The document discusses the history and uses of intravenous (IV) fluids, describing how IV fluids are used to maintain adequate fluid volume and electrolyte balance in the body. It also explains the concepts of osmosis, tonicity, and body fluid compartments as they relate to IV fluid administration and the goals of IV fluid therapy. Specific types of IV fluids, such as crystalloids and colloids, are categorized and their indications, contraindications, and potential complications are outlined.

4. Contents
General Description
 History
 Fluids and Human Body
 Uses of IV Fluids
 Goals of IV Fluids
 Assessment of Fluid volume status
Specific Description
 Concept of Osmosis
 Osmolarity
 Tonicity
 Body Fluid compartments
 Impact of IV Fluid on Fluid
Compartments

Something About Colloids
 Crystalloid
Categories of colloid & Crystalloid
Down sides
Rule of 4:2:1
Drip Rate
Pre, intra & post Operative Maintenance
Complications
Take home message

6. HISTORY
 The first record available that shows an understanding of
the need for fluid in injured patients was apparently from
Ambroise Paré (1510-1590), who urged the use of clysters
(enemas to administer fluid into the rectum) to prevent
“noxious vapors from mounting to the brain.”
 The term shock appears to have been first used in 1743 in
a translation of the French treatise of Henri Francois Le
Dran regarding battlefield wounds.

7.  In 1830, Herman provided one of the first clear
descriptions of intravenous (IV) fluid therapy. In response
to a cholera epidemic, he attempted to rehydrate patients
by injecting 6 ounces of water into the vein
 0.9% normal saline originated during the cholera pandemic
that afflicted Europe in 1831, but an examination of the
composition of the fluids used by physicians of that era
found no resemblance to normal saline. The origin of the
concept of normal saline remains unclear

8.  Sydney Ringer found three ingredients essential were
potassium, calcium, and bicarbonate. Ringer’s solution soon
became ubiquitous in physiologic laboratory experiments.
 In 1932, attempting to develop an alkalinizing solution to
administer to his acidotic patients, Hartmann modified Ringer’s
solution by adding sodium lactate. The result was lactated
Ringer’s (LR), or Hartmann’s solution.
 By world war II, shock was recognized as the single most
common cause of treatable morbidity and mortality. Out of
necessity, efforts to make blood transfusions available
heightened and led to the institution of blood banking for
transfusions.

9.  It maintains the shape and integrity of all cells in the body
 It maintains blood pressure/ volume
 A transport medium for ;
 Delivery of nutrients and oxygen to the tissues
 Removal of waste products from the body
 A medium for all the biochemical reactions necessary for life
 Approximately 60% of the body is water!

10.  Resuscitation
 Rehydration / Replacement
 Maintenance
 Special purpose

11. To maintain adequate oxygen delivery to the tissues
To maintain normal electrolytes concentration
To maintain normoglycemia

12. Look at the patient:
- Pulse
- Blood pressure
- Capillary refill
- Skin turgor
- Mucous membranes
- Peripheral circulation

13. “If the eyes are the windows to the soul,
then the kidneys are the windows to the
body”
Sandra Ouellette.

14. The principle of osmosis and tonicity.
The different fluid compartment of the body
Predict the effect that specific types of IV fluids
will have on the volume within different body fluid
compartments.

15. The Spontaneous movement of water across a
semipermeable membrane from a region of low
solute concentration to one of high solute
concentration , which tends to equalize the
solute concentrations on either side of the
membrane.

16. OSMOLALITY
Measure of a fluid’s capability to create osmotic pressure
is called osmolality or osmotic (osmolar) concentration of
a solution. In simple words, it is the concentration of
osmotically active substance in the solution. Osmolality is
expressed as the number of particles (osmoles) per
kilogram of solution (osmoles/kg H2O).
OSMOLARITY
Osmolarity is another term to express the osmotic
concentration. It is the number of particles (osmoles) per
liter of solution (osmoles/L).

20. The hydrostatic pressure necessary to counteract the process
of osmosis
The total number of solute particles per volume of solution
The difference in the osmolarity of two solutios on either side
of a semipermeable membrane.

