• GI disorders: vomiting, diarrhea, ascites
• Environmental exposure or neglect
• Renal salt wasting
Aim of Fluid resuscitation
• Early, complete restoration of tissue
• Minimal biochemical disturbance
• Preservation of renal function
• Avoidance of transfusion complications.
First Priority: Restore volume
Second Priority: Restore blood - oxygen carrying capacity
Third Priority: Normalize coagulation status
How to know that the patient has Hypovolemic Shock?
The patient has the following sings and symptoms:
1- Anxiety or agitation 2- Cool, Pale skin
3- Confusion 4- Decreased or no urine output
5- Rapid breathing 6- Disturbed consciousness
7- Low blood pressure 8- Low body temperature
9- Rapid pulse, often weak and
Combination of water and electrolytes
Balanced salt solution: electrolyte composition and osmolality
similar to plasma; example: lactated Ringer’s, Plasmlyte,
- Hypotonic salt solution: electrolyte composition lower than that of
plasma; example: D5W.
They are True solutions , No particulate
Expands IVC adequately (less than colloids), however Small
increase in plasma volume is observed.
Replenishes interstitial compartment
It leaves IVC faster ( t/2 20-30 minutes)
No risk of allergic reaction
A- 0.9% sodium chloride (Normal Saline)
Contains only water, sodium (154 mEq/L), and chloride
It's called "normal saline solution" because the
percentage of sodium chloride in the solution is similar
to the concentration of sodium and chloride in the
Solutions Na+ K+ Ca2+ Mg2+ Cl- HCO3
- Dextrose mOsm/L
0.9% NaCl 154 154 308
When to be given?
1- to treat low extracellular fluid, as in fluid volume deficit from
- Hemorrhage - Severe vomiting or diarrhea - Heavy drainage
from GI suction, fistulas, or wounds
3- Mild hyponatremia
4- Metabolic acidosis (such as diabetic ketoacidosis)
5- It’s the fluid of choice for resuscitation efforts.
6- it's the only fluid used with administration of blood
When to be used?
• Fluid losses due to burns and trauma
• To replace GI tract fluid losses ( Diarrhea or vomiting )
• Patients experiencing acute blood loss or hypovolemia
due to third-space fluid shifts.
Ringer's lactate or Hartmann solution
Both 0.9% sodium chloride and LR may be used in many clinical
situations, but patients requiring electrolyte replacement (such as
surgical or burn patients) will benefit more from an infusion of LR.
- LR is metabolized in the liver, which converts the lactate to
bicarbonate. LR is often administered to patients who have
metabolic acidosis not patients with lactic acidosis.
- Don't give LR to patients with liver disease as they can't
- used cautiously in patients with sever renal impairment because
it contains some potassium
- LR shouldn't be given to a patient whose pH is greater than 7.5
• It is considered an isotonic solution, but when the dextrose is
metabolized, the solution actually becomes hypotonic and
causes fluid to shift into cells.
• D5W provides free water that pass through membrane pores
to both intracellular and extracellular spaces. Its smaller size
allows the molecules to pass more freely between
compartments, thus expanding both compartments
D5W 50gm/l 278
It provides 170 calories per liter, but it doesn't replace electrolytes.
The supplied calories doesn't provide enough nutrition for
prolonged use. But still can be added to provide some calories
while the patient is NPO.
- D5W is not good for patients with renal failure or cardiac problems
since it can cause fluid overload.
- patients at risk for intracranial pressure should not receive D5W
since it could increase cerebral edema.
- D5W shouldn't be used in isolation to treat fluid volume deficit
because it dilutes plasma electrolyte concentrations.
- Never mix dextrose with blood as it causes blood to hemolyze.
- Not used for resuscitation, because the solution won't remain in
the intravascular space.
- Not used in the early postoperative period, because the body's
reaction to the surgical stress may cause an increase in antidiuretic
Be aware that patients being treated for hypovolemia can quickly
develop hypervolemia (fluid volume overload) following rapid or
overinfusion of isotonic fluids.
Document baseline vital signs, before beginning the infusion, and
continue monitoring during and after the infusion.
