This document discusses intravenous (IV) fluids, including their composition and uses. It covers the different fluid compartments in the body and variations that can occur. Various IV fluid types - isotonic, hypotonic, hypertonic and colloids - are described along with their indications, precautions, and how they alter fluid balance. Factors influencing fluid requirements and principles of fluid therapy for resuscitation, maintenance and replacement are outlined. Signs of overhydration and approaches to manage fluid overload are also summarized.

1. IV FLUIDS
DR. ANIRUDH AGRAWAL
DNB RESIDENT
GENERAL SURGERY

2. TOTAL BODY WATER
• APPROX 60% OF BODY WEIGHT (30l)
• VARIES WITH AGE , GENDER AND BODY WEIGHT

3. BODY WATER COMPARTMENT
• Intracellular volume- 2/3 of tbw (20 l)
• Extracellular volume – 1/3 of tbw (10l)
- intravascular – plasma volume (1/4) (2.5l)
- Extravascular – interstitial fluid and others (3/4)(7.5l)

4. Extra cellular fluid
1. interstitial compartment
• Small narrow space- between tissues or parts of an organ
• Interstitial fluid +
• excessive fluid accumulates – edema develops
2. Intra vascular compartment
• blood +
3. Third space
• Peritoneal cavity
• Pleural cavity
• Small amount of fluid present normally

5. Water- essential for cell life
• Minimum obligatory daily water input
• 500ml- ingested water
• 800 ml – water content in food
• 300 ml – water from oxidation
• Minimum obligatory daily water output
• 500 ml- urine
• 500 ml – skin
• 400 ml – respiratory tract
• 200 ml – stool
• Average – input and output – 2.4 l/day

6. ↑ Requirement of water in-
• Fever
• Burns
• Sweating
• Surgical drains
• GI loss thorugh vomiting and diarrohea
• Sweating
• Tachyponea
• Polyuria

7. Fluid therapy
• Osmolality – amount of solute dissolved in a solvent like water
measured in weight ( kg )
• Osmolarity - amount of solute dissolved in a solvent like water
measured in volume (l)
• Normal plasma osmolality – 275-295 mosm/kg

8. Principles of fluid therapy
Indications
• Rapid restoration of fluid and electrolytes
• Dehydration – vomiting , diarrhoea , shock ,
hemorrhage, sepsis , burns , shock
• TPN
• Anaphylaxis , cardiac arrest , hypoxia
• Post- GI surgeries
• For maintenance, replacement of loss or special fluid

9. Types of fluid
1. Colloid
• Solutions –large molecules – don’t pass cell membrane
• Remain in intra vascular compartment
• Expand intravascular volume
• Draw fluid from extra vascular spaces via oncotic pressure
2. Crystalloid
• Solutions –small molecules – easily pass cell membrane
• Increase fluid volume – interstitial + intra vascular
• Divided into- isotonic
hypotonic
hypertonic

10. Isotonic fluids
• concentration of the particles (solutes)=to that of plasma
• So it doesn't move into cells and remains within the extracellular
compartment thus intravascular volume.
Isotonic solutions include:
• 0.9% sodium chloride (0.9% NaCl)
• lactated Ringer's solution
• 5% dextrose in water (D5W)
• Ringer's solution

11. A. 0.9% sodium chloride (Normal Saline)
• 0.9% NaCl- 154-Na+ K+ Ca+2 Mg+2 Cl -154 Dextrose mOsm/L-308
• Normal saline - % Nacl similar to concentration of na+ and cl- in intra vascular space
• Used in –
• to treat low extracellular fluid, as in fluid volume deficit from- Hemorrhage
• Severe vomiting or diarrhea
• Heavy drainage fromGl suction, fistulas, or wounds
• Shock
• Mild hyponatremia
• Metabolic acidosis (such as diabetic ketoacidosis)
• It's the fluid of choice for resuscitation efforts.
• it's the only fluid used with administration of blood products
• Used cautiously- cardiac or renal patient( volume overload0

12. B. Ringer’s lactate or Hartmann solution
• Na -130 , k-4, Ca - 3 ,Cl-109 mosm/l -273
• most physiologically adaptable fluid - electrolyte content - body's
blood serum and plasma.
• choice for first-line fluid resuscitation- burn injuries or trauma
• Acute blood loss- third space fluid shift
• LR- metabolized- liver –lactate to bicarbonate ( metabolic acidosis )
• Cautious use – renal impairement( K)
Liver disease
ph> 7.5

