This document provides an overview of fluid therapy, including the classification, composition, and effects of intravenous fluids. It discusses crystalloids like normal saline and Ringer's lactate, as well as dextrose solutions. Normal saline is commonly used but can cause acidosis due to its strong ion difference of zero. Ringer's lactate more closely matches plasma composition. Dextrose solutions provide calories but can increase lactate levels in critically ill patients. The document also covers the indications, mechanisms of action, and limitations of different IV fluid types.
This document discusses intravenous (IV) fluid choice from an intensive care perspective. It begins by introducing IV fluids as a cornerstone treatment in emergency and intensive care medicine and discusses the debate around the relative safety of different IV fluid formulations. It summarizes the findings of several large randomized controlled trials that compared colloids to crystalloids and found increased risks of harm with some colloids. The document analyzes the safety of different IV fluid options like albumin, hydroxyethyl starches, and crystalloids based on evidence from major trials. It concludes that normal saline is generally the default fluid but that more physiological crystalloids may be preferable in some situations like burns or metabolic acidosis.
This document summarizes different intravenous (IV) fluid options used in intensive care, including crystalloids, colloids, and specific fluid products. Crystalloids like saline readily diffuse out of blood vessels, while colloids like albumin, hetastarch, and pentastarch remain in circulation longer due to their larger size. Albumin is the main protein in blood plasma and expands volume the least of colloids. Hetastarch is a synthetic starch that expands volume more than albumin but can cause coagulopathy in large doses. Pentastarch is a newer low-molecular-weight hetastarch derivative that may cause fewer side effects.
This document summarizes different types of colloid solutions that can be used for fluid resuscitation, including their properties and results from clinical trials comparing colloids to crystalloids. It discusses natural and synthetic colloids such as albumin, gelatin, starch, and dextran. For starch solutions, it describes concentration, molecular weight, degree of substitution, and C2:C6 ratio. It summarizes trials finding increased risks of death and kidney injury with some hydroxyethyl starches. Overall, the document recommends crystalloids as the initial fluid of choice in sepsis and considering albumin for large volume resuscitation, but against the use of some hydroxyethyl starches.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses fluid responsiveness and methods for assessing preload responsiveness. It summarizes that dynamic indices of preload responsiveness like pulse pressure variation (PPV) and stroke volume variation (SVV) can help identify patients who will respond to fluid by increasing their stroke volume. However, these indices have limitations and may not be reliable in patients with spontaneous breathing, arrhythmias, low tidal volumes, low lung compliance, high frequency ventilation, open chest conditions, or severe right ventricular failure. In these situations where the indices cannot be interpreted reliably, other dynamic tests are needed to assess fluid responsiveness.
This document discusses hypothermia and deep hypothermic circulatory arrest (DHCA). It explains that hypothermia decreases the rate of biological reactions and reduces the brain's metabolic needs, providing protection during periods of low or no blood flow. The document covers topics like the degree of hypothermia used for DHCA, organ protection strategies during DHCA like pharmacological adjuncts and temperature management, and debates around acid-base management approaches like alpha-stat vs. pH-stat. The optimal application of hypothermia and DHCA can facilitate complex cardiac surgery while minimizing neurological risks.
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.Joseph A. Di Como MD
A review of different types of shock encountered in patients. Hypovolemic, septic, cardiogenic and neurogenic shock. We review etiology, pathophysiology, diagnosis, treatment and how to differentiate between them.
The document discusses hypercapnia (excess carbon dioxide in the body) and its effects on different body systems. It classifies hypercapnia as moderate (PCO2 40-100 mmHg) or severe (PCO2 over 100 mmHg). Hypercapnia affects the central nervous system by impacting cerebral blood flow, intracellular pH, and having an inert gas narcotic effect. It can also stimulate the sympathetic nervous system, impacting the cardiovascular system by increasing heart rate and cardiac output while decreasing systemic vascular resistance. The document examines the effects of hypercapnia under different anesthetic agents as well.
This document discusses intravenous (IV) fluid choice from an intensive care perspective. It begins by introducing IV fluids as a cornerstone treatment in emergency and intensive care medicine and discusses the debate around the relative safety of different IV fluid formulations. It summarizes the findings of several large randomized controlled trials that compared colloids to crystalloids and found increased risks of harm with some colloids. The document analyzes the safety of different IV fluid options like albumin, hydroxyethyl starches, and crystalloids based on evidence from major trials. It concludes that normal saline is generally the default fluid but that more physiological crystalloids may be preferable in some situations like burns or metabolic acidosis.
This document summarizes different intravenous (IV) fluid options used in intensive care, including crystalloids, colloids, and specific fluid products. Crystalloids like saline readily diffuse out of blood vessels, while colloids like albumin, hetastarch, and pentastarch remain in circulation longer due to their larger size. Albumin is the main protein in blood plasma and expands volume the least of colloids. Hetastarch is a synthetic starch that expands volume more than albumin but can cause coagulopathy in large doses. Pentastarch is a newer low-molecular-weight hetastarch derivative that may cause fewer side effects.
This document summarizes different types of colloid solutions that can be used for fluid resuscitation, including their properties and results from clinical trials comparing colloids to crystalloids. It discusses natural and synthetic colloids such as albumin, gelatin, starch, and dextran. For starch solutions, it describes concentration, molecular weight, degree of substitution, and C2:C6 ratio. It summarizes trials finding increased risks of death and kidney injury with some hydroxyethyl starches. Overall, the document recommends crystalloids as the initial fluid of choice in sepsis and considering albumin for large volume resuscitation, but against the use of some hydroxyethyl starches.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses fluid responsiveness and methods for assessing preload responsiveness. It summarizes that dynamic indices of preload responsiveness like pulse pressure variation (PPV) and stroke volume variation (SVV) can help identify patients who will respond to fluid by increasing their stroke volume. However, these indices have limitations and may not be reliable in patients with spontaneous breathing, arrhythmias, low tidal volumes, low lung compliance, high frequency ventilation, open chest conditions, or severe right ventricular failure. In these situations where the indices cannot be interpreted reliably, other dynamic tests are needed to assess fluid responsiveness.
This document discusses hypothermia and deep hypothermic circulatory arrest (DHCA). It explains that hypothermia decreases the rate of biological reactions and reduces the brain's metabolic needs, providing protection during periods of low or no blood flow. The document covers topics like the degree of hypothermia used for DHCA, organ protection strategies during DHCA like pharmacological adjuncts and temperature management, and debates around acid-base management approaches like alpha-stat vs. pH-stat. The optimal application of hypothermia and DHCA can facilitate complex cardiac surgery while minimizing neurological risks.
Shock: A review of hypovolemic, septic, cardiogenic and neurogenic shock.Joseph A. Di Como MD
A review of different types of shock encountered in patients. Hypovolemic, septic, cardiogenic and neurogenic shock. We review etiology, pathophysiology, diagnosis, treatment and how to differentiate between them.
The document discusses hypercapnia (excess carbon dioxide in the body) and its effects on different body systems. It classifies hypercapnia as moderate (PCO2 40-100 mmHg) or severe (PCO2 over 100 mmHg). Hypercapnia affects the central nervous system by impacting cerebral blood flow, intracellular pH, and having an inert gas narcotic effect. It can also stimulate the sympathetic nervous system, impacting the cardiovascular system by increasing heart rate and cardiac output while decreasing systemic vascular resistance. The document examines the effects of hypercapnia under different anesthetic agents as well.
This article discusses the 'ROSE concept' of fluid management proposed by Malbrain et al. and its relevance for neuroanaesthesia and neurocritical care. The ROSE concept has four phases - resuscitation, optimisation, stabilisation, and evacuation. During the resuscitation phase, fluids are given aggressively to restore circulation. The optimisation phase aims for a neutral fluid balance to ensure tissue perfusion. Stabilisation focuses on maintaining neutral or negative balance. Finally, evacuation uses diuretics and albumin to achieve negative balance and 'de-resuscitation' in stable patients with fluid overload. The article concludes that while restriction of fluids is important to prevent increased intracranial pressure, neurosurgical
This document discusses PiCCO (Pulse induced Contour Cardiac Output), a system that uses transpulmonary thermodilution to measure hemodynamic parameters in critically ill patients. It provides indications for use including shock, sepsis, and organ failure. It defines cardiogenic shock and lists specific criteria. Contraindications include issues with vascular access and arrhythmias. Key parameters that can be measured include stroke volume, cardiac index, global end diastolic volume index, intrathoracic blood volume index, extravascular lung water index, and systemic vascular resistance index along with normal ranges.
This document provides an overview of colloids used for fluid resuscitation. It defines colloids and discusses their history, studies, scientists involved in research, and physiology. The document classifies and describes different types of colloids including albumin, dextran, and hydroxyethyl starches. It compares the differences between crystalloids and colloids, and concludes with a discussion of appropriate use and monitoring of colloid administration.
Resp failure talk 9 10 bipap and hfnc emphasisStevenP302
This document discusses respiratory failure and the use of high flow nasal cannula (HFNC) and bilevel positive airway pressure (BiPAP). It describes the three types of respiratory failure - inability to oxygenate, inability to ventilate, and inability to protect airway. HFNC provides high flow oxygen but no positive pressure, while BiPAP provides adjustable inspiratory and expiratory pressures for both oxygenation and ventilatory support. The document reviews indications, advantages, disadvantages, settings and monitoring for BiPAP use in treating respiratory failure.
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
Dr. Vijay Kumar discusses fluid management in the emergency department and intensive care unit. He covers the normal regulation of fluid balance, fluid imbalances that can occur in shock states, and indices used to assess successful fluid resuscitation. Both under-resuscitation and overzealous fluid administration can increase patient morbidity and mortality, so fluid therapy must be carefully titrated based on close monitoring of the patient's hemodynamic status and tissue perfusion.