Precautions in usage of Isotonic solutions
Frequently assess the patient's response to I.V. therapy,
monitoring for signs and symptoms of hypervolemia such as:
hypertension / bounding pulse / pulmonary
crackles / peripheral edema / dyspnea/ shortness
of breath / jugular venous distention (JVD)
Monitor intake and output
Elevate the head of bed at 35 to 45 degrees, unless
If edema is present, elevate the patient's legs.
monitor for signs and symptoms of continued hypovolemia,
urine output of less than 0.5 mL/kg /hour /
poor skin turgor
weak, thready pulse
Educate patients and their families about signs and symptoms of
volume overload and dehydration
instruct patients to notify if they have trouble breathing or notice any
Instruct patients and families to keep the head of the bed elevated
Suspension of particle rather than a solution
High Molecular Weight: Unable to pass through semi permeable
Remains confined to intra-vascular compartment (at least initially)
Do not correct water and electrolyte deficiencies
Examples: hetastarch (Hespan), albumin, dextran
Most logical choice for intravascular expansion.
Since greater portion remains in IVC & for longer time ( t/2 3-6
Less volume is required& initial resuscitation is rapid.
500 ml of colloids expands plasma by 500ml.
TYPES OF COLLOIDS
1) Blood-derived: Albumin 5%( Heated, Antigenic)
2) Dextran: Dextran 70, Dextran 40
3) Gelfusine (Anaphylaxis)
4) Hydroxy ethyl ether
5) Hetastarch 6%
MW = 450 000
Effective Plasma Expander
&Effect on Coagulation
Human albumin solution(1-5%):
- The most commonly utilized colloid solutions.
- It contains plasma protein fractions obtained from human plasma
and works to rapidly expand the plasma volume used for:
moderate protein replacement
achievement of hemodynamic stability in shock states.
- considered a blood transfusion product and requires all the same
nursing precautions used when administering other blood products.
-It can be expensive and its availability is limited to the supply of
Water soluble glucose polymers formed by bacterial
action(leucocytic mesenteroids)on sucrose through
Effective plasma volume expander due to colloid
Sp. Gravity is slightly greater than blood
Broken down enzymatically to dextranase and
excreted in urine.
Dextran 150 - 6% dextran in 5% glucose on normal
Dextran 110 – 5% dextran in 5% glucose on normal
Dextran 70 – 6% dextran
Dextran 60 – 3% dextran
Dextran 40 -- 10% dextran
Large dextran molecule can block renal tubules and damage
kidney, so dextrans should not be given more than 1-2 L in 24 hrs.
Limited daily dosing of 20ml/kg.
Decreases blood viscosity, platelet viscosity,RBC aggregation
Improves blood flow through microcirculation
Preloading with 10-15 ml/kg of dextran before SA block prevents
Clinical advantages of Dextran:
Periphereal vascular disease-improves blood flow through
Prevention of excessive platelet activation and release of micro
emboli during end arterectomy & skin grafting and other vascular
Highest risk of anaphylaxis
Prolongs BT- risk of bleeding
Intereferes with grouping and blood typing
Worsens renal failure
Impairs BT,Platelet function ,ESR
Known sensivity of dextran
Fixed low cardiac outpatient status
Raised ICT and marked hemorrhagic tendencies eg
Second most common plasma expander after HES.
Prepared from hydrolysis of polypeptides
Derived from Bovine collagen
Mol wt 30-35 KDA
Plasma half life 4-6 hrs
Cross linked gelatins- eg Gelofondiol
Urea linked gelatins- eg Haemaccel
Succinylated gelatins- eg Gelofusine
Haemaccel(300ml,500ml) obtained from high grade gelatins
Each 100 ml contains:
Polymer from degraded gelatine 3.5 gm
Na 145 mEq/ml, K 5.1 mEq/ml, Ca 6.25 mEq/ml, Cl 145mEq/ml
Molecular wt 30,000-35,000
Procedures involving extra corporeal circulation, eg -priming the
heart lung machine
Prevention and treatment of hypovolemia(burns, post op blood
loss, spinal/epidural anaesthesia)
Preservative free preparations
Rapid excretion through urine, plasma clearance of 3 days,
complete excretion from body in 1 wk.
