Intravenous IV Fluids Rational Use of Medicine Nursing Care Clinical Pharmacy

1. RATIONAL USE OF
INTRAVENOUS FLUIDS
KETOR E.C
Head of Pharmacy / Clinical Pharmacist
BPharm, MGCPharm, FPCPharm (Clinical Pharmacy), PharmD

2. INTRODUCTION
Water forms about 60% of the total body weight in adult
males and 50% of adult females
80% of total body weight in children
As a solvent, water provides the medium for dissolution
of nutrients and other substances in the body
Water and electrolytes may be lost in disease conditions
eg. Vomiting, diarrhoea etc.
Hence the importance of fluid and electrolyte therapy

3. INTRODUCTION
THIRD SPACE is normally not present in healthy individuals
It is a potential space which opens up when one is sick e.g. pleural
effusions
Upon resolution, the fluid goes back into second space.

4. FLUID COMPARTMENTS
K+ Mg2+ Na+ Cl- Na+ Cl-
Organic Phosphates
Proteins
RBCs INPUT
I.C.F Interstitial Vascular/Plasma
300 mOsm 300 mOsm 300 mOsm
E.C.F
FLUID SET-UP

5. RATIONAL USE OF MEDICINE
Rational Use of Medicine requires that patients
receive
medications appropriate to their clinical needs,
in doses that meet their own individual requirements
for an adequate period of time, &
at the lowest cost to their community. (WHO)

6. THERAPY PROBLEMS
Admitting most patients on IV Fluids – High dose
Disregard for Hypertensive status of patient in selection of IV
Fluids
Input & Output chat not monitored
Excess fluids prescribed and the challenge of refunds when
returned to Pharmacy
Satisfying patient demands and expectations
Frequent suspicion of dehydration and lethargy due to low sugar

7. TYPES OF IV FLUIDS

8. TYPES
CRYSTALLOIDS – Crystals reconstituted into solution
 Compounds of low molecular weight
 All have same osmolarity (Body osmolarity 290 mOsm/L)
 Examples: 5% Dextrose, Sodium Choride 0.9%, Ringer Lactate
COLLOIDS –
 Natural Colloids: Blood, plasma, human albumin solution, platelet solution
 Synthetic Colloids: Dextran, Hemacel, Dicks plasma, Gelofusine
 Colloids are large molecular weight and are largely collagens
 Effective in correcting shock and dehydration. Crystalloids are added to
achieve this.

9. VOLUME EXPANDERS
 Hypertonic solutions
 are also used to expand plasma volume
 draw water out of the intracellular space to increase extracellular fluid
volume
 Examples of hypertonic solutions: 3% Nacl
 Colloids
 Draw water out of interstitial spaces into the intravascular compartment
 Have high oncotic pressure
 Molecules remain in intravascular space longer
 Less total volume needed

10. SODIUM CHLORIDE SOLUTIONS
SODIUM CHLORIDE 0.18%
SODIUM CHLORIDE 0.45%
SODIUM CHLORIDE 0.9%
SODIUM CHLORIDE 2%

11. DEXTROSE SOLUTIONS
DEXTROSE 2.5%
DEXTROSE 4%
DEXTROSE 5%
DEXTROSE 10%
DEXTROSE 50%

12. DEXTROSE SALINE SOLUTIONS
DEXTROSE 2.5% in SALINE 0.45%
DEXTROSE 3.33% in SALINE 0.3%
DEXTROSE 4.3% in SALINE 0.18%
DEXTROSE 5% in SALINE 0.45%
DEXTROSE 5% in SALINE 0.9%
DEXTROSE 10% in SALINE 0.18%
DEXTROSE 10% in SALINE 0.9%

13. POLY-SALINE LACTATE SOLUTIONS
RINGERS INJECTIONS
DARROW’S SOLUTION (Full Str.)
DARROW’S ½ STREGTH SOLUTION
RINGER-LACTATE FULL STRENGTH
5:4:1 CHOLERA REPLACEMENT FLUID
 5g NaCl
 4g NaHCO3
 1g KCl

14. POLY-SALINE DEXTROSE SOLUTIONS
DEXTROSE 2.5% in ½ DARROW’S SOLUTION
DEXTROSE 3.33% in ½ DARROW’S SOLUTION
DEXTROSE 3.33% in 1/3 HARTMANNS SOLUTION