Geriatric anesthesia physiological changes and preoperative preparationTushar Chokshi
This document provides an outline for a lecture on anesthesia implications for elderly patients. It discusses the normal age-related physiological changes in several body systems and how they impact anesthesia considerations. Some key points include:
- The cardiovascular system shows decreased cardiac output, increased blood pressure, and reduced beta receptor response with age. This increases risks of hypotension, arrhythmias, and heart failure during anesthesia.
- Respiratory function declines with stiffer lungs and weaker muscles. Elderly are more prone to aspiration, infection, and oxygen desaturation.
- Other organ systems like kidneys, liver and skin also experience changes that slow drug metabolism and clearance. This increases risks of toxicity.
- Thorough
Htk costodial clinical effect edited nice Peter Flash
The document discusses the clinical impact of histidine ketoglutarate tryptophan (HTK) cardioplegia solution on patients undergoing open heart surgery. It provides a brief history of cardioplegia development, describing early solutions using potassium and hypothermia for cardiac arrest. Modern solutions like HTK and Bretschneider solutions induce nondepolarized cardiac arrest through calcium influx inhibition and metabolic substrate provision. Hypothermia further reduces oxygen demand and improves protection when combined with cardioplegia solutions.
VBG vs ABG (replacement of venous blood sample instead of arterial one for an...Reza Aminnejad
This document discusses the use of venous blood gas measurements compared to arterial blood gas measurements. It finds that central venous blood gases most closely correlate with arterial measurements, while peripheral venous measurements vary more. Specifically, venous pH is typically 0.02-0.05 lower, PCO2 is typically 3-8 mmHg higher, and bicarbonate may be up to 2 mEq/L higher compared to arterial values. Venous measurements can be used for monitoring patients without arterial access, but arterial measurements are still preferred, especially for hypotensive patients. Periodic correlation of venous and arterial values is recommended when using venous measurements serially.
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
This document discusses guidelines for extubation and managing risks associated with extubation. It begins by outlining criteria that must be met for safe extubation, such as adequate breathing and hemodynamics. It then describes methods for standard, awake, deep and difficult/high risk extubations. Risks of immediate extubation are outlined. The document provides detailed protocols for managing complications like laryngospasm and laryngeal edema to prevent reintubation. Prophylactic medications, strategies for difficult airways, and criteria for determining pre-extubation airway edema are discussed to ensure extubations are performed safely.
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMUShahnaali
Non-invasive ventilation (NIV) delivers mechanical ventilation without an endotracheal tube. It is used for acute or chronic respiratory failure. NIV uses interfaces like masks to deliver bilevel positive airway pressure (BiPAP). It has advantages over invasive ventilation like avoiding complications of intubation and allowing oral communication. Selection criteria, monitoring, interfaces, modes and settings are described. NIV is assessed for improvement in blood gases and symptoms. Weaning involves gradually decreasing pressure support. NIV may need to be changed to invasive ventilation if a patient deteriorates on NIV.
This document summarizes information about using sodium bicarbonate (NaHCO3) to treat acidosis. It discusses what bicarbonate is, how it works to neutralize acid in the blood, appropriate dosing, administration, safety issues, and contraindications. It specifically examines using bicarbonate to treat diabetic ketoacidosis (DKA) and lactic acidosis, noting that the evidence does not clearly support its routine use in DKA but it may be considered in severe cases with pH <6.9. For lactic acidosis, bicarbonate may help if pH is <7.1 but the evidence is limited and it could increase lactate levels and mortality. The
The document discusses arterial blood gas analysis and interpretation. It provides guidelines for deciding when to intubate based on clinical assessment rather than strict ABG value cutoffs. It also presents two scenarios to determine which case would warrant immediate ventilatory support. The key is that the decision to intubate should be based primarily on clinical factors, not just ABG values alone.
The document discusses ventilation and different modes of noninvasive ventilation. It provides details on:
1) How ventilation works through pressure differences that cause air to flow into and out of the lungs. Different factors like resistance and Boyle's law impact this process.
2) The history and development of noninvasive ventilation, from early negative pressure devices to current use of positive pressure ventilation delivered noninvasively through masks.
3) Modes of noninvasive positive pressure ventilation including volume ventilation, pressure ventilation, bilevel PAP, and CPAP. The benefits and limitations of noninvasive ventilation are also summarized.
Fluid balance and therapy in critically illAnand Tiwari
The document discusses various aspects of human body water content and distribution. It notes that water makes up 50-60% of total body weight, with 40% being intracellular fluid, 20% extracellular fluid, and 15% interstitial fluid. It also discusses fluid compartments, mechanisms of fluid movement, electrolyte concentrations, fluid requirements, types of intravenous fluids and their properties, and considerations in fluid resuscitation.
This document discusses the management of Acute Respiratory Distress Syndrome (ARDS). It begins with an overview of the pathophysiology of ARDS including pulmonary capillary leak, surfactant inactivation, and edema. It then discusses treatments such as positive end-expiratory pressure (PEEP), recruitment maneuvers, prone positioning, high frequency oscillatory ventilation, liquid ventilation, and medication administration. The document provides details on various ventilation strategies and technologies used in ARDS management.
1. Mitral stenosis is most commonly caused by rheumatic fever and results in thickening and calcification of the mitral valve, reducing the valve orifice area and obstructing blood flow from the left atrium to ventricle.
2. The pathophysiology involves elevated left atrial pressure, pulmonary hypertension, and reduced cardiac output. Symptoms range from easy fatigability to pulmonary edema.
3. Physical exam findings include an opening snap, rumbling diastolic murmur, and signs of right heart failure in severe cases. Severity is graded based on orifice area, pulmonary artery pressure, and NYHA functional
This document discusses fluid management in surgery. It begins by introducing the importance of fluid and electrolyte balance for maintaining homeostasis. Different types of fluids are indicated for various purposes like rapid resuscitation, total parenteral nutrition, and fluid maintenance. Common fluids discussed include normal saline, Ringer's lactate, plasmalyte, dextrose solutions, and dextrose saline. The document explains the composition, indications, advantages/limitations of each fluid. It also covers fluid distribution in the body, osmolality, tonicity, and the role of colloids in fluid balance.
fluids and blood transfusion therapy power point presentationAyushMahawar4
The document discusses intravenous fluid therapy, outlining the aims of fluid therapy in maintaining adequate hydration, blood volume, organ function, and electrolyte balance. It covers the types of intravenous fluids including crystalloids, colloids, their composition, properties, and indications. The document also discusses approaches to fluid management including estimating fluid requirements based on deficits and using goal-directed fluid therapy to target physiologic endpoints.
This article discusses the 'ROSE concept' of fluid management proposed by Malbrain et al. and its relevance for neuroanaesthesia and neurocritical care. The ROSE concept has four phases - resuscitation, optimisation, stabilisation, and evacuation. During the resuscitation phase, fluids are given aggressively to restore circulation. The optimisation phase aims for a neutral fluid balance to ensure tissue perfusion. Stabilisation focuses on maintaining neutral or negative balance. Finally, evacuation uses diuretics and albumin to achieve negative balance and 'de-resuscitation' in stable patients with fluid overload. The article concludes that while restriction of fluids is important to prevent increased intracranial pressure, neurosurgical
This document discusses PiCCO (Pulse induced Contour Cardiac Output), a system that uses transpulmonary thermodilution to measure hemodynamic parameters in critically ill patients. It provides indications for use including shock, sepsis, and organ failure. It defines cardiogenic shock and lists specific criteria. Contraindications include issues with vascular access and arrhythmias. Key parameters that can be measured include stroke volume, cardiac index, global end diastolic volume index, intrathoracic blood volume index, extravascular lung water index, and systemic vascular resistance index along with normal ranges.
This document provides an overview of colloids used for fluid resuscitation. It defines colloids and discusses their history, studies, scientists involved in research, and physiology. The document classifies and describes different types of colloids including albumin, dextran, and hydroxyethyl starches. It compares the differences between crystalloids and colloids, and concludes with a discussion of appropriate use and monitoring of colloid administration.
Resp failure talk 9 10 bipap and hfnc emphasisStevenP302
This document discusses respiratory failure and the use of high flow nasal cannula (HFNC) and bilevel positive airway pressure (BiPAP). It describes the three types of respiratory failure - inability to oxygenate, inability to ventilate, and inability to protect airway. HFNC provides high flow oxygen but no positive pressure, while BiPAP provides adjustable inspiratory and expiratory pressures for both oxygenation and ventilatory support. The document reviews indications, advantages, disadvantages, settings and monitoring for BiPAP use in treating respiratory failure.
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
Dr. Vijay Kumar discusses fluid management in the emergency department and intensive care unit. He covers the normal regulation of fluid balance, fluid imbalances that can occur in shock states, and indices used to assess successful fluid resuscitation. Both under-resuscitation and overzealous fluid administration can increase patient morbidity and mortality, so fluid therapy must be carefully titrated based on close monitoring of the patient's hemodynamic status and tissue perfusion.
Geriatric anesthesia physiological changes and preoperative preparationTushar Chokshi
This document provides an outline for a lecture on anesthesia implications for elderly patients. It discusses the normal age-related physiological changes in several body systems and how they impact anesthesia considerations. Some key points include:
- The cardiovascular system shows decreased cardiac output, increased blood pressure, and reduced beta receptor response with age. This increases risks of hypotension, arrhythmias, and heart failure during anesthesia.
- Respiratory function declines with stiffer lungs and weaker muscles. Elderly are more prone to aspiration, infection, and oxygen desaturation.
- Other organ systems like kidneys, liver and skin also experience changes that slow drug metabolism and clearance. This increases risks of toxicity.