No effects on coagulation
Bovine source- risk of transmission of disease
Incidence of anaphylactic reaction
Histamine release- Haemaccel preparation
Cannot be given with blood
Not more than 1L in 24 hrs
Shock due to septicemia, cardiogenic, anaphylactoid shock
Oedema due to CCF,RF, DIC
Hydroxy-ethyl starch (HETASTARCH):
Natural non synthetic product
Available along with isotonic NaCl
Osmolarity is similar to normal physiological osmolarity
Available concentration 3% 6% 10% in isotonic NaCl or RL with or
Features of HES:
Low incidence of anaphylactoid reaction
Metabolized by body amylase and excreted by renals
Undergoes phagocytosis in RE system
Improve splanchnic perfusion in both trauma and septic patients
Severe pruritis; very rare chance of anaphylaxis (0.006%)
Rise in serum amylase levels (macroamylasemia)
Dehydration of interstitial space may occur and impair transport
and exchange of nutrients between the body compartments
Cardiac priming during cardiopulmonary bypass
Patient allergic to starch
B- HYPOTONIC FLUIDS
Compared with intracellular fluid (as well as compared with isotonic
solutions), hypotonic solutions have a lower concentration of
solutes (electrolytes). And osmolality less than 250 mOsm/L .
Hypotonic crystalloid solutions lowers the serum osmolality within
the vascular space, causing fluid to shift from the intravascular
space to both the intracellular and interstitial spaces.
These solutions will hydrate cells, although their use may deplete
fluid within the circulatory system.
TYPES OF HYPOTONIC FLUIDS
0.45% sodium chloride (0.45% NaCl), 0.33% sodium
chloride, 0.2% sodium chloride, and 2.5% dextrose in
Hypotonic fluids are used to treat patients with
conditions causing intracellular dehydration, when fluid
needs to be shifted into the cell , such as:
2. Diabetic ketoacidosis
3. Hyperosmolar hyperglycemic state.
Precautions with hypotonic solutions
• Never give hypotonic solutions to patients who are at risk for
increased ICP because it may exacerbate cerebral edema.
• Don't use hypotonic solutions in patients with liver disease,
trauma, or burns due to the potential for depletion of intravascular
• The decrease in vascular bed volume can worsen existing
hypovolemia and hypotension and cause cardiovascular
• Monitor patients for signs and symptoms of fluid volume deficit .
• In older adult patients, confusion may be an indicator of a fluid
• Solutions that have a higher tonicity or solute concentration than
the plasma of blood
• Hypertonic fluids have an osmolarity of 375 mOsm/L or higher
The osmotic pressure gradient draws water out of the intracellular
space, increasing extracellular fluid volume, so they are used as
Some examples and Indications:
1) 3% sodium chloride (3% NaCl):
May be prescribed for patients in critical situations of severe
Patients with cerebral edema may benefit from an infusion of
hypertonic sodium chloride.
2) 5% Dextrose with normal saline (D5NS):
• It replaces sodium, chloride and some calories.
Precautions with hypertonic fluids:
• Hypertonic sodium chloride solutions should be administered only
with constant surveillance for potential complications .
• Maintain vigilance when administering hypertonic saline solutions
because of their potential for causing intravascular fluid volume
overload and pulmonary edema.
COMPARING CRYSTALLOID V/S
Aqueous solutions of low molecular
weight ions with or without glucose
High molecular weight substances,
similar to plasma proteins
Readily pass through semi-permeable
membrane (“Extra vascular space
Molecular size is large and do not cross
capillary membrane (“Intravascular
Intravascular t1/2 = 20-30 minutes Intravascular t1/2= 2-8 hours
Reduce plasma colloid osmotic pressure Maintain plasma colloid osmotic
Have poor capillary perfusion Have good capillary perfusion
Risk of over hydration/tissue edema is obvious It is insignificant
No anaphylactic reaction Risk of anaphylaxis is more
Readily available, easy to store and well
tolerated by patients – some advantages
Rx of dehydration of any cause,
Hypoglycemia (5% 10% D)
Hypochloremia, hyponatremia of any cause
Preloading fluid in regional block(SA)
Fluid resuscitation prior to arrival of blood
Fluid boluses in critically ill patient where
crystalloid use would be excessive.
How to calculate maintenance fluid flow rates?
The most commonly used formula is (4/2/1) rule a.k.a ( Weight+40),
which is used for both adults and pediatrics.
