DR.V.USHAPADMINI M.D.

,
SENIOR ASSISTANT PROFESSOR,
DEPARTMENT OF MEDICINE
COIMBATORE MEDICAL COLLEGE AND HOSPITAL
COIMBATORE
INTRODUCTION
Many adult inpatients need IV therapy to prevent or
correct problems with their fluid and electrolyte status

Deciding on the optimal amount and composition of

IV fluids to be administered and the best rate at which
to give them can be a difficult and complex task and
decisions must be based on careful assessment of the
patients individual needs
INTRODUCTION
Surveys have shown that many staff who prescribe IV
fluids know neither the likely fluid and electrolyte
needs of individual patients nor the specific
composition of fluids available to them
Fluid prescribing should be given the same status as
drug prescribing
1 in 5 patients on IV fluids and electrolytes suffer
complications or morbidity due to their inappropriate
administration
DISTRIBUTION OF BODY FLUIDS
Total body water is 60% of the total body weight

2/3 rd is Intracellular and 1/3rd is Extracellular

In the Extracellular compartment 1/3rd is Intravascular

and 2/3rd is Interstitial
TOTAL DAILY FLUID REQUIREMENT
IN A NORMAL ADULT
Approximately 2500 ml-But how?

Output-Urine-1500ml+Stools -200ml+Insensible water

loss-800ml

Intake-food- 1000ml+drink 1500 ml

PRINCIPLES AND PROTOCOLS FOR
IV FLUID THERAPY
ALWAYS REMEMBER 5RS
Resuscitation

Routine maintanence

Replacement

Redistribution

Reassessment
ASSESSING FLUID BALANCE
History:Ask about H/O vomiting ,diarrhoea,

fever,surgery,trauma,alcohol intake,bleeding,

thirst,drug intake

and comorbid illnesses

CLINICAL EXAMINATION
Pulse/HR->90 bpm

SBP-<100mmHg ,postural hypotension

Capillary refill time>2 secs

RR>20bpm

JVP falls

Presence of pulmonary or peripheral edema

Urine output <30ml/hour

CLINICAL AND LABORATORY
MONITORING
Daily fluid balance charts and twice a week of weight
measurement

Full blood count and daily monitoring of

urea,creatinine and electrolytes

Urinary sodium helpful in high volume GI losses<30

mmol/l indicates total body sodium depletion even if
plasma levels are normal
TYPES OF IV FLUIDS
CRYSTALLOIDS AND COLLOIDS
Crystalloids have sterile water and electrolytes to
approximate the mineral content of the human
plasma,Ringers lactate is the most physiological fluid
Colloids in addition to fluid and electrolytes have
HMW substance that does not freely diffuse across a
semipermeable membrane ,expensive ,less safe than
crystalloids
TYPES OF FLUIDS
CRYSTALLOIDS:Ringers lactate,Normal
saline,Dextrose normal saline,5% dextrose

COLLOIDS:Albumin,dextran,Haemaccel,Hetastarch
OVERVIEW OF IV FLUIDS
5% dextrose

Corrects intracellular dehydration

Administered when there is a need of water but not

electrolytes

Aggravates cerebral edema

Avoid in acute ischemic stroke ,Neuro surgery and

Hypovolemic shock
ISOTONIC SALINE
Provides major extracellular electrolytes

Indications-Diarrhoea,Vomiting,DKA,Hypercalcemia
of malignancy,Fluid challenge In Prerenal uraemia

Increases the intravascular volume

s
Hypertonic and hypotonic preparations only for
specialist use
DEXTROSE NORMAL SALINE
Supplies Electrolytes and energy

Corrects Hypochloremic alkalosis due to Vomiting or

Nasogastric aspiration

DEXTROSE WITH1/2 NS-Maintenance fluid

Early post op patients,paediatric patients and severe

Hypernatremia
RINGERS LACTATE
Electrolyte content very similar to plasma

Large volumes can be infused rapidly without risk of

electrolyte imbalance

Indications:Post op ,Burns,Fractures,Diarrhoea and

DKA

Contraindications-Liver disease,CCF and Vomiting

ISOLYTE G
Gastric replacement solution

Corrects metabolic alkalosis due to vomiting and

continuous gastric aspiration

Contraindications-Hepatic failure,Rena
failure,Metabolic acidosis
ISOLYTE M
Richest source of potassium,useful to treat
Hypokalemia

Indications-Diarrhoea,Bilious vomiting,UC

Contraindications-Burns and Renal failure

ISOLYTE P
Maintenance fluid in children
Contraindications-Hyponatremia and Renalfailure

ISOLYTE-E-Only fluid which corrects magnesium

deficiency
Indications-Diarrhoea,Metabolic acidosis
COLLOIDS
ALBUMIN-Maintains colloid osmotic pressure

Corrects Hypoproteinemia of liver disease,Nephrotic

syndrome , malnutrition and plasma replacement in
theraupeutic plasmapheresis

Fever and allergic reactions can occur

100ml,25%albumin or 500 ml,5%albumin given-

1ml/min
DEXTRAN
Glucose polymer available in 2 forms-40,LMW and
70,HMW

Indications-Improves micro circulation,used as

prophylaxis for DVT,Post op and Post traumatic
thrombo embolism

Adverse effects-Hypersensitivity and AKI

Interferes with Blood grouping and cross matching

Haemaccel
Gelatin polymer

Indications-Burns ,Trauma post op blood loss

Does not interfere with blood grouping or cross

matching

Adverse effects-Hypersensitivity,Bronchospasm and

Hypotension
HETASTARCH
Hydroxy ethyl starch-synthetic colloid

Less expensive than albumin,NOT antigenic ,once

daily infusion and does not interfere with blood
grouping or cross matching

Disadvantages-increases Serum Amylase values so

difficult to diagnose Acute pancreatitis
RESUSCITATION FLUIDS
Use crystalloids that contain sodium in the range of
130-154mmol/l with a bolus of 500ml over less than 15
minutes

Do not use tetra starch for fluid resuscitation

Consider human albumin for resuscitation only in

patients with severe sepsis
ROUTINE MAINTENANCE
25-30ml/kg/day of water+1mmol/kg/day of potassium
sodium and chloride

Approximately 50-100 g/day of glucose to limit starvation

ketosis

In obese patients adjust IV fluid prescription to their ideal

body weight

Prescribing >2.5 litres/day increases the risk of

Hyponatremia
REPLACEMENT AND
REDISTRIBUTION
To account for ongoing losses or abnormal
distribution

Consider less fluid 20ml/kg day for patients who are

old,renal impairment,CCF,malnourished

Give IV fluids for maintenance during daytime hours

to promote sleep and wellbeing
CALCULATING RATE OF FLUID
INFUSION

Routine IV set1ml=15 drops

Infusion for 24 hrs-Rule of 10

IVF in litres/24 hrsx10=drop rate/min
Eg.3L/24 HRS x10=30 drops /min

Infusion for 1 hour-Rule of 4

Volume in ml/hr/4=drop rate/min
Eg.400ml/hr/4=100 drops/mins
TAKE HOME MESSAGES
Oral route always preferred over IV route

Fluid prescription should be given the same status as

drug prescribing

Maintain strict asepsis-all cannulae carry a risk of

MRSA infection

Resume oral fluids as soon as possible