- Thorough
Htk costodial clinical effect edited nice Peter Flash
The document discusses the clinical impact of histidine ketoglutarate tryptophan (HTK) cardioplegia solution on patients undergoing open heart surgery. It provides a brief history of cardioplegia development, describing early solutions using potassium and hypothermia for cardiac arrest. Modern solutions like HTK and Bretschneider solutions induce nondepolarized cardiac arrest through calcium influx inhibition and metabolic substrate provision. Hypothermia further reduces oxygen demand and improves protection when combined with cardioplegia solutions.
VBG vs ABG (replacement of venous blood sample instead of arterial one for an...Reza Aminnejad
This document discusses the use of venous blood gas measurements compared to arterial blood gas measurements. It finds that central venous blood gases most closely correlate with arterial measurements, while peripheral venous measurements vary more. Specifically, venous pH is typically 0.02-0.05 lower, PCO2 is typically 3-8 mmHg higher, and bicarbonate may be up to 2 mEq/L higher compared to arterial values. Venous measurements can be used for monitoring patients without arterial access, but arterial measurements are still preferred, especially for hypotensive patients. Periodic correlation of venous and arterial values is recommended when using venous measurements serially.
APRV (Airway Pressure Release Ventilation) is a ventilation mode that applies continuous positive airway pressure (CPAP) for a prolonged high-pressure phase (T high) to recruit and maintain lung volume. It then has a brief low-pressure release phase (T low) where most ventilation and CO2 removal occurs. Compared to conventional ventilation, APRV may cause less ventilator-induced lung injury due to maintaining higher end-expiratory lung volumes without repetitive opening/closing of alveoli. It also allows for spontaneous breathing which improves patient comfort and outcomes. While APRV does not reduce mortality, it can improve other outcomes such as shorter ventilation times and ICU stays.
This document discusses guidelines for extubation and managing risks associated with extubation. It begins by outlining criteria that must be met for safe extubation, such as adequate breathing and hemodynamics. It then describes methods for standard, awake, deep and difficult/high risk extubations. Risks of immediate extubation are outlined. The document provides detailed protocols for managing complications like laryngospasm and laryngeal edema to prevent reintubation. Prophylactic medications, strategies for difficult airways, and criteria for determining pre-extubation airway edema are discussed to ensure extubations are performed safely.
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMUShahnaali
Non-invasive ventilation (NIV) delivers mechanical ventilation without an endotracheal tube. It is used for acute or chronic respiratory failure. NIV uses interfaces like masks to deliver bilevel positive airway pressure (BiPAP). It has advantages over invasive ventilation like avoiding complications of intubation and allowing oral communication. Selection criteria, monitoring, interfaces, modes and settings are described. NIV is assessed for improvement in blood gases and symptoms. Weaning involves gradually decreasing pressure support. NIV may need to be changed to invasive ventilation if a patient deteriorates on NIV.
This document summarizes information about using sodium bicarbonate (NaHCO3) to treat acidosis. It discusses what bicarbonate is, how it works to neutralize acid in the blood, appropriate dosing, administration, safety issues, and contraindications. It specifically examines using bicarbonate to treat diabetic ketoacidosis (DKA) and lactic acidosis, noting that the evidence does not clearly support its routine use in DKA but it may be considered in severe cases with pH <6.9. For lactic acidosis, bicarbonate may help if pH is <7.1 but the evidence is limited and it could increase lactate levels and mortality. The
The document discusses arterial blood gas analysis and interpretation. It provides guidelines for deciding when to intubate based on clinical assessment rather than strict ABG value cutoffs. It also presents two scenarios to determine which case would warrant immediate ventilatory support. The key is that the decision to intubate should be based primarily on clinical factors, not just ABG values alone.
The document discusses ventilation and different modes of noninvasive ventilation. It provides details on:
1) How ventilation works through pressure differences that cause air to flow into and out of the lungs. Different factors like resistance and Boyle's law impact this process.
2) The history and development of noninvasive ventilation, from early negative pressure devices to current use of positive pressure ventilation delivered noninvasively through masks.
3) Modes of noninvasive positive pressure ventilation including volume ventilation, pressure ventilation, bilevel PAP, and CPAP. The benefits and limitations of noninvasive ventilation are also summarized.
Fluid balance and therapy in critically illAnand Tiwari
The document discusses various aspects of human body water content and distribution. It notes that water makes up 50-60% of total body weight, with 40% being intracellular fluid, 20% extracellular fluid, and 15% interstitial fluid. It also discusses fluid compartments, mechanisms of fluid movement, electrolyte concentrations, fluid requirements, types of intravenous fluids and their properties, and considerations in fluid resuscitation.
This document discusses the management of Acute Respiratory Distress Syndrome (ARDS). It begins with an overview of the pathophysiology of ARDS including pulmonary capillary leak, surfactant inactivation, and edema. It then discusses treatments such as positive end-expiratory pressure (PEEP), recruitment maneuvers, prone positioning, high frequency oscillatory ventilation, liquid ventilation, and medication administration. The document provides details on various ventilation strategies and technologies used in ARDS management.
1. Mitral stenosis is most commonly caused by rheumatic fever and results in thickening and calcification of the mitral valve, reducing the valve orifice area and obstructing blood flow from the left atrium to ventricle.
2. The pathophysiology involves elevated left atrial pressure, pulmonary hypertension, and reduced cardiac output. Symptoms range from easy fatigability to pulmonary edema.
3. Physical exam findings include an opening snap, rumbling diastolic murmur, and signs of right heart failure in severe cases. Severity is graded based on orifice area, pulmonary artery pressure, and NYHA functional
This document discusses fluid management in surgery. It begins by introducing the importance of fluid and electrolyte balance for maintaining homeostasis. Different types of fluids are indicated for various purposes like rapid resuscitation, total parenteral nutrition, and fluid maintenance. Common fluids discussed include normal saline, Ringer's lactate, plasmalyte, dextrose solutions, and dextrose saline. The document explains the composition, indications, advantages/limitations of each fluid. It also covers fluid distribution in the body, osmolality, tonicity, and the role of colloids in fluid balance.
fluids and blood transfusion therapy power point presentationAyushMahawar4
The document discusses intravenous fluid therapy, outlining the aims of fluid therapy in maintaining adequate hydration, blood volume, organ function, and electrolyte balance. It covers the types of intravenous fluids including crystalloids, colloids, their composition, properties, and indications. The document also discusses approaches to fluid management including estimating fluid requirements based on deficits and using goal-directed fluid therapy to target physiologic endpoints.
The document summarizes key concepts about fluid and electrolyte balance. It discusses how the body maintains strict control over water and electrolyte distribution through complex interplay of cellular membranes, organ functions, and hormones. It describes fluid compartments and electrolytes like sodium, potassium, and calcium. It covers abnormalities in fluid and electrolyte balance like hypernatremia, hyponatremia, hyperkalemia, hypokalemia, hypercalcemia, and hypocalcemia. It discusses evaluation and treatment approaches for restoring normal balance.
WATER AND ELECTROLYTE IMBALANCE Brief presentationRajkanth
- Water makes up 50-60% of body weight and is divided between intracellular and extracellular fluid compartments. Sodium, chloride, and bicarbonate ions are major extracellular particles while potassium and phosphates are major intracellular particles.
- Blood contains both extracellular plasma and intracellular red blood cell fluid. Hematocrit measures the fraction of blood composed of red blood cells.
- The distribution of fluid between intracellular and extracellular compartments is determined by osmotic effects of ions like sodium and chloride across the semipermeable cell membrane. This maintains isotonicity between compartments.
Fluid and electrolyte balance in oral surgeryPunam Nagargoje
• ELECTROLYTE BALANCE
• Def: - concentration of individual electrolytes in the body fluid compartments is normal and remains relatively constant.
• Electrolytes are dissolved in body fluids
• Sodium predominant extracellular cation, and chloride is predominant extracellular anion. Bicarbonate also in extracellular spaces
• Electrolyte balance
• Na + (Sodium)
– 90 % of total ECF cations
– 136 -145 mEq / L
– Pairs with Cl- , HCO3- to neutralize charge
– Low in ICF
– Most important ion in regulating water balance
– Important in nerve and muscle function
• Electrolyte imbalances: Sodium
• Hypernatremia (high levels of sodium)
– Plasma Na+ > 145 mEq / L
– Due to ↑ Na + or ↓ water
– Water moves from ICF → ECF
– Cells dehydrate
• HYPERATREMIA
• Hypernatremia Due to:
– Hypertonic IV soln.
– Oversecretion of aldosterone
– Loss of pure water
• Long term sweating with chronic fever
• Respiratory infection → water vapor loss
• Diabetes – polyuria
– Insufficient intake of water .
• Clinical manifestations
of Hypernatremia
• Thirst
• Lethargy
• Neurological dysfunction due to dehydration of brain cells
• Decreased vascular volume
• TREATMENT OF HYPERNATREMIA:
• Lower serum Na+
– Isotonic salt-free IV fluid [5% dextrose]
– Oral solutions preferable
• Hyponatremia
• Overall decrease in Na+ in ECF
• Two types: depletional and dilutional
• Depletional Hyponatremia
Na+ loss:
– diuretics, chronic vomiting
– Chronic diarrhea
– Decreased aldosterone
– Decreased Na+ intake
• Clinical manifestations of Hyponatremia
• Neurological symptoms
– Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma
• Muscle symptoms
– Cramps, weakness, fatigue
• Gastrointestinal symptoms
– Nausea, vomiting, abdominal cramps, and diarrhea
• Tx – limit water intake or
• discontinue medicines such as diuretics
• TREATMENT OF HYPONATREMIA
• Hyponatremia which develops quickly should be treated quickly & vice-versa
• Patients with severe hypoNa (<115) are at risk of neurological damage
• Too rapid correction causes CENTRAL PONTINE MYELINOLYSIS.