15. DEXTRAN SOLUTIONS
DICKS PLASMA 40
DICKS PLASMA 70
DEXTRAN 40, 10% in SALINE 0.9%
DEXTRAN 40, 10% in DEXTROSE 5%
DEXTRAN 70, 6% in SALINE 0.9%
DEXTRAN 70, 6% in DEXTROSE 5%

16. SPECIAL SOLUTIONS
 MANNITOL 10%
 MANNITOL 20%
 GELOFUSINE or GELOFLEX
 GLYCINE 1.5%
 BADOE’S MAINTENANCE SOLUTION
 GASTRO INTESTINAL REPLACEMENT FLUID
 SORBITOL 2.7%
 PERITONEAL DIALYSIS ISOTONIC & HYPERTONIC

17. FLUID ELECTROLYTE THERAPY

18. FLUID AND ELECTROLYTETHERAPY
The body maintains its internal environment by balancing
fluids, electrolytes, acids and bases
Water constitute more than half of the body weight and
so important
Although people can live for weeks without food, they
can only survive few days without water in the body
Decision to use IV Fluids depends on:
 History of the patient
 Clinical signs and symptoms
 Biochemical examinations

19. WHY USE IV FLUIDS?
• For resuscitation and/ patients in shock
• For administration of drugs
• For feeding/ nutrition/vitamin supplementation
• Prevent against dehydration in emergencies or post op
IV Fluids are given under:
 Maintenance condition
 Emergency condition

20. PHYSIOLOGY OF WATER
BALANCE

21. FUNCTIONS OFWATER
 Biochemical activities take place in the body in the medium of water
 Dissolved, suspended or formed substances in water perform
 Metabolism of nutrients and drugs (enzymes)
 Generation of energy (glucose)
 Repair and manufacture of body components (amino acids)
 Medium for excretion of waste substances
 Temperature regulation
 Blood volume maintenance
 Nutrient and electrolyte transport
NB: Volume, composition and pH of internal fluid allows these functions to be done efficiently

22. PHYSIOLOGY OF BODY WATER BALANCE
 Body water divided into three compartments
 Intracellular – ICF
 Interstitial
 Vascular
 In the non-obese, well-conditioned 70kg man,
 ICF – 40-45% (30L)
 Interstitial – 11-15% (10L)
 Vascular – Approx. 5% (3.5L)
 Factors affecting amount of water in the body
 Age: elderly have less water than younger one of same weight
 Sex: Men have higher water content than women of same weight, height and age
 Muscle/Fat ratio: Obese people have less amount of water
ECF

23. WATER REQUIREMENTS
 Body loses water through expired air, skin, urine and faeces
 Body gains water through food, protein, fat and liquids endogenous
metabolism of carbohydrate
 Na+ & K+ are lost in sweat, urine and faeces and are replaced from food.
Tropics Temperate Regions
LOSSES Pulmonary & Cutaneous 1,700 ml 1,000 ml
Urine 1,500 ml 1,500 ml
Faeces 200 ml 200 ml
Total 3,400 ml 2,700 ml
GAIN Endogenous production from
metabolism of carbohydrate etc
200 ml 200 ml
NET requirement 3, 200 3,200 ml

24. WATER
The surgical patient who usually requires parenteral fluid
therapy is not likely to be passing faeces and so requires
in 24hrs, 3000 ml of water in a tropical region
For every 1oC rise in body temp., 10-12% of the daily
requirement is added to compensate for water lost in
sweating.

25. ELECTROLYTES

26. ELECTROLYTES
 These are subs. that carry electric charge and can conduct electric
current when they are dissolved in water or in their molten state.
E.g. Na+, Cl-, K+ etc.
 Na+ and Cl- are major Cations and Anions in ECF
 K+ and Phosphate (PO4
2-) are those in ICF
 Salt and water balance is maintained primarily by the equilibrium
between
 oral intake of fluids and electrolytes,
 Evaporation of solute-free water across the skin and lungs
 Controlled renal excretion of water and electrolytes
 Daily variations in oral fluid and electrolyte intake is compensated
by ADH & Aldosterone

27. ELECTROLYTES
Ion Extracellular mmol/l Intracellular mmol/l
Na+ 135-145 8.0
K+ 3.5-5.0 140.0
Cl- 95-115 8.0
PO4
2- 0.8-1.4 25.8
Ca2+ 2.1-2.8
Mg2+ 0.75-1.0
HCO3- 22-28 14.0