21. Extracellular Fluid
(1/3 TBW)
Capillary Membrane

22. Tonicity #Osmolarity
Osmilarity is dependent upon all particles of solute
Tonicity is dependent just upon those particles when exert an
osmotic force (i.e. those which cannot permeate through cell
membrane
Example: Urea creates osmolarity but does not contribute to
tonicity since it freely moves through the cell membrane

27. IV Fluid containing osmotic pressure due to presence of large
molecules is called colloid
Osmotic pressure due to such molecules is sometimes
referred to as oncotic pressure
If Oncotic pressure in an infused fluid exceeds that in the
plasma, it can pull water from interstitial space into the
intravascular space.

28. List the categories of IV fluids , and several examples of each (e.g.
NS, D5W, LR,albumin, hydroxyethyl starch, etc….)
Constitunts of common IV Fluids
Primary Indication, contraindications aside effects of common IV
fluids.

29. Relatively high tendency
to stay intravacualr
Examples: Albumin
Fresh frozen Plasma
Dextran
Hydroxyethyl starch
Electrolyte-Free Water
Examples: D5W, D10W
Blood
Examples: Packed RBCs

30. FLUID Na+
mEq/L
Cl
mEq/L-
K+
mEq/L
Ca2+
mEq/L
Glucose
g/L
Buffer Osmolarity
mOsm/L
Tonocity Typical
Indication
Normal
Plasma
140 100 4 2.4 0.85 HCO3-
24mEq/L
290 N/A N/A
0.9%
Saline
(a.k.a NS)
154 154 0 0 0 0 308 Isotonic Resuscitation
0.45%
saline
(a.k.a)1/2
NS
77 77 0 0 0 0 154 Hypotenic Maintenance
3% Saline 513 513 0 0 0 0 1026 Hypertoni
c
Severe
Hyponatremia
D51/2
NS+
20mEqKC
L
77 97 20 0 50 0 446 Hypertoni
c--
Hypotonic
Maintanance
D5W 0 0 0 0 50 0 252 Hypotonic Hypernatremia
Hypoglycemia
Lactated
Ringer’s
(LR)
13 109 4 3 0 Lactate
28mEq/L
273 Isotonic Resuscitation

31. Large volume s of NS can lead to a normal anion gap
metabolic acidosis
LR is relatively contraindicated in:
Hyperkalemia (due to presence of K+) usually a
minimal concern
Concurrent blood transfusion ( due to binding of
Ca+ with citrate in blood products)

32. Colloids can be divided in to natural (e.g. albumin, FFP) and
synthetic (e.g. Dextran , hydroxyethyl starch, gelatins )
Volume expansion due to colloid is determined by its molecular
wight and concentration.
Colloid fluids can be either saline based solutions or balanced
solutions
Colloids are typically only used for resuscitation in severe
hypovolemia
Exception include use of albumin in cirrhotic patients and renal
failure

33. FLUID Avg
Molecular
Weight(kD)
Osmotic
Pressure(m
mHg)
Initial
Volume
expamsion
Duration of
Volume
expansion
4-5%
Albumin
69 20-30 70-100% 12-24 hrs
20-25% 69 70-100 300-500% 12-24 hrs
10% Dextran
40
40 20-60 100-200% 1-2 hrs
6%
Hydroxyethyl
Starch
(Hespan)
450 25-30 100-200% 8-36 hrs

34. To about the rule of maintenance fluid and rate of IV drip

35. 0-10 kgs 4ml/kg/hr
10-20 kgs 2ml/kg/hr
>20 kgs 1 ml/kg/hr
For Example :
1. 1.5 kg pt
so
1.5kg x 4= 20ml/hr
2.15kg
so
10 x 4 = 40ml/hr
5 x 2 = 10 ml/hr
50ml/ hr

36. 3. 25kgs
10 x 4 = 40ml/hr
10 x 2 =20 ml/hr
5 x 1 = 5 ml/hr
65ml/hr
In adult > 20 kgs
Simply add age with 40
For example:
A 25 kgs pt
then 40 + 25 = 65ml/kg/hr