13. C. Dextrose 5%
• Dextrose – 50 gm/l mosm/l-278
• Isotonic – when metabolized – become hypotonic – fluid shift into cells
• Provides free water – expand intra + extra cellular compartment
• 170 calories/l – no electrolytes
• Do not use – renal failure – fluid overload
cardiac failure
ICP - Cerebral edema
Mix with blood – hemolyze
Not used for resuscitation – won’t remain in intravascular space
Early postoperative period - ADH secretion due to surgical stress

14. Precaution in usage of isotonic fluids
• Hypovolemia to hypervolemia
• Signs and symptoms of hypervolemia
• 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 contraindicated.
• If edema is present, elevate the patient‘s legs

15. • signs and symptoms of continued hypovolemia, including:
• urine output of less than 0.5 mL/kg /hour
• poor skin turgor
• Tachycardia
• weak, thready pulse
• hypotension

16. Hypotonic fluids
• hypotonic solutions - concentration of solutes (electrolytes)
• osmolality < 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.

17. Types of hypotonic fluids
• 0.45% sodium chloride (0.45% NaCl),
• 0.33% sodium chloride
• 0.2% sodium chloride
• 2.5% dextrose inwater
• Hypotonic fluids are used in conditions causing intracellular
dehydration
• fluid needs to be shifted into the cell- Hypernatremia
Diabetic ketoacidosis
Hyperosmolar hyperglycemic state.

18. Hypotonic fluids
• Precaution – ICP - Cerebral edema
Liver disease
Trauma
Burns
• depletion of intravascular fluid volume- hypovolemia and
hypotension- Cardiovascular collapse
• Monitor patients for signs and symptoms of fluid deficit

19. Hypertonic solutions
• Solution - higher tonicity or solute concentration.
• osmolarity of 375 mOsm/L or higher
• The osmotic pressure gradient draws water out of the intracellular
space, increasing extracellular fluid volume- volume expander

20. Types and indications
• 3% sodium chloride (3% NaCl): severe hyponatremia.
cerebral edema
• 2- 5% Dextrose with normal saline (D5NS): replaces sodium, chloride
and some calories
• Precautions-
• Intra vascular volume overload – pulmonary edema

21. Colloid solutions
• expand the intravascular volume by drawing fluid from the interstitial
spaces into the intravascular compartment through their higher
oncotic pressure.
• the same effect as hypertonic crystalloids solutions but it requires
administration of less total volume and have a longer duration of
action because the molecules remain within the intravascular space
longer.
• Its effect can last for several days if capillary wall linings are intact
and working properly.

22. Colloid solutions
• Examples-
• 1- 5% albumin (Human albumin solution)- most commonly used
• - It contains plasma protein fractions obtained from human plasma and works to rapidly expand
the plasma volume used for
• volume expansion
• moderate protein replacement
• achievement of hemodynamic stability in shock states
• Contraindications- severe anemia
Heart failure
ACEI – stop for 24 hours – atypical reaction- flushing and hypotension
2. Hydroxyethalstarches
• contain – Na and Cl – hemodynamic volume replacement and burns
• Less expensive

23. • Precautions – risk for fluid volume overload
• Monitor for signs and symptoms of hypervolemia
• Monitor input /output
• Interfere with platelet function – bleeding time
• Anaphylactoid reactions

24. Components of fluid therapy
• Maintenance therapy- replaces normal ongoing losses( peri-operatively or
on ventilator)- 4-2-1 rule (weight +40 )
• 4ml/kg/hr for first 10 kg
• 2ml/kg/hr for next 10 kg
• 1 ml/kg/hr for any kgs above that
• Fluid Resuscitation- corrects any existing water and electrolyte deficits.(
hypovolemic shock )
• Parameters- BP
Urine output
JVP
Urine Na concentration

25. • Rate of Repletion of Fluid deficit
1. Severe volume depletion or hypovolemic shock
• Rapid infusion of 1-2L of isotonic saline (0.9% NS) to restore tissue
perfusion
2- Mild to moderate hypovolemia: Choose a rate that is 50-100mL/h
greater than estimated fluid losses. calculating fluid loss as follows
Urine output=50ml/h
Insensible losses = 30ml/h
Additional loss such as Vomiting or Diarrhea or high fever (additional
100-150 ml/day for each degree of temp >37

26. Fluid overload ( hypervolemia )
• Excessive- fluid accumulation
• Excessive parenteral infusion
• Deficiency in cvs or renal fluid regulation
• Management
• Prevention is the best way
• Sodium restriction
• Fluid restriction
• Diuretics
• Dialysis