This document discusses fluid therapy and intravenous fluid administration. It begins by explaining normal water balance and insensible fluid loss. The basic principles of IV fluid therapy are then outlined, including advantages like accurate administration and rapid response, as well as indications like dehydration and shock. Contraindications and complications are also reviewed. The document then describes the types of IV fluids, including crystalloids like saline and lactated Ringer's, as well as colloids like albumin. Special fluids like sodium bicarbonate and potassium chloride are also covered. Guidelines for fluid administration and monitoring are provided.

1. FLUID THERAPY
-DR. THASNEEM ARA
M.D. (INTERNAL MEDICINE)
DCMS

3. NORMAL WATER BALANCE
• Oral (or I.V.) fluid intake and urine outpur are important measurable parameters
of body fluid balance.
• NORMAL DAILY INSENSIBLE FLUID LOSS = 700 ml
• So Daily fluid requirement = urine output + 700 ml.
Insensible fluid loss Insensible fluid input
Skin - 500 ml
Lungs - 400 ml
Faeces - 100 ml
Total - 1000 ml
Metabolism - 300 ml

4. BASIC PRINCPLES OF IV FLUID THERAPY
Advantages:
1. Accurate, controlled and predictable way of
administration.
2. Immediate response due to direct infusion in
intravascular compartment.
3. Prompt correction of serious fluid and electrolyte
distribution.

5. CONTINUED.,
Indications:
1. Coma and Anaesthesia Surgery.
2. Severe vomiting and Diarrhoea.
3. Moderate to severe dehydration and shock.
4. Hypoglycaemia.
5. As a vehicle for various IV medications e.g. antibiotics,
chemotherapeutic agents, insuin, vasopressor agents.
6. TPN.
7. Treatment of critical problems : Shocks, Anaphylaxis, severe
asthma, cardiac arrest and forced diuresis in drug overdose,
poisoning, urinary stone.

6. CONTINUED.,
Disadvantages:
1. More expensive, needs strict asepsis.
2. Possible only in hospitalized patient under skilled
supervision.
3. Improper selection of type of fluid used can lead to
serious problems.
4. Improper volume and rate of infusion of fluid can be
life threatening.
5. Improper technique of administration can lead to
complications.

7. CONTINUED.,
CONTRAINDICATIONS:
1. I.V. fluid should be avoided if patient is able to take oral fluid.
2. Preferable to avoid I.V. fluid in patient with congestive heart failure or
volume overloaded.
COMPLICATIONS:
1. Local : Haemetoma, infiltration and infusion phlebitis.
2. Systemic : Circulation overload with rapid or large volume infusion
especially in patients with cardiac problems. Rigors, air embolism and
specticaemia.
3. Others : Fluid contamination, fungus in I.V. fluids, mixing of
incompatible drugs, improper technique of infusion, I.V. set or I.V.
catheter related problems and human error related problems.

10. TYPES OF I.V. FLUIDS
1. Crystalloids
NS, DNS, 5%D, 25%D, RL, Isolyte-G, Isolyte-M,
Isolyte-P,
Isolyte-E, NACL, KCL.
2. Colloids
Albumin, Dextran, Hydroxy-ethyl starch, Penta
Starch.

11. TYPES OF I.V. FLUIDS
Crystalloids
NS, DNS, 5%D, 25%D, RL,
Isolyte-G, Isolyte-M, Isolyte-P,
Isolyte-E, NACL, KCL.
Colloid
Albumin, Dextran, Hydroxy-ethyl
starch, Penta Starch.

13. COMPOSITION OF I.V. FLUIDS
RINGER’S LACTATE ISOTONIC
SALINE(0.9% NS)
DNS (5% dextrose
with 0.9% NACL)
5% DEXTROSE
Most physiological
fluid ~ ECF. Glucose
free
Maximum sodium
and chloride.
Glucose free
Maximum sodium
and chloride. 50gm
glucose
Glucose 50gm
Indications: 1. Correction of
severe
hypovolemia
2. DKA
3. Post operative
patients, burns,
fractures.
1. Hypovolemic
shock
2. Diarrhoea,
vomiting,
excessive
diuresis.
3. Initial fluid
therapy in DKA
4. Treatment of
hypercalcemia
5. Fluid challenge in
prerenal ARF
6. Can be given
safely with blood.
1. Correction of salt
depletion and
hypovolemia with
supply of energy.
2. Correction of
vomiting or
nasogastric
aspiration induced
alkalosis and
hypochloraemia
along with blood
transfusion
3. Fluid compatible
with blood
transfusion.
1. For Pre and
post-operative
fluid
replacement.
2. For treatment
or prevention of
ketosis in
starvation,
diarrhoea,
vomiting and
high grade fever
3. Adequate
glucose infusion
protects the
liver against
toxic
substances.