4 ml/kg/hr for first 10 kg (=40ml/hr)
then 2 ml/kg/hr for next 10 kg (=20ml/hr)
then 1 ml/kg/hr for any kgs over that
This always gives 60ml/hr for first 20 kg
then you add 1 ml/kg/hr for each kg over 20 kg
Weight in kg + 40 = Maintenance IV rate/hour
For any person weighing more than 20kg
HOW TO CALCULATE IV FLUID FLOW RATES
• Intravenous fluid must be given at a specific rate, neither too fast nor
• The specific rate may be measured as : ml/hour, L/hour or drops/min.
• To control or adjust the flow rate only drops per minute are used.
What is a drop factor?
Drop factor is the number of drops in one milliliter used in IV fluid
administration (also called drip factor). A number of different drop factors
are available but the Commonest are:
1) 10 drops/ml (blood set)
2) 15 drops / ml (regular set)
3) 60 drops / ml (microdrop, burette)
The formula for working out flow rates is:
1500 ml IV Saline is ordered over 12 hours. Using a drop factor of
15 drops / ml, how many drops per minute need to be delivered?
Volume (ml) X drop factor (gtts / ml)
= gtts / min
1500 (ml) X 15 (drop / ml)
12 x 60 (gives us total minutes)
= 31 drop/ minute
FLUID RESUSCITATION IN BURNS
Parkland formula is used for resuscitation of burns patients:
• Total Fluid requirement in 1st 24 hrs = 4 x Patient’s weight in Kg x
Percentage of burns.
• 50% of the fluid given in 1st 8 hrs
• Rest 50 % fluid given over next 16 hrs .
FLUID OVERLOAD (HYPERVOLEMIA)
Signs and Symptoms
1- Edema (swelling) - particularly feet, and ankles
2- Difficulty in breathing while lying down
3- Crepts on auscultation
4- High blood pressure
6- Jugular vein distension
7- Shortness of breath (dyspnea)
8- Strong, rapid pulse
MANAGEMENT OF HYPERVOLEMIA
1- Prevention is the best way
2- Sodium restriction
3- Fluid restriction
It is a procedure in which a patient receives a blood product
through an intravenous line.
A process of transferring blood-based products from one person
into the circulatory system of another.
Blood Transfusion = Liquid organ Transplantation.
blood and blood transfusions 46
TYPES OF BLOOD TRANSFUSION
Based on time of transfusion
◦ Fresh whole blood transfusion
◦ Transfusion of stored Blood
Based on composition
◦ Whole blood
◦ Blood components ( Packed red cells , FFP , Platelets ).
Based on the donor
◦ Autologous blood transfusion
◦ Blood from different donor’s.
blood and blood transfusions 47
Packed Red Blood Cells Platelet Rich Plasma
High Speed Centrifugation
1 Unit of Random Donor
1 Unit of Fresh Frozen Plasma
Thawing precipitates the
SCREENING BEFORE BLOOD
Donor’s blood sample should be screened for :
• HIV 1 & 2.
• Cross matching should be done between Donor’s RBC’s and
Patients plasma and serum .
◦ Stored At 4°c for up to 35 days
◦ Massive Blood Loss/Trauma/Exchange Transfusion
Blood of same ABO group and Rh Type as that of the recipient’s
blood should be transfused.
PACKED RED CELLS
◦ 4° for up to 42 days, can be frozen
◦ Recipient must not have antibodies to donor RBC’s
◦ Usual dose 10 cc/kg (will increase Hb by 2.5 gm/dl)
◦ Usually transfuse over 2-4 hours .
◦ Transfusion of 1 unit of whole blood or packed red cells will raise
the hematocrit by 3% and the hemoglobin by 1-1.5 gm/dL .
Typing of RBC’s for ABO and Rh are determined for both donor
◦ Donor cells and recipient serum are mixed and evaluated for
◦ It is Supplied in 250ml bags.
◦ Usual dose of 10 cc/kg infused over 2-4 hours
◦ Maximum dose of 15-20 cc/kg can be given.