28. ELECTROLYTES
Route Tropics Temperate Regions
SODIUM Urine 114 mmol 80-110 mmol
Sweat 10-16 -
Faeces 10 10
Total 130-140 mmol 90-120 mmol
POTASIUM Urine 50 mmol 60mmol
Sweat - -
Faeces 10 10
Total 60 mmol 70 mmol
Surgical patient who requires parenteral therapy is not likely to pass faeces so
he/she will conserve those electrolytes lost through faeces

29. ENERGY REQUIREMENT
 Body’s store of glycogen is small – 400g and provides only about
6694J of energy
 This energy is used up in the first day of starvation
 After which 75-90% of the energy requirement for basal
metabolic activities is provided by the combustion of fat and the
rest by protein
 1800 Cal of energy is needed within 24 hrs for basal metabolic
activities

30. SUMMARY OF DAILY REQUIREMENTS
TROPIC TEMPERATE
Water 3 Litres 2.5 Litres
Sodium 130 mmol 80-100 mmol
Potassium 50 mmol 60 mmol
Carbohydrate 100 g 100 g
100 g of Calorie is needed to prevent gluconeogenesis daily

31. DEFICIT/EMERGENCY FLUID ADMIN
A patient with diarrhoea, vomiting, amoebiasis etc will need
deficit or emergency fluid administration because
 Cannot eat
 Has lost fluid e.g. 2L of fluid ( hence <42L body)
There is therefore a need for Deficit and Maintenance fluid
Volumes are higher in emergency fluid administration
Deficit admin is done at a faster rate = resuscitation
Maintenance is given over 24 hrs , slower

32. PARAMETERS USEDTO DETERMINE….
 Fluid Deficit
 BP
 Urine Output
 Jugular Venous Pressure
 Urine Sodium concentration
 Hypovolemic shock
 Anxiety or agitation
 Confusion & disturbed consciousness
 Rapid breathing
 Low blood pressure, often weak and thread
 Cool pale skin & low body temperature
 Decreased or no urine output

33. FLUIDS USED FOR DEFICIT FLUID ADMIN
 Ringer’s Lactate
 Normal Saline
 Dextrose Solution
 Colloids such as hemacel, gelofusine, dicks plasma
 NB: Colloids are not used for maintenance regimes!!

34. MAINTENANCETHERAPY
 Commonly used formula in adults and pediatrics (4/2/1) and (weight + 40)
 4/2/1 Rule
 4ml/kg/hr for first 10kg (=40ml/hr)
 then 2ml/kg/hr for the next 10kg (=20ml/hr)
 then 1 ml/kg/hr for any kg over that
 This always give 60ml/hr for first 20kg
 Then you add 1ml/kg/hr for each kg over 20kg
 So: weight in kg + 40 = Maintenance IV rate/hr
for any person weighing more than 20kg

35. CALCULATING IV FLOW RATES
Drop/drip factor
 Number of drops in one milliliter used in IV fluid administration
 Common types are:
 10 drops/ml (blood set)
 15 drops/ml (Regular set)
 60 drops/ml (microdrop-burette)
Flow rate formula:

𝑉𝑜𝑙𝑢𝑚𝑒 𝑚𝑙 𝑥 𝑑𝑟𝑜𝑝 𝑓𝑎𝑐𝑡𝑜𝑟 (
𝑔𝑡𝑡𝑠
𝑚𝑙
)
𝑡𝑖𝑚𝑒 (𝑚𝑖𝑛)
= gtts/min
EXAMPLE
 1500ml IV saline is ordered over
12 hours using a drop factor of
15 drops/ml/. How many
drops/min need to be delivered?
 Flow rate formula:

1500𝑚𝑙 𝑥 15𝑔𝑡𝑡𝑠/𝑚𝑙
12 𝑥 60 𝑚𝑖𝑛
= 31 gtts/min

36. DISPOSITION

37. VOLUMETO GIVE IN DEHYDRATION
 Mild dehydration:
Only mucous membranes are dry (patient however is well). From research the patient
loses about 2% of water (from body weight)
Calculation: 2/100 x weight in Kg = 2/100 x 60 = 1.2L of water (assuming standard
temp and pressure)
 Moderate dehydration :
Mucous membranes dry, tongue dry, lips and tongue cracked, skin turgor impaired.
Patient loses equivalent of 4% of body weight in terms of water = 2.4L
 Severe dehydration :
Mucous membrane dry, tongue dry, lips and tongue cracked, impaired skin turgor,
sunken eyes, oliguria or anuria, low or unrecordable BP, High Pulse rate.
Patient loses equivalent of 6% of body weight in terms of water = 3.6L