• Targeted rate of correction: 0.5-1.0 mEq/L/hour
• Raise plasma Na by <10-12 mEq/L on first day
• Correction @ rate >25mEq/L places at high risk for central pontine myelinolysis
• Hypokalemia
• Normal serum k+ conc is 3.5 to 5.0 mEq/l
• Serum K+ < 3.5 mEq /L
• Beware if diabetic
– Insulin gets K+ into cell
– Ketoacidosis – H+ replaces K+, which is lost in urine
• β – adrenergic drugs or epinephrine
• Causes of Hypokalemia
• Decreased intake of K+
• Increased K+ loss
– Chronic diuretics
– Acid/base imbalance
– Trauma and stress
– Increased aldosterone
– Redistribution between ICF and ECF
• Treatment of hypokalamia
• Metabolic acidosis increases serum K+ levels & vice versa
• Post-op patients on fluid therapy should receive approx 60mEq/day to prevent hypokalemia
• 1mEq/L fall in serum K+= 200-400 mEq total body K+ deficit
• Failure to ↑ Sr. K+ even after sufficient correction should
This document provides an overview of fluids and electrolytes in surgical patients. It discusses body water volumes, osmotic pressure, signs and symptoms of volume disturbances, and various electrolyte abnormalities including hypernatremia, hyponatremia, hyperkalemia, and hypokalemia. Common causes and clinical manifestations of each electrolyte imbalance are presented. The document also reviews intravenous fluid types, including crystalloids like lactated Ringer's solution and normal saline, as well as colloid solutions. Fluid and electrolyte requirements in surgical patients are discussed. References utilized include Schwartz's Principles of Surgery and Sabiston Textbook of Surgery.
Human excretory system for Nurses Class 2.pptxJacobKurian22
The document discusses fluid and electrolyte balance in the human body. It covers topics such as fluid compartments, electrolyte distribution, mechanisms of fluid movement, assessment of fluid status, causes of fluid and electrolyte imbalances, and management of volume deficits and excesses. Specifically, it provides details on:
- The normal distribution of total body water and fluid compartments in a 70kg male.
- How the kidneys and hormones regulate fluid volume and balance sodium levels.
- Common intravenous fluid types used in treatment, including crystalloids and colloids.
- Clinical signs of moderate and severe volume deficits and how to evaluate chronic vs acute deficits.
- Causes of fluid losses or gains in surgical
Crystalloid solutions are aqueous solutions of low-molecular-weight ions (salts) with or without glucose. They are used to provide maintenance of water, electrolytes, and intravascular fluid volume. Common crystalloid solutions include normal saline (0.9% NaCl), Ringer's lactate, dextrose 5% in water, and dextrose normal saline. Each solution has different properties and indications/contraindications depending on its electrolyte content and osmolarity. Crystalloids are distributed between intravascular and extracellular fluid spaces after administration and have a more transient hemodynamic effect than colloid solutions.
Crystalloids are electrolyte solutions that can freely diffuse throughout the extracellular space. The principal crystalloid is isotonic saline (0.9% NaCl), which expands the interstitial space rather than plasma volume. Ringer's lactate is also commonly used as it more closely matches plasma composition. Dextrose 5% in water (D5W) is hypotonic and expands both intra and extracellular spaces, providing calories but not electrolytes. Each crystalloid has different indications and disadvantages to consider when selecting the appropriate fluid for treatment.
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2. INTRODUCTION
• In 1861 Thomas Graham’s investigated and classified substances as crystalloids and
colloids depending on their ability to diffuse through a parchment membrane.
Intravenous fluids are similarly classified based on their ability to pass through capillary
walls that separate the intravascular and interstitial fluid compartments
• Crystalloid fluids are electrolyte solutions with small molecules that can diffuse freely
from intravascular to interstitial fluid compartments
• Colloid fluid is a saline solution with large solute molecules that do not pass readily
from plasma to interstitial fluid. The retained molecules in a colloid fluid create an
osmotic force called the colloid osmotic pressure or oncotic pressure that holds water in
the vascular compartment
3. COMPOSITION OF BODY FLUIDS
• Water is the most abundant constituent in the body, comprising approximately
50% of body weight in women and 60% in men
• 55–75% is intracellular [ICF] and 25–45% is extracellular [ECF]
• The ECF is further subdivided into intravascular (plasma water) and extravascular
(interstitial) spaces in a ratio of 1:3
• Fluid movement between the intravascular and interstitial spaces occurs across the
capillary wall and is determined by Starling forces, i.e., capillary hydraulic
pressure and colloid osmotic pressure
4. • Principal component of extracellular
fluid is Sodium responsible for
much of extracellular fluid
osmolality
• Principal component of intracellular
fluid is Potassium key role in the
maintenance of transmembrane
potentials
5. The aims of IV fluid administration should be to
• Avoid dehydration
• Maintain an effective circulating volume
• Prevent inadequate tissue perfusion during a period when the patient is unable to
achieve
These goals through normal oral fluid intake
“Intravenous fluids have a range of physiologic effects and should be considered to
be drugs with indications, dose ranges, cautions, and side effects.”
6.
7. CLASSIFICATION
I V Fluids
Blood and Products Non blood I V Fluids
Crystalloids
•Glucose Containing
•Electrolyte
solutions
•Mixed
Colloids
Proteinous Non proteinous
Gelatins
• Haemaccel
• Gelofusin
Albumin
20% & 5%
Starch Dextrans
HES
PentaStarch
Tetrastarch
9. CRYSTALLOIDS
Crystalloid are electrolyte solutions with small molecules that can diffuse freely
intravascular to interstitial fluid compartments
from
• The principal component of crystalloid fluids is sodium chloride. Sodium is the
principal determinant of extracellular volume, and is distributed uniformly in the
extracellular fluid
• Because the plasma volume is only 25% of the interstitial fluid volume only 25% of an
infused crystalloid fluid will expand the plasma volume, while 75% of the infused
volume will expand the interstitial fluid.
• Thus, the predominant effect is only 25% of transfused crystalloids remains in the
intravascular space and 75% diffuses into interstitial space
10. General characteristics of Crystalloid
• Contains water and electrolytes
• Non ionic solutions expands
extracellular space
all the compartments i.e intracellular and
• Sodium cannot gain access into the intracellular space. Hence all sodium will
remain in the extracellular space thus expanding it
11. The effects of selected colloid and crystalloid fluids on the plasma volume and
interstitial fluid volume
13. NORMAL SALINE
• One of the most commonly administered crystalloids
• Using in vitro red cell lysis experiments, Hamburger ascertained that 0.9% was
the NaCl concentration that was isotonic with human plasma. It was not initially
developed with the aim of in vivo administration, yet has entered widespread
clinical use despite having a Na+ and Cl− concentration far in excess of that of
plasma
• 0.9% saline also known as normal saline, physiological saline, isotonic saline - but
none of these names are appropriate as chemically it is not normal because the
concentration of a one-normal (1 N) NaCL solution is 58 grams per liter (the
combined molecular weights of sodium and chloride), while 0.9% NaCL contains
only 9 grams of NaCL per liter
14. • Composition
Na-154 meq/l
Cl- 154 meq/l
pH- 5.7
hence it affects the acid base balance of the body
• Pharmacological basis
1. Provide major extracellular electrolytes.
2. Corrects both water and electrolyte deficit.
3. Increase the intravascular volume substantially.
15. Volume effects of NS
• Infusion of one liter of 0.9% NaCL adds 275 mL to the plasma volume and 825 mL to
the interstitial volume
• one unexpected finding; i.e., the total increase in extracellular volume (1,100 mL) is
slightly greater than the infused volume. This is the result of a fluid shift from the
intracellular to extracellular fluid, which occurs because 0.9% NaCL is slightly
hypertonic in relation to Extracellular fluid
Acid-Base Effect
• Large-volume infusions of 0.9% NaCL produce a metabolic acidosis
• The saline-induced metabolic acidosis is a hyperchloremic acidosis, and is caused by
the high concentration of chloride in 0.9% saline relative to plasma (154 versus 103
mEq/L)
16. Interstitial edema
Promote interstitial edem more than other crystalloid fluids with a lower sodium
content (e.g., Ringer’s lactate, Plasma-Lyte) through
1. Increased sodium load from 0.9% NaCL, which increases the “tonicity” of
the interstitial fluid
2. Sodium retention by suppressing the renin-angiotensin-aldosterone axis
3. Decreases in renal perfusion have also been observed after infusion of 0.9%
NaCL,presumably as aresult of chloride-mediated renal vasoconstriction.
17. STRONG ION DIFFERENCE (SID)
• It is the difference between strongest cation and strongest anion in a particular
compartment.
• Electrical neutrality needs cation = anions
Strong ion difference + [H+] – [OH-] = 0
• Since hydroxyl ion is negligible ,
Strong ion difference + [H+] = 0
• normal SID = Na – Cl
= 140 – 103
= 40 meq/ litre
18. • Strong ion difference + [H+] = 0
• therefore, if SID increases , [H+] decreases to maintain electrical neutrality.
• In 0.9% NaCl , SID=0
• Hence [H+] increases = pH decreases = acidosis.
• The SID of intravenous fluids determines their ability to influence the pH of
plasma. The SID of 0.9% NaCL is zero (Na – CL = 154 – 154 = 0) , so infusions
of 0.9% NaCL will reduce the SID of plasma and thereby reduce the plasma pH.
The SID of Ringer’s lactate fluid is 28 mEq/L (Na + K + Ca – CL= 130 + 4 + 3 –
109 = 28) if all the infused lactate is metabolized
19. Indications
• To maintain effective blood volume and blood pressure in emergencies
• Water and salt depletion – diarrhoea, vomiting, excessive diuresis or excessive perspiration
• Hypovolemic shock- distributed in extracellular space expanding the intravascular volume.
Ideal fluid to increase blood pressure.
