2. INTRODUCTION
• Crystalloid solutions are aqueous solutions of low-
molecular-weight ions (salts) with or without glucose.
• May be isotonic, hypertonic or hypotonic salt solutions.
• Crystalloid solutions are used to provide maintenance
water and electrolytes and to maintain intravascular
fluid volume.
• The replacement requirement is threefold to fourfold
the volume of blood lost because administered
crystalloid is distributed in a ratio 1 : 3 similar to ECF,
which is composed of about 3 L intravascularly (plasma)
and about 9 L extravascularly(interstitial).
3. Advantage and Disadvantage of Crystalloids
Advantages-
Crystalloids are inexpensive and non allergic.
They are more effective at replacing ECF and
are not associated with transmission of infection,
impairment of coagulation or cross matching.
Disadvantages-
Crystalloids exert short lived hemodynamic effect in
comparison to colloids. When used for massive fluid
resuscitation, they invariably produce peripheral
edema and occasionally pulmonary edema.
4. Water+electrolytes high mol wt subs.
Osmotic pressure oncotic pressure.
Reduced increased.
Extravascular sp. Intravascular sp.
Transient sustained.
3-4 times of loss equal to loss.
No effect interfere.
Produce do not.
No may occur.
Economic costly…
Composition
Pressure
Oncotic press.
Distribution
Half life.
Volume req.
X matching.
Edema.
Anaphylaxis.
Cost
Differences between crystalloid and colloid solution
Crystalloid Colloid
7. ISOTONIC SALINE (0.9% NaCl)
MECHANISM-
• Principle component is NaCl
• Na is most abundant extracellular solute.
• 75-80% of extracellular Na is in interstitial space as the ECF.
• I.V administered NaCl solutions follow the same principle.
• 1L of .9%NaCl adds 275 mL to plasma volume and 825 mL
to interstitial volume.(total 11oo mL)
Electr
olytes
pH Na
mEq/L
K
mEq/L
Cl
mEq/L
Ca
mEq/L
Mg
mEq/L
Lact.
mEq/L
Gluco
se/L
Acetat
e/L
NH4cl
/L
Osmol
arity
mOsm
/L
0.9%
NS
5 154 154 308
8. INDICATIONS
• Hypovolemic shock
• Tt of alkalosis ( vomiting) with dehydration .
• In hyponatremia .
• Initial fluid therapy in DKA.
• Water and salt depletion as in diarrhoea , vomiting ,
excessive diuresis and perspiration.
• Tt of hypercalcemia
• Fluid challenge in prerenal ARF
• Irrigation for washing of body fluid and cavity .
9. CONTRAINDICATION
Cautious use or avoid in hypertensive or
preeclamptic patients and in patients with edema
due to CHF , renal Disease and cirrhosis.
• Dehydration with severe hypokalemia :- with
severe hypokalemia there is deficit of even ICF
potassium so infusion of NaCl without additional
Potassium supplement will aggravate electrolyte
imbalance of ICF.
• Infusion of large amount of isotonic saline can
produce hyperchloremic metabolic acidosis.
9
10. RINGER’S LACTATE
Physiological basis:-
• Also known as Hartman solution.
• Ringer lactate is the most physiological fluid as its
electrolyte conc. and Osmolality is near to plasma,
even in larger amount of RL can be infused without or
with minimal electrolyte imbalance.
• It is also useful in correction of metabolic acidosis .
• Lactate is used as a buffer instead of bicarbonate
because in stored solution lactate is more stable .
• It is slightly hypotonic, providing approximately 100
mL of free water per liter and tending to lower
serum sodium.
11. REABSORPTION
INDICATION
1. Replacement fluid in perioperative period, burn and
fracture.
2. Diarrhoea induced hypovolemia with hypokalemic
metabolc acidosis.
3. For maintaining normal ECF and electrolyte during and
after surgery.
Electr
olytes
pH Na
mEq/L
K
mEq/L
Cl
mEq/L
Ca
mEq/L
Mg
mEq/L
Lact.
mEq/L
Gluco
se/L
Acetat
e/L
NH4cl
/L
Osmol
arity
mOsm
/L
RL 6.5 130 4 109 3 28 274
12. CONTRAINDICATIONS
1. Liver disease , severe hypoxia and shock - lactate
metabolism is severely impaired. RL infusion can lead to
lactic acidosis in such patients.
2. CHF- lactic acidosis takes place , which is more in heart
tissue. Lactate given can’t be utilized, so it ppt condition .
3. Vomiting or continuous NG aspiration – here hypovolemia
is associated with metabolic alkalosis , as RL provide bicarb
so its worsen alkalosis.
4. Calcium in RL- bind with citrate (CPDA) in blood
transfusion and this can inactivate the anticoagulant and
promote the formation of clot in donor blood .