37. A certain amount of liquid, a time period, and a drop factor (gtts/mL)
x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min)
Volume (mL)
Time in min
Formula:
Example: Calculate the IV flow rate for 1200 mL of NS to be infused in 6
hours. The infusion set is calibrated for a drop factor of 15 gtts/mL.
Time (min)
x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min)
Convert 6 hours to minutes.
 min ← hr ( x by 60 )
 6 hr x 60 = 360 min
1200 mL
360 min
x 15 gtts/mL = 50 gtts/min
Volume (mL)

38. Example: Calculate the IV flow rate for 200 mL of 0.9% NaCl IV over 120 minutes. Infusion
set has drop factor of 20 gtts/mL.
Time (min)
x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min)
200 mL
120 min
x 20 gtts/mL = 33 gtts/min
Volume (mL)

39. Pre-operative fluid therapy
IV Fluid Calculation
 4 mL/kg for first 10 kg
 2 mL/kg for next 10 kg
 1 mL/kg for every kg over 20 kg
E.g. for 45-kg patient:
 10 kg × 4 mL / kg = 40 mL
 10 kg × 2mL / kg = 20 mL
 25 kg ×1mL / kg = 25mL
Maintenance rate = 85mL/hr, 2000 ml/day

40.  Alternative approach is to replace the calculated daily
water losses in urine, stool, and insensible loss with a
hypotonic saline solution.
 An appropriate choice of 5% dextrose in 0.45% sodium
chloride at 100 ml/h as initial therapy, with potassium
added for patients with normal renal function.
 Volume deficits should be considered in patients who
have obvious GI losses, such as through emesis or
diarrhea, as well as in patients with poor oral intake
secondary to their disease.

41. Intra-operative fluid therapy
 With the induction of anesthesia, compensatory
mechanisms are lost, and hypotension will
develop if volume deficits are not appropriately
corrected.
 In addition to measured blood loss, major open
abdominal surgeries are associated with
continued extracellular losses in the form of
bowel wall edema, peritoneal fluid, and the
wound edema during surgery.

42.  Large soft tissue wounds, complex fractures with
associated soft tissue injury, and burns are all
associated with additional third-space losses that must
be considered in the operating room. These functional
losses have been referred to as parasitic losses,
sequestration, or third-space edema, because the lost
volume no longer participates in the normal functions of
the ECF.
 Replacement of ECF during surgery often requires 500
to 1000 ml/h of a balanced salt solution to support
homeostasis.

43. Post-operative fluid therapy
 Postoperative fluid therapy should be based on the
patient’s current estimated volume status and
projected ongoing fluid losses.
 Any deficits from either preoperative or intraoperative
losses, third-space losses should be included in fluid
replacement strategies.
 The adequacy of resuscitation should be guided by
the restoration of acceptable values for vital signs and
urine output.
 If uncertainty exists, particularly in patients with renal
or cardiac dysfunction, a central venous catheter may
be inserted to help guide fluid therapy.

44.  In the initial postoperative period, an isotonic solution
should be administered.
 After the initial 24 to 48 hours, fluids can be changed to
5% dextrose in 0.45% saline in patients unable to
tolerate enteral nutrition.
 If normal renal function and adequate urine output are
present, potassium may be added to the IV fluids.
 Daily fluid orders should begin with assessment of the
patient’s volume status and assessment of electrolyte
abnormalities. All measured losses, including losses
through vomiting, nasogastric suctioning, drains, and
urine output, as well as insensible losses, are replaced
with the appropriate parenteral solutions.

45.  Infiltration
 Extravasation
 Infection
 Thrombophlebitis
 Severed catheter
 Fluid overload
 Air embolism

46.  Fluid is like “prescription” so give it with caution.
 Children are more vulnerable for rapid fluid loss.
 Maintenance calculation by “4-2-1” rule or Holliday Segar’s
formula.
 Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM
SODIUM CONCENTRATION while giving fluid is must.
 As far as possible try to give maintenance fluid requirement orally.
 0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children
requiring maintenance therapy.
 Replacement of fluids should be prompt & appropriate.