• Preferred in case of brain injury, hypochloraemic metabolic alkalosis , hyponatraemia
• Initial fluid therapy in DKA
• In patients with hyperkalemia like renal failure
• Hypercalcaemia
• Fluid challenge in prerenalARF
• Irrigation for washing of body fluids
• Vehicle for certain drugs
20. Limitations/ Contraindications
• Avoid in Hypertension, Preeclamsia and in patient with edema due to CCF, renal
failure and cirrhosis
• In dehydration with severe hypokalaemia – deficit of intracellular potassium –
infusion of NS without additional K+ supplementation can aggravate electrolyte
imbalance
• Large volumes or too rapid administration can cause sodium accumulation and
pulmonary edema.
• Increased chloride content in relation to plasma can cause hyperchloremic
metabolic acidosis in large volume administration
21. RINGER'S FLUIDS
• In 1880, Sydney Ringer , a British physician studied the contraction of isolated
frog heart
• He introduced a solution that contained calcium and potassium in sodium chloride
solution to promote cardiac contraction and cell viability. This is known as
Ringer`s injection
• In early 1930, an American pediatrician named Alex Hartmann added sodium
lactate to Ringer`s solution as a buffer to metabolic acidosis
• This is known as Hartmann`s solution or Ringer`s lactate
23. Advantage :
• Lack of significant effect on acid base balance
Disadvantage:
• Presence of ionized calcium in ringer’s lactate can binds to citrated anticoagulant in
stored blood and promote formation of clots. (clot formation does not occur if the
volume of Ringer’s solution does not exceed 50% of the volume of packed RBCs)
• In critically ill patients with impaired lactate clearance due to circulatory shock or
hepatic insufficiency, Ringer’s lactate infusion can increase serum lactate levels
24. Pharmacological basis
• Ringer`s lactate is the most physiological fluid as the electrolyte content is similar
to that of plasma . Larger volumes can be infused without the risk of electrolyte
imbalance
• Due to high Na ( 130mEq/L) content RL rapidly expands intravascular volume
effective in treatment of hypovolemia
• Sodium lactate in RL is metabolized to bicarbonate in the liver -- useful in
correction of metabolic acidosis
25. Indications :
• Correction in severe hypovolaemia
• Replacing fluid in post operative patients, burns , fractures.
• Diarrhoea induced hypokalemic metabolic acidosis and hypovolemia.
• Fluid of choice in diarrhoea induced dehydration in paediatric patients.
• In DKA , provides glucose free water, correct metabolic acidosis and supplies
potassium
• Maintainance fluid during surgery
26. Contraindications
• Severe liver disease, severe hypoxia , shock – impaired lactate metabolism –lactic
acidosis.
• Severe CHF - lactic acidosis takes place.
• Addison’s disease
• In vomiting or continuous nasogastric aspiration, hypovolemia is associated with
metabolic alkalosis - as RL provides HCO3- Worsens alkalosis.
• Simultaneous infusion of RL and blood- inactivation of anticoagulant by binding
with calcium in RL – clots in donor blood.
• Certain drugs – amphotericin, thiopental, ampicillin, doxycycline should not be
mixed with RL – calcium binds with these drugs and reduces bioavailability and
efficiency
27. DEXTROSE SOLUTIONS
• D5 water (5%D)
• Dextrose with 0.9% NS ( DNS ).
• Dextrose with 0.45% NS (D 1/2NS )
• 10% dextrose
• 25% dextrose
EFFECT OF DEXTROSE IN FLUID :
Protein sparing effects
Volume effect
Lactate production.
Effect of hyperglycemia
28. Protein sparing effect
• Earlier it was used to provide calories in patients who were unable to eat
• 50 grams of dextrose per liter provides 170 kcal
• Infusion of 3 liters of a D5 solution daily (125 mL/min) provides 3 x 170 = 510
kcal/day, which is enough nonprotein calories to limit the breakdown of
endogenous proteins to provide calories (i.e., protein-sparing effect)
• It is no longer used frequently as most patients with long-term Nil by mouth have
enteral tube feedings or TPN
29. Volume Effects
5%D
• 50 g of dextrose adds 278 mOsm/L to IV fluids
• For a 5% dextrose the added dextrose brings the osmolality close to that of plasma.
However, dextrose is taken up by cells and metabolized, this osmolality effect rapidly
wanes, and the added water then moves into cells.
• The infusion of one liter of 5D results in an increase in ECF (plasma plus interstitial
fluid) of about 350 mL, which means the remaining 650 ml (two-thirds of the infused
volume) has moved intracellularly. Therefore, the predominant effect of D5W is cellular
swelling.
DNS
• Total osmolality of DNS fluid is 560 mOsm/L (278 of dextrose and 308 0f 0.9 NaCl)
which is almost twice the normal osmolality of the extracellular fluid. If glucose
utilization is impaired (as is common in critically ill patients), large-volume infusions
of D5W can result in cellular dehydration
30. Enhanced lactate production
• In healthy individuals 5% of infused glucose is directed towards lactate formation.
• In critically ill patients 85% of glucose is diverted to lactate production.
• when circulatory flow is compromised, infusion of 5% dextrose solutions can result in lactic
acid production and significant elevations of serum lactate
Hyperglycemia
It has several deleterious effects in critically ill patients including –
• immune suppression .
• increased risk of infection .
• aggravation of ischemic brain injury
Considering the high risk of hyperglycemia in ICU patients, and the numerous adverse
consequences of hyperglycemia, infusion of dextrose containing fluids should be avoided
whenever possible.
31. 5 % DEXTROSE
Composition : Glucose 50 gms/L + free water
Pharmacological Basis
•Corrects DehydrationAnd Supplies Energy ( 70kcal/L)
•Administered safely at the rate of 0.5gm/kg/hr without causing glycosuria
Metabolism
Dextrose is metabolised leaving free water distributed in all compartments of the
body.
Aproportion of dextrose load contributes to lactate formation –
5% in healthy subjects
85% in critically ill patients ----hence not the preferred fluid.
32. Indications of 5%D
• Prevention and treatment of intracellular dehydration
• Cheapest fluid to provide adequate calories to body
• For pre and post operative fluid management
• IV administration of various drugs
• Treatment and Prevention of ketosis in starvation, vomiting, diarrhoea
• Adequate glucose infusion protects liver against toxic substances.
• Correction of hypernatraemia due to pure water loss ( Diabetes insipidus)
33. Limitations of 5D
1. Neurosurgical procedures - can aggravate Cerebral oedema and increase ICT
2. Acute ischaemic stroke-
• hyperglycemia aggravates cerebral ischaemic brain damage.
• Dextrose metabolism aggravates tissue acidosis in ischaemic areas- anerobic oxidation
of glucose produces more lactic acid and free radicals
3. Hypovolemic shock
• Poor expansion of intracellular volume.
• Faster rate of infusion causes osmotic diuresis worsens shock and false impression
of the hydration status reduced fluid replacement.
4. Hyponatremia & water intoxication - 5%D worsens both conditions
34. Limitations of 5D
5. Hypernatremia – fast infusion of 5D rapidly corrects hypernatremia but correction
occurs slowly in brain cells, so swelling of brain cells can lead to permanent
neurological damage. Moreover rapid infusion of 5D induces osmotic diuresis
which aggravates hypernatremia
6. Can cause Hypokalemia, hypomagnesemia and hypophosphatemia
7. Blood and dextrose solutions should not be administered in same IV line –
haemolysis , clumping seen due to hypotonicity of the solution.
8. Uncontrolled DM , severe hyperglycemia
35. DEXTROSE SALINE (DNS)
Composition
Na- 154 mEq/L
CI- 154mEq/L
Glucose- 50 gm/L
Pharmacological basis
• supply major extracellular electrolytes, energy and fluid to correct dehydration
• In presence of incompletely or partially corrected shock patient will have increased
urine output (due to diuresis)
• Unlike 5D, DNS is not hypotonic (due to Nacl) and hence it is compatible with blood
transfusion
36. Indications
• Conditions with salt depletion and hypovolaemia - not the ideal fluid though.
Faster rate of infusion causes osmotic diuresis worsens shock and false
impression of the hydration status reduced fluid replacement
• Correction of vomiting or nasogastric aspiration induced alkalosis and
hypochloremia along with supply of calories
Limitations
• Anasarca – cardiac, hepatic or renal cause
• Severe hypovolemic shock – rapid correction is needed. Faster infusion can cause
osmotic diuresis and worsen the condition
37. DEXTROSE WITH HALF STRENGTH SALINE
•Composition : 5% dextrose with 0.45% NS NaCl – 77 meq/L each, glucose 50 gm/L
• Contains 50% salt as compared to DNS /NS and used when there is need for calories ,
more water and less salt.
•Indications
1. Fluid therapy in paediatric – In paediatric group ratio of requirement of water : NaCl
is double as compared to adults
2. Treatment of severe hypernatremia – It corrects hypernatremia gently, it avoids
cerebral edema
3. Maintenance fluid therapy and in early post operative period.
•Limitations
1. Hyponatremia
2. Severe dehydration where larger salt replacement is needed
38. 10% DEXTROSE & 25% DEXTROSE
Composition
1 liter of 10%D has 100 gms glucose
1 liter of 25%D has 250 gms glucose
Pharmacological basis:
• It is hypertonic crystalloid fluid
• Supplies energy and prevents catabolism useful when faster replacement of glucose is
needed like in Hypoglycemic coma
• In patients with fluid restriction- CCF, Cirrhosis and Renal failure
39. Indications
• Rapid correction of hypoglycaemia .
• In liver disease, if given as first drip, it inhibits glycogenolysis and gluconeogenesis
• Nutrition to patients on maintainance fluid therapy.
• Treatment of hyperkalemia with Insulin
Limitations
• In patients with dehydration , anuria , intracranial hemorrhage
tremens
• Avoided in patients with diabetes unless there is hypoglycemia.