5. Calcium in RL- binds with certain drugs (thiopental,
doxycycline, ampicillin ,aminocaproic acid) and reduce their
effectiveness.
13. DEXTROSE - 5%
•PHARMACOLOGICAL BASIS:-
• Corrects cellular dehydration and supplies energy- After
consumption of dextrose , remaining water distributed in all
compartment of body proportionately and less than 10% of
the volume remains in the vascular compartment .
• Therefore D-5% is best agent to correct intracellular
dehydration .
• D-5 % is selected when there is need of water but no
electrolyte
• 1 gm dextrose provide 3.4 kcal energy( 170 kcal/L ).
Electr
olytes
pH Na
mEq/L
K
mEq/L
Cl
mEq/L
Ca
mEq/L
Mg
mEq/L
Lact.
mEq/L
Gluco
se/L
Acetat
e/L
NH4cl
/L
Osmol
arity
mOsm
/L
5%D 4.2 50g/L 253
14. 1. For treatment of
ketosis in starvation
, diarrhoea ,
vomiting , high
grade fever.
2. Adequate glucose
infusion protects
the liver against
toxic substances.
3. Correction of
hypernatremia due
to pure water loss (
eg DI ).
• Cerebral edema
• Neurosurgical procedure
• Acute ischaemic stroke
• Hypovolemic shock :- as it doesn’t
substantially increase intravascular
volume .moreover fast replacement
can lead to hyperglycemia and osmotic
diuresis.
• Hyponatremia and water intoxication.
• Blood transfusion :-not given with
same I.V line as hemolysis and
clumping can occur.
DEXTROSE - 5%
• INDICATIONS:- • CONTRAINDICATION
15. DNS (5% dextrose with 0.9 % NaCl)
• PHARMACOLOGICAL BASIS :- DNS has advantage of
providing both 5% dextrose ( for energy ) and NaCl
(for salt ). So DNS is useful to supply major E.C.
electrolyte and energy along with fluid to correct
dehydration .
• As DNS increase only ECF volume , it can be consider
in treatment of hypovolemia . But like D-5 % , faster
infusion of larger volume of DNS will lead to large
glucose load (> 25 gm / hr), leading to hyperglycemia
induced osmotic diuresis.
• Unlike D-5 %, DNS is not hypotonic ( due to NaCl) and
hence it is compatible with blood transfusion .
16. INDICATIONS
• Correction of salt depletion and hypovolemia with supply
of energy .
• Correction of vomiting or NG aspiration induced alkalosis
and hypochloremia along with supply of calories.
• Fluid compatible with blood product.
Electr
olytes
pH Na
mEq/
L
K
mEq/
L
Cl
mEq/
L
Ca
mEq/
L
Mg
mEq/
L
Lact.
mEq/
L
Gluco
se
acetat
e
NH4cl Osmo
larity
mOs
m/L
5%DN
S
154 154 50g/L 564
17. CONTRAINDICATION
• Cautious use in cardiac , renal disease .
• Hypovolemic shock:- not preferred in severe
hypovolemic shock , when rapid replacement with
larger volume of fluid is required .
o Rapid infusion of DNS can cause hyperglycemia
and osmotic diuresis.
o It can result in metabolic acid production instead
of metabolic energy production.
18. HYPERTONIC SALINE(3% NaCl)
INDICATIONS-
• In severe salt depletion when rapid electrolyte
restoration is of paramount importance.
• Cerebral and pulmonary edema.
CONTRAINDICATIONS
• should be used with great care, if at all, in patients
with congestive heart failure, severe renal
insufficiency, and in clinical states in which there is
sodium retention with edema.
19. • PHARMACOLOGICAL BASIS:-
• I.V. fluid which fulfill maintenance requirement of
children. As compare to adult , children need
more water and same electrolyte . So it contains
double water but same electrolyte as ISO-M.
ISO – P
Electr
olytes
pH Na
mEq/
L
K
mEq/
L
Cl
mEq/
L
Ca
mEq/
L
Mg
mEq/
L
Lact.
mEq/
L
Gluco
se
aceta
te
NH4cl Osmo
larity
mOs
m/L
Iso -P 25 20 22 50g/L 23 410
20. • INDICATION
• Chiefly used as
maintenance fluid in
infant and children to
provide daily water
and electrolyte .
• Excessive water loss or
inability to
concentrate urine ( DI)
• CONTRAINDICATION
• HYPONATREMIA ( low Na+)
• RENAL FAILURE ( high K+)
• HYPOVOLEMIC SHOCK :-
isolyte –P is not suitable to
correct hypovolemic shock
(diarrhoea, vomiting)
because
1. low Na+ ,
2. high K+ in oliguric state in
not safe .
3. And rapid infusion of large
ISO-P can cause
hyperglycemia and
osmotic diuresis.
ISO - P
21. ISO - E
• PHARMACOLOGICAL BASIS:
• ISO-E is extracellular replacement solution. Electrolyte are
similar to ECF except that it has double the concentration of
K+ and acetate.