38. POTASSIUM
Oral or Intravenous replacement of maintenance needs
should always include sodium and potassium
K+ is the principal cation in the intracellular fluid
Functions
 Impulse transmission
 Cardiac Contractility
 Aldosterone secretion
Excreted via kidney

39. SODIUM
 Major Cation in the ECF
 Function
 Maintenance of plasma osmolarity
 Generation and transmission of action potentials
 Maintenance of acid base balance
 Maintenance of electro neutrality
 Hypernatraemia: > 145 mmol/l
 Free water deficit
 High salt intake
 Hyponatraemia: < 135 mmol/l
 CNS water intoxication
 Dilution or depletion

40. FLUID MANAGEMENT IN RENAL DISORDERS
Fluids with high Potassium should be avoided in renal
failure as it can aggravate hyperkalemia
Disordered Ca and Phosphate handling
 eGFR used as a guide.

41. FLUID MANAGEMENT IN LIVER DISORDERS
In liver disease, lactate metabolism is impaired and hence
Ringer Lactate use should be avoided
R/L can cause Lactic Acidosis
Marked Na and water retention
Do not give hypotonic solutions – potential of intravascular
fluid volume depletion

42. BURNS
Fluid replacement necessary when burn > 10-15% of BSA
Parkland Formula: (%BSA burn x Wt x 4ml)/24 hrs)
Fluid of choice is Ringer Lactate
Aim: minimum urine output of 0.5ml/kg/hr.
Rise of serum lactate may indicate more fluid required
Avoid hypotonic solutions - potential of intravascular fluid
volume depletion

43. TRAUMA
2L of warmed Ringer Lactate followed by assessment of
response
Early aggressive correction of acute coagulopathy using
blood and blood products
Avoid hypotonic solutions - potential of intravascular
fluid volume depletion

44. SEPSIS
Volume deficit due to combination of
 Vasodilation
 Capillary leak
 Insensible losses
Need for aggressive fluid replacement particularly in 1st
24hrs
Choice: crystalloid (saline) or albumin

45. SOME IV INFUSIONS AND THEIR
APPLICATIONS

46. SODIUM CHLORIDE 0.9%
 Composition
mEq/L
Na+ 154
Cl- 154
 Properties and Therapeutic effects
 Correct serious sodium deficit
 Not indicated in cases of dehydration or lack of water without sodium
deficit
 Excess of sodium may lead to peripheral or pulmonary oedema
 Used in diabetic ketoacidosis
 Contraindicated in hypertension
 Choice of strength depends on severity of the sodium deficit
 others 0.45% & 20%
 Rate: 240 – 480 ml/hr (60 -120 drops per min)

47. SODIUM CHLORIDE 0.45%
It is hypotonic solution
It hydrates cells and cause fluids to shift from intravascular to
ICF and Interstitial space
In Diabetic Ketoacidosis, there is intracellular dehydration
therefore fluid need to be shifted into the ICF
Other uses of 0.45% NaCl are:
 Hypernatremia
 Hyperosmolar hyperglycemic state

48. DEXTROSE 5%
 Composition: Cal/litre
 Dextrose 200
 Properties and therapeutic effects
 Used for dehydration in case of water deficit
 Dextrose enable water to be taken into the cells
 It provides some amount of calories
 Isotonic solution hence can be given I.M and I.V or S.C
 Higher strength used when high amount of calorie is needed e.g. 50% in
hypoglycaemia
 Contraindications
 Diabetes Mellitus
 Patients at risk of intracranial pressure
 Not used for resuscitation – Solution does not remain in intravascular space

49. DEXTROSE 5%
5% Dextrose is considered isotonic solution but when the
dextrose is metabolized, the solution actually becomes
hypotonic and causes fluid to shift into cells
Avoid in renal failure or cardiac problems due to risk of
fluid overload
Never mix dextrose with blood as it hemolyzes blood due
to free water content that moves into intracellular space