• Rapid infusion of 25D can cause glycosuria . Hence in
hypoglycemia it should be infused slowly over 45 - 60 min
and in delirium
the absence of
41. MANNITOL
• Mannitol is an osmotic diuretic that is metabolically inert in humans
• Mannitol elevates blood plasma osmolality, resulting in enhanced flow of
water from tissues, including the brain and cerebrospinal fluid, into interstitial
fluid and plasma
• As a result cerebral edema, elevated intracranial pressure, and cerebrospinal
fluid volume and pressure may be reduced
• Benificial effects are due to the reduction in blood viscosity
• Complications associated are
• Rebound edema
• Dehydration due to osmotic diuresis
• Renal failure
42. Limitations
• Anuria due to severe renal disease
• Cannot be used in patients with hypotension
• Severe pulmonary congestion or frank pulmonary edema
• Active intracranial bleeding except during craniotomy
• Severe dehydration
• Progressive renal damage or dysfunction after institution of mannitol therapy,
including increasing oliguria and azotemia
44. PHARMACOLOGICALPROPERTIES
The hypertonic nature of these solutions draws water out of the intracellular
compartment into the extracellular compartment
USES
•Plasma volume expansion: The hypertonic nature of these solutions draws water
out of the intracellular compartment and into the extracellular (including plasma)
volume and may therefore achieve plasma volume expansion while minimizing the
volume of fluid administered. However, clinical trials have not shown any benefits.
• Correction of hypo osmolar hyponatremia
• Treatment of raised ICT - superior to mannitol
• 7.5% - endothelial injury used as sclerosant
46. INDICATIONS AND LIMITATIONS
Isolyte G :
Vomiting / NGT induced hypochloremic , hypokalemic metabolic alkalosis.
NH4 gets converted to H+ and urea in the liver.
Treatment of metabolic alkalosis.
Limitations : hepatic failure , renal failure , metabolic acidosis
ISOLYTE M:
Richest source of potassium (35mEq)
correction of hypokalaemia.
LIMITATIONS : Renal failure ,burns, adrenocortical insufficiency.
47. ISOLYTE P:
Maintenance fluid for children.
Excessive water loss or inability to concentrate urine .
LIMITATIONS : hyponatremia , renal failure.
ISOLYTE E:
Extracellular replacement fluid, additional potassium and acetate.
Corrects Mg deficiency.
Treatment of diarrhoea and metabolic acidosis.
LIMITATIONS : metabolic alkalosis.
48. PLASMA-LYTE
• Ionic concentration of 1 litre Na+- 140 mEq ,K+- 5 mEq ,Mg2+ - 3 mEq, Cl- --98 mEq ,
27 mEq acetate, and 23 mEq gluconate with a pH of 7.4.
• The caloric content is 21 kcal/L.
• Each 100 mL contains - 526 mg of NaCl; 502 mg of Sodium Gluconate; 368 mg of Sodium
Acetate Trihydrate; 37 mg of KCl and 30 mg of Magnesium Chloride.
• Osmolarity 295 mOsmol/L .
• Acetate and gluconate ions are metabolized ultimately to carbon dioxide and water, which
requires the consumption of hydrogen cations alkalinizing effect.
• Caution : in patients with hyperkalemia, severe renal failure, and in conditions in which
potassium retention is present.
51. COLLOIDS
• The term colloid is derived from Greek word “Glue”.
• These solutions are also called suspensions
• Colloid fluid is a saline fluid with large solute molecules that do not readily pass
from plasma to interstitial fluid.
• Colloids have large molecular weight >30000 Daltons that largely remain in
intravascular compartment.
• The retained molecules create an osmotic force called colloidal osmotic pressure
or oncotic pressure.
• In normal plasma the plasma proteins are the major colloids present
52. General characteristics of colloids
This characteristic determines their behaviour in the intravascular compartment
1. Molecular weight.
2. Colloid molecular size- monodisperse and polydisperse
3. Plasma volume expansion- determined by the molecular weight.
4. Osmolality.
5. Colloid osmotic pressure – determines the volume of expansion.
6. Plasma Half Life- depends on the molecular weight and the route of
elimination.
7. Electrolyte content – Na content.
8. Acid base composition – albumin and gelatin have physiologic pH, others are
acidic
53. Capillary fluid Exchange
• The direction and rate of fluid exchange (Q) between capillary blood and interstitial
fluid is determined, in part, by the balance between the hydrostatic pressure in the
capillaries (Pc), which promotes the movement of fluid out of capillaries, and the colloid
osmotic pressure of plasma (COP), which favors the movement of fluid into capillaries.
Q ≈ PC – COP
• Normal Pc averages about 20 mm Hg (30 mm Hg at the arterial end of the capillaries
and 10 mm Hg at the venous end of the capillaries); the normal COP of plasma is about
28 mm Hg, so the net forces normally favor the movement of fluid into capillaries
(which preserves the plasma volume)
• About 80% of the plasma COP is due to the albumin fraction of plasma proteins
54. Resuscitation Fluids
• Crystalloid fluids reduce the plasma COP (dilutional effect), which favors the
movement of these fluids out of the bloodstream
• Colloid fluids can preserve the normal COP (iso-oncotic fluids), which holds these
fluids in the bloodstream, or they can increase the plasma COP (hyperoncotic
colloid fluids), which pulls interstitial fluid into the bloodstream
55. CHARACTERISTICS OF I.V. COLLOIDS FLUIDS PER 100ML INFUSION
Colloid fluid is about 3 times more effective in expanding the plasma volume than
the crystalloid fluid
FLUID TYPE ONCOTIC PRESSURE
(mmHg)
PLASMA VOLUME
EXPANSION
DURATION OF
EFFECT
5% Albumin 20 70-130 ml 12 h
25% albumin 70 400-500 ml 12 h
10% Dextran-40 40 100-150 ml 6 h
6% Dextran -70 80 ml 12 h
6% Hetastarch 30 100-130 ml 24 h
10% Pentastarch 150 ml 8 h
57. ALBUMIN
• Albumin is a versatile plasma protein synthesized only in the liver and has a half-life of
approximately 20 days.
• Principal determinant of plasma colloid osmotic pressure COP ( 75% of the oncotic
pressure), principal transport protein in blood, has significant antioxidant activity, and
helps maintain the fluidity of blood by inhibiting platelet aggregation
• 5% albumin ( 50gm/L or 5gm /dl) has COP of 20 mmHg (similar to plasma) & expands
plasma volume to same as volume infused
• 25% albumin ( 250gm/L or 25gm /dl) has COP of 70 mmHg & expands plasma volume
by 4 to 5 times the infused volume
In adults – Initial Infusion Of 25 gm
1 To 2 ml/min – 5%Albumin
1 ml/min - 25%Albumin
58. Indications:
• Emergency treatment of shock specially due to the loss of plasma.
• Acute management of burns
• Fluid resuscitation in intensive care
• Clinical situations of hypo-albuminemia
I. Following paracentesis.
Ii. Patients with liver cirrhosis.
Iii.After liver transplantation.
• Spontaneous bacterial peritonitis
• Acute lung injury
• Correction of diuretic resistant nephrotic syndrome
• In therapeutic plasmapheresis, albumin is used as an exchnage fluid to replace
removed plasma
59. Precautions and contraindications
• Because it does not replace lost volume, but instead shifts fluid from one
compartment to another, 25% albumin should not be used for volume resuscitation
in patients with blood loss
• 5% albumin is safe to use as a resuscitation fluid, except possibly in traumatic
head injury
• Hyperoncotic (25%) albumin has been associated with an increased risk of renal
injury and death in patients with circulatory shock
• Fast infusion will rapidly increase circulatory volume with resultant vascular
overload and pulmonary oedema
• Contraindicated in severs anaemia and cardiac failure
• Dehydrated patient may require additional fluids along with albumin
• Should not be used as parenteral nutrition
60. Disadvantages
1. Cost effectiveness:Albumin is expensive as compared to synthetic colloids
2.Volume overload: In septic shock the release of inflammatory mediators has been
implicated in increasing the ‘leakiness’ of the vascular endothelium. The
administration of exogenous albumin may compound the problem by adding to the
interstitial edema.
61. GELATIN POLYMERS( HAEMACCEL)
• Gelatin is a large molecular weight protein formed from hydrolysis of bovine
collagen.
• Gelatin solutions were first used as colloids in man in 1915.
• The MW ranges from 5,000 to 50,000 with a weight average MW of 35,000.
3 types of gelatin solutions-
• Succinylated or modified fluid gelatins (e.g.,Gelofusine, Plasmagel, Plasmion)
• Urea-crosslinked gelatins (e.g., Polygeline)
• Oxypolygelatins (e.g., Gelifundol)
62. Physiochemical properties:
• Both succinylated gelatin and polygeline are supplied as preservative-free, sterile solutions
in sodium chloride.
• Polygeline is supplied as a 3.5% solution
• electrolytes (Na+ 145, K+ 5.1, Ca++ 6.25 & Cl- 145mmol/l) .
Metabolism:
• It is rapidly excreted by the kidney.
• Peak plasma concentration falls by half in 2.5 hours.
• duration of action is shorter in comparison to both albumin and starches
Indications :
• Rapid Plasma Volume Expansion In Hypovolemia
• Volume Pre Loading In RegionalAnaesthesia
• Priming Of Heart Lung Machines
63. Advantages:
• Cost effective: It is cheaper as compared to albumin and other synthetic colloids.
• No limit of infusion: Gelatins do not have any upper limit of volume that can be
infused as compared to both starches and dextrans.
• Less effect of renal impairment: Gelatins are readily excreted by glomerular
filtration as they are small sized molecules.
Disadvantages:
• Anaphylactoid reactions: Gelatins are associated with higher incidence of
anaphylactoid reactions as compared to natural colloid albumin.