◦ Can be stored Up to 5 days at 20-24°c
◦ Thrombocytopenia – Platelet count <15,000
◦ Bleeding and Platelet count of <50,000
◦ While performing Invasive procedures when Platelet count is
◦ 1 unit/10 kg of body weight increases Plt count by 50,000
◦ Donor and Recipient preferably must of same blood group ,
However platelets of any group can be transfused in cases of
• One unit will usually raise the platelet count 5-10,000/ dl.
• Each unit of platelets should be administered over 20-40 minutes.
FRESH FROZEN PLASMA
Contains all Clotting Factors (1 unit/ml)
◦ Comes in 200ml bags.
Can be stored upto 12 months at -18 degrees.
It is a source of vit k- dependent clotting factors and factor - V.
Indications for Transfusion:
◦ Coagulation Factor deficiency, fibrinogen replacement, DIC,
liver disease, conditions with raised APTT.
◦ Plasma should be recipient RBC ABO compatible
◦ Preferably , should also be Rh compatible.
◦ Usual dose is 20 cc/kg
◦ 1 unit FFP = 3% increase in CF levels
◦ Precipitate formed/collected when FFP is thawed at 4°c.
Each unit (around 10 to 15 mL) typically provides:
Fibrinogen- 150-250 mg with a half-life of 100-150 hours.
Factor VIII - 80-150 U with a half-life of 12 hours.
Von Willebrand Factor - 100-150 U with a half-life of 24
Factor XIII - 50-75 U with a half-life of 150-300 hours.
◦ After collection, refrozen and stored up to 1 year at -18°
◦ Fibrinogen deficiency or dysfibrinogenemia
◦ Von Willebrands Disease
◦ Factor VIII or XIII deficiency
◦ DIC .
◦ ABO compatible preferred (but not limiting)
◦ Usual dose is 1 unit/5-10 kg of recipient body weight.
Most common type of transfusion reaction , it usually occurs due
to allergies to specific proteins in the donor’s plasma.
Symptoms – Flushing , itching , urticaria , difficulty in breathing/
can be avoided with future transfusions by pretreatment with
antihistamines or steroids.
Management – antihistaminics preferred , if not controlled then
I.M - Adrenaline can be given.
Incidence of 1 in ~25,000 transfusions ; fatality rate 10% .
Most often Occurs due to ABO mismatch of transfused blood
(i.e., the wrong blood and/or the wrong recipient).
Fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest
or back pain, flushing and severe anxiety and pain at the infusion
Stop the transfusion
Keep the vein open by running in saline
Check the urine for hemoglobin
Give mannitol for inducing Diuresis.
Monitor for DIC.
Defined to be a rise in temperature of 1 °C or more and >=38 °C,
within 60-90 mins after transfusion ,without evidence of a hemolytic
It is caused due to cytokines in the blood itself and/or produced in
the patient from sensitivity to the HLA molecules on platelets and
white cells of the donors blood.
• Blood transfusion should be stopped immediately.
• Antihistaminics and Antipyretics should be administered.
More common and more severe with platelet transfusion
(Because platelets are stored at room temperature 20-240 ).
◦ Platelets—Gram (+) organisms, ie Staph/Strep
◦ RBC’s—Yersinia, enterobacter
Transfusion should be stopped and the bag sent for gram stain
The Blood Bank should be notified.
The patient should have blood cultures obtained and, if
appropriate, IV antibiotic therapy begun
host disease (TA-GVHD).
Occurs due to the donor T-cells attacking the recipient’s tissues.
Symptoms occur within 1-2 weeks after transfusion.
blood and blood transfusions 61
Transfusion Related Acute Lung Injury
It is “noncardiogenic pulmonary edema”.
Defined as ARDS which occurs within 6 hours of a transfusion with
no other clear cause .
It occurs when donor plasma contains an antibody, usually against
the patient's HLA or leukocyte specific antigens.
The cause is apparently antibodies in the donor plasma against the
patient’s neutrophils (which, in the sick, are marginated in the lung
Incidence of 1 in 1000; fatality rate <1% with estimates varying
Monitor patient clinical status and vital signs.
Monitor renal status (BUN, creatinine).
Monitor coagulation status (DIC panel– PT/PTT, fibrinogen, D-
dimer/FDP, Plt, Antithrombin-III).
Monitor for signs of hemolysis (LDH, serum bilirubin).
Treatment is mainly supportive .