14. COMPOSITION OF I.V. FLUIDS
RINGER’S LACTATE ISOTONIC
SALINE(0.9% NS)
DNS (5% dextrose
with 0.9% NACL)
5% DEXTROSE
Contraindications: 1.Liver failure
2. Renal failure
3. CHF
4. Vomiting/
continuous
nasogastric
aspiration
5. Along with
blood transfusion.
6. Drugs like
amphotericin,
thiopental,
ampicillin,
doxycycline etc
1. In hypertensive
or preeclamptic
patients
2. In patients with
oedema due to
CHF, cirrhosis
and renal failure.
3. Dehydration with
severe
hypokalemia
1. Anasarca
2. Hypovolemic
shock
1. Cerebral edema.
2. Neurosurgical
procedure
3. Acute ischaemic
stroke.
4. Hypovolemic
shock
5. Hyponatremia
and water
intoxication
6. Hypernatremia.
7. Blood
transfusion.
8. Uncontrolled
diabetes.

15. SPECIAL FLUIDS
Sodium Bicarbonate:
Routinely Used preparation is inj.NaHco3 7.5%,25 ml
ampoule.
• Each ampoule contains 22.5meq sodium and 22.5 meq
bicarbonate.
• Indications:
1. Treatment of metabolic acidosis.
2. For cardiopulmonary resuscitation and shock
3. Treatment of hyperkalemia
4. Alkaline forced diuresis along with diuretics in

16. WHY TO TREAT METABOLIC ACIDOSIS
• Metabolic Acidosis Suppresses Cardiac
Contractility- leads to hypotension.
• Persistent metabolic acidosis causes osteoporosis
and rickets
• It causes nephrocalcinosis and nephrolithiasis.

17. HOW MUCH TO GIVE ?
• Amount Of NaHCO3 required (in mEq/L) = 0.5 X weight
in kg X (desired HCO3 – Actual HCO3).
• Do not correct metabolic acidosis rapidly or completely.
• Desired value of HCO3 is usually 10-15 mEq/L, and not
normal value of 24 mEq/L.
• In absence of contraindications, approximately 50% of
the calculated deficit is corrected in 24hrs and rest
gradually over 24hrs.
• Sodium bicarbonate is added to D-5% and infused at
desired rate for correction.

18. SPECIAL PRECAUTIONS
• Not given as bolus except in emergency cases.
• Establish proper large I.V. line for infusion.
• Monitoring pH.
• Never acidosis without treating the etiology.
• Should be avoided in renal failure.
• Never correct acidosis without correcting
hypokalemia.
• Do not mix injection calcium with injection sodium
bicarbonate.

19. COMPLICATIONS
• Overshoot, Post Treatment Metabolic Alkalosis.
• Hypokalemia
• Volume overload
• Hypocalcemia.
• Contraindications
1. Respiratory alkalosis, metabolic alkalosis and
hypokalemia.
2. Correct dehydration, hypokalemia and hypocalcemia
prior to treatment with NAHCO3.
3. CHF, CRF, Cirrhosis of liver or hypertension.

20. CONTINUED.,
INJ. POTASSIUM CHLORIDE:
Routine preparation 15% 10ml ampoule
1ml = 150mg KCL = 2 mEq Potassium.
Indications:
• Hypokalemia
• Added to potassium free peritoneal dialysis
• During cardiac bypass surgery for achieving cardiac
stand-still after preparation of heart-lung bypass.

21. BASIC RULES IN USE OF INJ.KCL
• Never give direct I.V. KCL injection
• Never add more 40 mEq potassium/ltr
• Never infuse more than 10 mEq potassium/hour.
• Never add potassium chloride in in Isolyte-M.
• Monitor serum K+ level closely and if possible, also by ECG
monitoring during infusion.
Contraindications:
1. Renal Failure
2. Never use inj.KCL without knowing potassium status.