64. HYDROXYETHYL STARCH
• Hydroxyethyl starch (HES) is a chemically modified polysaccharide composed of
long chains of branched glucose polymers substituted periodically by hydroxyl
radicals (OH), which resist enzymatic degradation
• HES elimination involves hydrolysis by amylase enzymes in the bloodstream,
which cleave the parent molecule until it is small enough to be cleared by the
kidneys
• HES are derivatives of amylopectin, which is a highly branched compound of
starch
65. Physiochemical Properties
1.Concentration: low (6%) or high (10%).
Concentration mainly influences the initial volume effect:
• 6% HES solutions are iso-oncotic
• 10% solutions are hyperoncotic
2. Average Molecular Weight (MW):
• low (70 kDa),
• medium ( 200 kDa)
• high ( 450 - 480 kDa)
66. 3. Molar substitution (MS)
• low (0.45-0.58) or high (0.62-0.70)
• The degree of substitution refers to the modification of the original substance by the
addition hydroxyl radical
•
• The higher the degree of molar substitution --- the greater the resistance to degradation
and longer half life of colloid
• MS is thus the average number of hydroxyethyl residues per glucose subunit
• Names are applied to describe other levels of substitution: hetastarch
hexastarch (MS 0.6), pentastarch (MS 0.5), and tetrastarch (MS 0.4)
(0.7),
67.
68. Indications
a) Stabilization of systemic haemodynamics
b) Anti-inflammatory properties: HES has been shown to preserve intestinal
microvascular perfusion in endotoxaemia due to their anti-inflammatory properties
Advantages
1.Cost effectiveness: HES is less expensive as compared to albumin and is associated
with a comparable volume of expansion.
2.Maximum allowable volume: Maximum volume which can be transfused of medium
weight HES (130 kDa) with medium degree of substitution (0.4)
is greater as compared to other synthetic colloids like dextrans.
3.The estimated incidence of anaphylactic reactions is less compared to other colloids.
69. Disadvantages
• Increase in Serum amylase concentration during and 3-5 days after discontinuation
• Affects coagulation by prolonging PTT, PT and bleeding time by lowering
fibrinogen , decrease platelet aggregation , VWF , factor VIII
• HES products with medium to high MW are associated with oliguria, increased
creatinine, and acute kidney injury in critically ill patients with preexisting renal
impairment
• Occumulates in reticuloendothelial system and causes pruritis
70. DEXTRAN
• Dextrans are highly branched polysaccharide molecules which are
available for use as an artificial colloid
• These glucose polymers are produced by bacterium (leuconostoc
mesenteroides) incubated in sucrose medium by bacterial dextran
sucrase
Physicochemical properties
• Two dextran solutions are now most widely used,
6% solution with an average molecular weight of 70,000 (dextran 70)
10% solution with an average weight of 40,000 (dextran 40, low-
molecular-weight dextran).
71. Pharmacological basis
• Effectively expand intravascular volume -- dextran 40 produces greater plasma
expansion than dextran-70 but short duration( 6hrs) and rapid renal excretion
• Anti thrombotic effect - inhibits platelet aggregation
• Improves micro circulatory independently of volume expansion by by decreasing
the viscosity of blood by haemodilution and by inhibiting erythrocytic
aggregation
Metabolism & Excretion
• Kidneys primarily excrete dextran solutions
• Smaller molecules (14000-18000 kda) are excreted in 15minutes whereas larger
molecules stay in circulation for several days
• Up to 40% of dextran-40 and 70% of dextran-70 remain in circulation at 12 hrs.
72. Degree of volume expansion
• Both dextran preparations have a colloid osmotic pressure of 40 mm Hg, and
cause a greater increase in plasma volume than either 5% albumin or 6%
hetastarch. Dextran-70 may be preferred because the duration of action (12 hours)
is longer than that of dextran-40
•
Indications
• Improves microcirculatory flow in microsurgical re-implantations alsoand used for
DVT prophylaxis
• Extracorporeal circulation: It has been used in extracorporeal circulation during
cardio-pulmonary bypass
• Correction of hypovolemia – from burns, surgery, trauma. There is 100- 150%
increase in intravascular volume.
73. Contraindications
• Severe oligo-anuria and renal failure
• Severe CHF
• Bleedind disorders- Thrombocytopenia, hypofibrinogenemia…
• Severe dehydration
• Known hypersensitivity to dextran
Precautions
• Administered with caution in CLD, Impaired renal function ( osmotically mediated
renal injury), active haemorrhage
• Correct dehydration before or during dextran infusion to preventARF
• Dextrans coat the surface of red blood cells and can interfere with the ability to cross-
match blood
• Anticoagulant effect of heparin is enhanced
• Dextrans produce a dose-related bleeding tendency-- impaired platelet aggregation,
decreased levels of Factor VIII and von Willebrand factor, and enhanced fibrinolysis.
The hemostatic defects are minimized by limiting the daily dextran dose to 20 mL/kg.
74. COLLOID ALBUMIN HETASTARCH TETRASTARCH
COST EXPENSIVE CHEAP EXPENSIVE
USE LONG TERM SHORT TERM ANY
COAGULATION NO INCREASED
BLEEDING
RENAL
TRANSPLANTATION
PERIOPERATIVE
NO INCREASED INCREASED BLEEDING
BLEEDING
SAFE PREDISPOSES TO ARF NO EVIDENCE OF RISK
TILL DATE
PRE EXISTING IMPAIRMENT
RENAL SAFE OSMOTIC NEPHROSIS LIKE
LESIONS
NO EVIDENCE OF RISK
TILL DATE.
HEPATIC SAFE ASCITIS,ACCUMULATION NO EVIDENCE OF RISK
TILL DATE
76. HYPOVOLEMIC SHOCK
Isotonic saline (NS) is selected as an initial fluid because
1 litre of NS will expand intravascular volume by 300ml
Unknown glycemic status (Dextrose solutions will rise glucose level rapidly)
Unknown renal status – RL can cuase hyperkalemia or lactic acidosis
Reaction free (compared to colloids), Least expensive and readily available
RL is preferred IV fluid after urine out is established
RL is most physiological fluid, so large volume can be infused without
electrolyte imbalance
In shock hepatic conversion of lactate to bicarbonate is unpredictable
1 Litre FLUIDS ECF - Intravascular ECF- Interstitial ICF
NS 300 ml 700 ml NIL
5%D 83 ml ( 75-100) 260 670
COLLOIDS 1000 ml
77. Colloids in Hypovolemic shock
More effective plasma expanders as these agents are restricted to intravascular
compartments
Lesser risk of pulmonary oedema
Primary indication is hypotension in protein losing state –burns
Although used in shock , they offer little or no advantages over crystalloids
Blood in hypovolemic shock
In patients who are bleeding
SevereAnaemia
However with blood transfusion haematocrite should not be raised over 35% -
increase in blood viscosity lead to stasis
78. SEPSIS
• Cardiovascular instability may be a particular problem, contributed by
• endothelial dysfunction
• intravascular fluid loss
• vasodilation with fluid maldistribution
• sympathetic redistribution of blood volume away from the peripheral circulation,
and
• impairment of cardiac function
• Fluid resuscitation, with the goal of maintaining adequate end-organ perfusion is
therefore a key part of the first 6 hours of sepsis treatment.
79. • Targets suggested for patients with sepsis who have tissue hypoperfusion, defined by
blood lactate concentration >4 mmol/L or hypotension persisting after initial IV fluid
challenge:
• CVP 8 to 12 mm Hg (12 to 15 mm Hg in patients on ventilation)
• MAP 65 mm Hg or greater
• Urine output 0.5 mL/kg/hr or greater
• Scvo2 greater than 70%
• In the critical care setting, the use of colloids as resuscitation fluid has been the
subject of a number of important recent publications, which have led to the
withdrawal of HES.
• The crystalloid versus hydroxyethyl starch (CHEST) trial compared the use of
starches for resuscitation with crystalloids and showed not only no survival benefit
with the use of starch but also increased risk ofAKI.
80. • The use of expensive synthetic colloids is difficult to justify as there is a failure to
identify a mortality benefit associated with their use
• However, if the endothelial glycocalyx is impaired (as it is in severe sepsis), then
intravascular retention of any colloid may be no better than that of crystalloid.
• In patients with established acute respiratory distress syndrome (ARDS)- the focus
of fluid therapy is the fine balance between avoiding an increase in lung edema
while maintaining adequate tissue perfusion.
• Amore conservative approach has proven beneficial over liberal fluid therapy
• However, there is a lack of adequately powered studies on the choice of colloid or
crystalloid for intravascular volume replacement in patients withARDS.
81. RECOMMENDATIONS
• Guidelines on IV fluid therapy published by the National Institute for Health and
Care Excellence (NICE) recommend the use of crystalloid solutions containing a
sodium concentration in the range of 130– 154 mmol litre for i.v. fluid resuscitation,
and recommend against the use of tetrastarch for this purpose
• Current recommendations are to use 30 mL/kg of crystalloid in a protocolized
fashion to achieve the described targets
• In patients requiring further fluid, albumin should be considered, along with
vasopressors, inotropes, and RBC transfusion to attain these goals.
82. FLUID CHALLENGE
• The fluid challenge is considered the gold standard for diagnosis of fluid
responsiveness.
• The volume of fluid infused must be sufficient to increase right ventricular diastolic
volume and subsequently stroke volume (SV) as described by the Frank-Starling law.
• Fluid responsiveness is conventionally defined as an increase of at least 10% to 15%
in SV in response to a fluid challenge.
• Patients who reach this threshold are considered ‘fluid responders’.
• The duration of the fluid infusion in a fluid challenge has a significant influence on
fluid responsiveness.
• The proportion of patients deemed to respond to a fluid challenge is influenced by
the characteristics of a fluid challenge technique, in addition to intravascular filling,
vascular tone or ventricular contractility.
83. A4-step process for giving a fluid challenge involves consideration of
Type of fluid- No ideal intravenous fluid solution, crystalloids usually used.