50. DEXTROSE 5% IN SALINE 0.9%
 Composition
 Na+ 154 mEq/litre
 Cl- 154 mEq/litre
 Dextrose 200 Cal/litre
 Properties and therapeutic effects
 Supplies same amount of N+ and Cl- as in Normal Saline
 It also provides extra calories
 Indicated for correcting serious sodium deficits but not indicated in
case so pure water deficiency
 Contraindication
 Hypertension
 Diabetes Mellitus
 Rate: 240-480 ml/hr (60-120 drops a minute)

51. RINGER-LACTATE (HARTMANN’S SOLUTION)
 Composition mEq/litre
 Na+ 130.5
 K+ 5.4
 Ca2+ 3.6
 Cl- 111.3
 Lactate 28.2
Properties and Therapeutic Effects
 Electrolyte composition closely resembles plasma
 Supplies K+ and bicarbonate ions
 R/L should not be infused with blood in the same line. Calcium present in R/L
can bind citrate anticoagulant in blood and can precipitate blood clotting.

52. RINGER-LACTATE (HARTMANN’S SOLUTION)
Indicated in:
 Mild metabolic acidosis
 Replacement in dehydration or shock due to diarrhoea and
vomiting, peritonitis and interstitial obstruction
 Treatment after serious burns
 Ketonuria
 Contraindication: Cautious in oedematous patients suffering from
cardiac, renal or hepatic conditions
 Do not give in patients whose pH is > 7.5
 Give cautiously in renal impairment because it contains K
 Rate: 500 ml/hr

53. MANNITOL 10% , 20%
 Composition: 100g/L, each ml contains 100mg mannitol
 Osmolarity: 549 mOsm/l pH- 4.7 -7
 It is an osmotic diuretic
 Properties and Therapeutic effect
 Reduction of intracranial pressure and cerebral oedema
 Reduction of elevated intraocular pressure when it cannot be lowered
by other means
 Promotion of renally excreted toxic substances in poisoning
 Promotion of diuresis in the prevention and/or treatment of oliguric
phase of acute renal failure
 Dose: Adult – 0.25-2g/kg over 30-60min. May be repeated if necessary1-2
times after 4-6hrs

54. MANNITOL 10% , 20%
 Choice: choice of specific concentration, dosage and rate of
administration depends on:
 Age
 Weight
 Clinical and biological condition of the patient
 Concomitant therapy
 Contraindication
 Pre-existing plasma hyperosmolarity
 Severe dehydration
 Well established anuria
 Severe heart failure
 Severe pulmonary congestion
 Active intracranial bleeding except during craniotomy
 Hypersensitivity to mannitol

55. PAEDIATRICS
Maintenance fluid
0.45% Dextrose in 0.18% Saline for less than 10Kg
5% Dextrose in 0.9% Saline for more than 10Kg
 Potassium requirement of children is 2mEq per 100 ml
of maintenance fluid

56. MONITORING PATIENTS ON IV FLUIDS
Sensorium Assessment
 Ask patient where he is?
 Ask patient who the people around him are?
 Ask him what time he thinks it is?
Skin turgor, skin temp., hydration of eyes
Pulse rate and BP every 15 min
Measure urine output (perfusion rate)
Listening to the base of the lungs for rales and crepitations

57. COMPLICATIONS OF IVTHERAPY
 Infections from fluid administered
 Air embolism (the system should be air tight)
 Pulmonary Oedema
 Febrile from pyrogens
 Cardiac arrest
 Administering old blood which has hemolyzed with high K+ level
 Blood that is too cold!! Always warm the blood!!
 Electrolyte imbalances
 Thrombophlebitis

58. PRECAUTIONS IN IVTHERAPY
If edema is present , elevate patient’s legs
Elevate the head of bed at 35 and 45 degrees unless
contraindicated

59. CONCLUSION
 Normal requirements of body
 Water 35ml/kg or 2.5-3L/day for 70kg Male
 Na+ 1-1.5 mmol/kg/day
 K+ 1 mmol/kg/day
 Fluid therapy should be individualized
 Beware not to give inadequate or excessive fluid therapy
 Unnecessary/irrational use of IV fluids should be avoided. When
they are needed, they should be stopped as soon as possible
 Choose fluid type based on co-existing electrolyte disturbances

60. THANKYOU
LAST SLIDE

61. REFERENCES
Intravenous Infusions Plc, Fluid & Electrolyte Therapy
Dr. Kyere (tutorial)
Dr. Satish Deopujari
Dr. Nilesh Darvhekar
Dr. Vivek Shivhare
WHO