%

65

17 149

Isolyte-E

142 10

IV fluids useful in paediatric practice

Name

Dextrose Na K Cl BicarbonateCal

1. Isolyte-M

5%

39 35 36

2. Ringer Lactate

131 5 111

29

3. Isolyte-P

5%

26 21 21

The crystalloid versus colloid debate

Pts who receive crystalloid require less ventilatory
support, easier to wean, less EVLW after
resuscitation
Velanovich et al.
No distinct survival advantage
Use of colloid solutions - malnourished individual
? Fluid therapy

specific physiologic actions of each agent

problems underlying pathophysiology
physiologic criteria
physiologic endpoints to determine optimal therapy
when to change type of fluid

Conclusions
Optimal fluid management - condition & response.

?Colloid Vs ?crystalloid ?

Selection of fluid - pt's individual situation

Majority of routine surgical cases - isotonic crystalloids
-sufficient and cost effective
Crystalloid - useful in depleted interstitial space

?fear of pulm. oedema

Addition of a colloid - the amt & time of fluid needed

 Both intravascular space & interstitial space depleted

colloid, first alternative
Choice of colloid - plasma volume supporting capacity,
intravascular persistence, safety and modulation of the
cascade system
Hypertonic - ? potential metabolic complications
Hypertonic solutions suppress neutrophil activation and
post traumatic complications
Further research effects on endothelial inflammation and
immunological system

References
1. Walter S Nimmo, David J. Rowbothom, Graham Smith. Anaesthesia 2 nd
edition, chapter28, crystalloid fluid therapy:554-567
2. Paul G Barash, Bruce F Cullen, Robert K Stoelting. Basic Principles of
Anaesthesia Practice, 3rd edition, chapter 9, Acid-base fluids and
electrolytes
3. Vincent J Collins; Physiologic and pharmacologic bases of Anaesthesia ;
fluids and electrolytes,chapter 10, 165-187 .
4. J Boldt; Volume replacement in surgical patient Does the type of
solution make a difference ? BJA 84(6) : 783-93 (2000)
5. Lloyd E Ratner; Gardner W Smith ; Surgical clinics of North America ;Vol
73.Number2; Apr 1993; 229-240
6. H Hjelmqvist; Focus on fluid therapy ; Current Anaesthesia and Critical
care 2000(11),7-10

Composition of common IV fluids

Approximate volume effects of different colloidal

plasma substitutes HES: hydroxyethylstarch solution
Colloid
Volume-restoring effect (h) Initial effect (%)
5-6
Long-acting
6% Dextran 60
120
6% HES 450/0.7
100
6% HES 200/0.62
100
5-4
Medium-acting
10% Dextran 40
200
6% HES 200/0.5
100
10% HES 200/0.5
130
1-2
Short-acting
6% HES 70/0.5
70
3% Gelatin
70
5% Albumin
70-90

Advantages:
Crystalloids

Colloids

- Inexpensive

- Longer intravascular life

- Easily available

- Improve cardiac output

- Non allergenic

- Open up the microcirculation

- Do not interfere with coagulation

- Do not contribute to interstitial edema

- Can be rapidly diuresed

Disadvantages:
Crystalloids

Colloids

- Larger volumes needed

- Expensive

- Do not carry O2

- Anaphylaxis known

-Contribute to peripheral and pulmonary edema

- May interfere with coagulation.

- Redistribute within an hour

- Can cause electrolyte imbalance.

- If capillary endothelium is leaking, pulmonary
edema occurs

 Pentastarch: conc10%, Mw-260kDA,MS-0.45

COP & vol expanding capacity. Serum half life 2.5hrs,
cleared within 24 hrs
Pentafraction- diafiltered new starch sol ~ pentastarchbetter initial volume expansion, no accumulation in RES
Tetrastarch (Voluven)

6%HES (130/0.4) in isotonic saline solution,

Isooncotic, volume effect approximately 100%
Intravascular half life 3hrs, Volume stabilization 4-6hrs
blood loss during major surgery

Composition of commonly used colloid solutions

COMPOSITION OF COLLOIDS
Colloid
5% albumin
Dextran 40
Dextran 70
6%
Hetastarch
Pentastarch

Vol
effect
%
100
120
150
100

Mol wt

Osmo
mosm
/kg
330
255

COP

pH

310

19
40
70
30

7.4
4.0
4.0
5.9

308

40

3.56.5

140

69,000
41,000
70,000
69,000
to2.0 lac
120,000

Pentafraction
Gelofusine

140
80

110,000
22,600

40

Haemaccel

140

35,000

34-38

7.3

PV
expansion
/L of fluid
490ml
600ml
790 ml
710 ml

Duration
of action

Half life

24-36 hrs
4-6 hrs
24 hrs
24-36 hrs

15 hrs
3-12 hrs
3-12 hrs
17 days

500ml

18-24 hrs

8-12 hrs

500ml

18-24hrs

8-12 hrs
2-3 hr s

500ml

48 hrs

4-6 hrs