• So this fluid provide all ECF electrolyte , supply energy ,
replace water deficit .
Electr
olytes
pH Na
mEq/L
K
mEq/L
Cl
mEq/L
Ca
mEq/L
Mg
mEq/L
Lact.
mEq/L
Gluco
se
acetat
e
NH4cl Osmol
arity
mOs
m/L
Iso - E 140 10 103 5 3 50g/L 47 368
22. ISO–M
• PHARMACOLOGICAL BASIS:-ISO- M is richest source of K+ . So
very useful to treat hypokalemia. Before adm. ensure good urine
output and renal function .
• As it contain low Na+( 40 mEq/L),so should be avoided in
hyponatremia .
Electr
olytes
pH Na
mEq/L
K
mEq/L
Cl
mEq/L
Ca
mEq/L
Mg
mEq/L
Lact.
mEq/L
Gluco
se
acetat
e
NH4cl Osmol
arity
mOsm
/L
Iso -M 40 35 40 50g/L 20 580
23. ISO – G
• PHARMACOLOGICAL BASIS :-
• During vomiting or continuous NG aspiration there is loss of gastric
juice , which lead to hypochloraemic , hypokalemic metabolic
alkalosis.
• ISO-G is gastric replacement solution . It provide all electrolytes lost
by gastric juice, corrects alkalosis and provides calories.
• Ammonium ions in ISO-G are converted into urea and hydrogen ion in
liver.
• So ISO-G only fluid which directly correct metabolic alkalosis if any.
Electr
olytes
pH Na
mEq/
L
K
mEq/
L
Cl
mEq/
L
Ca
mEq/
L
Mg
mEq/
L
Lact.
mEq/
L
Gluco
se
aceta
te
NH4cl Osmo
larity
mOs
m/L
Iso -G 63 17 150 50g/L 70 274
24. Which fluid to give and how fast ?
• Fluid depends on nature of loss ,
hemodynamics & electrolyte and
underlying disease.
• Fluid should be which correct volume
and electrolyte abnormality.
• Elderly and anemic patient require
slower and more careful correction and
monitoring.
25. • Hypotonic fluids (0.45%ns,0.33%NS,5%D)
– Maintenance, intracellular dehydration
– Avoid –head injury, trauma, burns
• Isotonic fluids (RL, 0.9%NS)
– Hypovolemic patients
• Hypertonic fluids (3%NS, 5%DNS,10%D)
– Hypovolemia
– Nutrition, electrolyte disturbances
– Hypertonic saline in cerebral and pulmonary edema.
– Use with caution- impaired renal and cardiac function
– Avoid in cellular dehydration
Choice of fluids
27. • Prevention of contrast induced nephropathy –
Hydration with normal saline at 100-150ml/hr.
• Reduce intake in patients who are oliguric
• Avoid K containing solution
• Use hypertonic solutions with caution.
• In polyuric phase – replacement with NS. Rate equal
to previous hours urine output.
• Monitor electrolytes.
• Liver failure - use dextrose, avoid RL
Renal failure and liver failure
28. • Resuscitate with isotonic fluids preferably NS.
• Avoid synthetic colloid in patients with head injury
or intracranial bleeding.
• Avoid dextrose containing solutions
• Avoid hypotonic solutions
• There is no advantage in hypertonic fluids with
brain injury.
• Mannitol effective only if BBB intact
• Avoid electrolyte disturbances
Trauma patients with head injury
29. • Loss of Na and water in first 6-8hrs and continues for 48hrs
• Initial resuscitation –Parkland formula
– First 24 h: RL at 4ml/kg/% TBSA; give half in first 8 h & the
remaining over next 16 h
– Second 24 h: colloid at 20-60% of calculated plasma volume to
maintain adequate urinary output
• After initial resuscitation use a combination fluid infusion of
albumin and 5%D.
• From 3rd day reduce intake as there is sodium and water
reabsorption.
Burns
30. • Water and electrolyte loss due to osmotic diuresis
• Hyperkalemia due to acidosis. However there is total body
potassium deficit
• Initial resuscitation with isotonic saline or RL along with IV insulin
0.1units/kg/hr
• After 3-4L of NS give 0.45%NS to avoid hyperchloremic acidosis.
• Give 0.45%DNS when blood sugar is <200mg/dl
• 20-30mEq/L K+ to be added if Sr K+ <5.3 and patient has good urine
output
Diabetic ketoacidosis
31. • Treat IV fluids as “prescription” like any other
medication.
• Determine if patient needs maintenance or
resuscitation.
• Choose fluid type based on co-existing and
anticipated electrolyte disturbances.
• Choose rate of fluid administration based on weight
and minimal daily requirements.
• Monitor electrolytes.
• Always reassess whether the patient continues to
require IVF.
Summary