22. INJECTION 25% DEXTROSE
• Available as 25ml ampoule and 100ml infusion bottle.
• 100ml of 25% dextrose contains 25gm glucose.
Indications:
• Rapid correction of hypoglycemia or hypoglycemic coma.
• To provide nutrition to patients or to provide fluid
therapy.
• For the treatment of hyperkalemia, with 10 units of
regular insulin, 25%D 100ml is infused to prevent
hypoglycemia.

23. CONITNUED.,
CONTRAINDICATIONS:
• In dehydrated patient with anuria.
• Intracranial or intraspinal haemorrhage
• In delirium tremens.
• In diabetic patients unless there is severe hypoglycemia.
CAUTION:
• 100 ml of 25%D should be infused slowly over a period
of 45-60 mins in absence of hypoglycemia.

24. COLLOID SOLUTIONS
ALBUMIN:
• Available as 5% solution (50 gm/L) and a 25%
solution (250 gm/L).
• 5% albumin solution has a colloid osmotic pressure
of 20 mm of Hg. The oncotic effect of albumin lasts
12-18 hours.
• 25% albumin solution has a colloid osmotic pressure
of 70 mm of Hg.
• Expands the plasma volume by 4-5 times the volume
infused.
• 25% albumin should not be used volume

25. CONTINUED.,
INDICATIONS:
• Plasma volume expansion.
• Correction of hypoproteinemia
• As an exchange fluid
ADVERSE EFFECTS:
• Nausea, Vomiting, febrile reaction and allergic
reaction including anaphylactic shock.

26. CONTINUED.,
PRECAUTIONS AND COTRAINDICATIONS:
• Should avoid fast infusion
• Contraindicated in severe anaemia and cardiac
failure.
• Dehydrated patients may require additional fluids
along with albumin infusion.
• Albumin solution should not be used in parenteral
nutrition.
INFUSION RATE:

27. HOW MUCH FLUID SHOULD BE GIVEN TO CORRECT
HYPOVOLEMIA
ECF deficit (L) = 0.2 X lean body weight X (Current
Hct/Normal Hct -1)
Effective rate of fluid replacement per hour
= 50 to 100 ml
+ Urine output per hour
+ Ongoing loss (Such as diarrhoea or tube drain
per hour)

28. MONITORING FLUID THERAPY
• Weight
• Skin and tomgue
• Sensorium
• Urine output > 30-50 ml/hour in adults
• Pulse rate
• Blood pressure
• Haematocrit
• Blood urea and serum creatinine
• Urinary Sodium (>25 mEq/L)
• Metabolic acidosis.
• CVP or PAWP

29. CVP
• Normal value of CVP ranges from 2 to 14 (usually 6-10) cm of water.
Factors which determine CVP:
• Vascular volume, right ventricular function, intra thoracic pressure and
vascular tone.
LOW CVP:
• True hypovolemia as in blood loss and dehydration.
• Relative hypovolemia caused by peripheral vasodilation as in spinal
anaesthesia, septicaemia and anaphylactic shock.
HIGH CVP:
• Volume Overload.
• Cardiac causes like CHF, cardiac tamponade, TR and constrictive
pericarditis.
• Pulmonary causes like embolism, tension pneumothorax, COPD and cor
pulmonale and IPPV.

30. PAWP
• It reflects left ventricular end diastolic pressure.
• PAWP accurately reflects left atrial pressure and left ventricular
function, it is better guide for fluid replacement
Low PAWP:
• Suggests hypovolemia.
High PAWP:
• Suggests volume overload in the absence of LVF, MS, MR,
Cardiac tamponade or constrictive pericarditis.
• A marked elevation in PAWP frequently occurs prior to overt CHF.
• Timely alteration can avoid clinical CHF.

31. WHY PAWP BETTER COMPARED TO CVP
• Even hypovolemic patients can have high CVP due to RVF and
pulmonary hypertension or patients requiring mechanical
ventilatory support.
• In all these conditions, PAWP is low in hypovolemic patients.
INDICATIONS:
• In critically ill, haemodynamically unstable patients.
• In elderly patients or patients with history of ischemic heart disease
requiring massive fluid replacement e.g. severe dehydration and
shock, burns etc.
• In ARDS, for controlled optimum fluid delivery.
• Pre and intraoperative monitoring of fluid replacement in seriously

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