Rate of administration - modified depending upon the patient and underlying disease
process . It is important to define the amount of fluid to be given over a defined interval
(eg: 250- 1000mL of crystalloids over 30 minutes) .
In whom to do fluid challenge test.?
Hypotension secondary to hypovolaemia - clinically demonstrated by a MAP <
65mmHg - 70mmHg.
Tachycardia due to hypovolaemia.
Low urine output secondary to hypovolaemia when urine output is less than 0.5
mL/kg/hr (lean body mass), for a period of at least 2 consecutive hours.
Low cardiac output secondary to low filling pressures in patients with invasive
haemodynamic monitoring.
84. Safety Limits
•Monitor for signs of pulmonary oedema secondary to fluid overload, which is a
serious complications of fluid administration.
• Monitor CVP trends as a safety limit in patients who do not have intrinsic heart or
lung disease to guide therapy.
•More invasive haemodynamic monitoring with a pulmonary artery catheter may be
considered in patients with intrinsic heart or lung disease.
A fluid challenge may continue until the goal is reached as long as the safety limit is
not reached first.
85. CONGESTIVE HEART FAILURE
Oedema in CCF is due to water and salt retention (water retention is more than
salt leads to hyponatremia)
Oral route always preferred – provides better nutrition and salt restriction
DON’T
Don’t correct hyponatremia with salt supplementation- because it is dilutional
Don’t treat hyponatremia with sodium rich fluids - treat with ionotropes
Don’t chase urine output – diuretic induced
DO’S
Give less fluid
Restrict sodium
Correct potassim deficit induced by diuretic – oral route safer than IV fluid
86. ARF
General principles of Fluid and electrolyte management
Fluid restriction in oedematous and oliguric patients
Fluid intake = urine output + 500ml/day
Salt restriction – 2 to 3 gm per day
Avoid hyperkalemia
Acute renal failure (ARF) – Fluid management as per presentation
1. Prerenal azotemia
In oliguric patients who are not volume overload and prerenal azotemia
is likely, fluid challenge is appropriate
500-1000ml of NS over 30-60 min may results in increased urine flow ,
if no response add Frusemid
I V fluid in hypotensive state is NS
87. 2. Non oliguric ARF
Due to septicemia, aminoglycosides, acute interstitial nephritis
Carry risk of hyperkalemia and acidosis - K⁺ intake should be restricted
3. OligiricARF
Due to acute tubular necrosis usually last for 1-3 week
Urine output < 400 ml/day or < 0.5 ml/kg/hr
Fluid, salt and K are restricted
If patient needs preferred I V fluid is 5% dextrose or 10% dextrose
4. Diuretic phase ofARF
Volume depletion and dehydration should be avoided
Preferred I V fluid is Half strength saline (0.45%) with K⁺
requirement
as per
88. HEPATIC FAILURE
ASCITIES IN CIRRHOSIS OF LIVER
Plasma volume expansion during paracentesis by colloids like albumin, plasma
proteins, blood transfusion prevents hypotension and permits large volume
paracentesis
6-8 gm of albumin for per litre of ascitic fluid removed
FFP for coagulation disorder and whole blood for anaemia
HEPATIC ENCEPHALOPATHY
Preferred fluid → 10% dextrose, 20% dextrose and DNS to prevent hypoglycemia
Avoid
5% dextrose - hypotonic fluid aggravate cerebral edema
Isolyte-G - contains ammonium chloride which precipitate hepatic precoma
RL – contains lactate which gets converted into bicarbonate by liver →
alkalosis If lactate metabolism is impaired leads to lactic acidosis
89. BURNS
• Extensive burns causes copious fluid loss from the circulation combined with
particular sensitivity to the effects of excess fluid administration.
• Local impairment of endothelial barrier function loss of oncotically active plasma
constituents increased capillary filtration into the interstitial compartment and
evaporative transcutaneous fluid loss due to loss of skin integrity.
• Fluid administration is based on formulas such as the Parkland formula or the Muir
and Barclay versions.
• Fluids are down-titration of administered fluid volumes if urine output is adequate
(0.5 to 1 mL/kg/hr)
90. FLUID THERAPY IN VOMITING
vomiting and nasogastric aspiration commonly encountered problems are
Hypovolemia –dehydration due to loss of fluid
Hypokalemia ↓
Loss in vomitus
Loss Na⁺ in gastric juice → ↑aldosteron → Na⁺ reabsorption and K excretion
Metabolic alkalosis
Upper GI loss of H⁺
Hypovolemia → ↑reabsorption of HCO₃ in proximal tubules
High aldosteron will secrete H⁺ ion ( insterad of K⁺ ) →Aciduria → metbolic
alkolosis
Loss chloride lead increased HCO₃ reabsorption
Hypochloremia – loss in GIT → ↑ renal absorption of HCO₃ → alkalosis
91. Isotonic saline
Corrects fluid deficit → ↑ECF → ↓HCO3 absorption → Correction M.Alkalosis
Correction of volume and Na⁺ → ↓ aldosteron → ↓ K⁺ and H ⁺secretion →
Correction of hypokalemia and alkalosis
Corrects Hypochloremia → fovours HCO₃ secretion → correction of
M.alkalosis
Isotonic saline corrects all biochemical abnormalities except K⁺ deficit
Isolyte-G
Is the specific fluid for upper replacement of GI loss, it corrects H⁺, Cl⁺, K⁺ and
Na⁺
92. TRAUMA
• Large volumes of IV crystalloids or colloids in early resuscitation will cause
hemodilution and dilute clotting factors, and saline-based fluids may aggravate the
acidosis associated with major blood loss
• Rather, packed RBCs (PBRCs), clotting factors (e.g., fresh frozen plasma [FFP])
and platelets should be replaced early
• Studies show that “high” ratios of FFP to PRBC (e.g., 1:1 to 1:2) are associated
with the best outcomes in massive transfusion.
93. NEUROSURGICAL CASES
• Aim is to keep patient normovolemic and normo or slightly hyperosmolar with
normal sodium balance
• Safe I V fluids- NS, 5% albumin, 6% hetastarch are iso to hyperosmotic, so they
have minor effect on brain’s water content or ICP
• Cautious use – osmolarity of RL is 274 mOsm/L and 5%dextrose is 278 mOsm/L.
Both are hypotonic can cause cerebral edema and raised ICP
• Dextrose produces hyperglycemia and anaerobic oxidation of glucose produces
lactic acid which further damages brain
• Mannitol is the mainstay of therapy for raise ICP – Mannitol is impermeable to BBB
therefore drains water out of edenatous brain into plasma
• NS has 308 mOsm/L osmolality is ideal and cheap
94. CRYSTALLOIDS COLLOIDS
Aqueous solution of low molecular weight ions
with or without glucose
High molecular weight substances similar to
plasma proteins
Readily pass through semi permeable membrane –
extravascular space expanders
Do not cross capillary membrane – intravascular
space expanders.
Intravascular t1/2 – 20-30 min 2-8 hrs
Reduces colloid oncotic pressure Maintain colloid oncotic pressure
Poor capillary perfusion Good
Risk of overhydration tissue edema Insignificant.
No anaplylactic reactions More
In expensive Expensive
Readily available, well tolerated by patients Not so
95. COLLOID–CRYSTALLOID CONUNDRUM
• There is a longstanding debate concerning the type of fluid that is most appropriate for
volume resuscitation, and each type of fluid has its loyalists who passionately defend
the merits of their chosen fluid.
• Crystalloid fluids were popularised for volume resuscitation for their ability to expand
interstitial volume than plasma volume.
• But recently, importance was given to promote cardiac output , systemic oxygen
delivery as the primary focus of volume resuscitation .Here ,colloids have proven
superior.
96. • Despite the superiority, crystalloids remain popular choice for volume resuscitation
because of
• Lower cost of crystalloid fluid.
• Lack of survival benefit with colloid resuscitation.
• The problem with crystalloid resuscitation – promotes edema ,positive fluid balance
increasing morbidity and mortality.
• No clear consensus exists on which intravenously administered fluid is associated with
the best clinical outcomes in the perioperative setting.
• Comparisons of “balanced” with “unbalanced” and “crystalloid” with “colloid” fluids
are being studied in many clinical settings but definitive conclusions are often lacking.
• The approach to fluid and electrolyte management may need adapting to numerous
patient and surgical factors.
• Hence ,a problem based approach is necessary .
97. A problem-based approach
• The colloid-crystalloid controversy is fueled by the premise that one type of fluid is optimal
in all cases of hypovolemia.
• This seems unreasonable , since no single resuscitation fluid will perform optimally in all
conditions associated with hypovolemia.
• Example:
• life threatening hypovolemia due to blood loss – blood products / albumin
• Hypovolemia due to dehydration – crystalloid resuscitation
• Tailoring the type of resuscitation fluid to the specific cause and severity of hypovolemia is
a more reasoned approach than using the same type of fluid for all cases of hypovolemia.
98. Sir Henry Tizard quoted-
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99. REFERENCES
• Miller’s Anaesthesia- 8th edition.
• The ICU book – Paul marino - 4th edition.
• Morgan and Mikhail's Clinical Anaesthesiology - 5th Edition
• Stoelting's Pharmacology and Physiology in Anaesthetic Practice - 5th Edition.
• Practical guidelines on fluid therapy – Dr. sanjay Pandya – 2nd edition.
• Toscani et al. Critical Care (2017) 21:207 DOI 10.1186/s13054-017-1796-9What is the impact of the fluid
challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-
analysis Laura Toscani, Hollmann D. Aya, Dimitra Antonakaki, Davide Bastoni, Ximena Watson, Nish Arulkumaran, Andrew
Rhodes and Maurizio Cecconi
• Indian Journal of Anaesthesia 2009; 53 (5):592-607Are All Colloids Same? How to Select the
Right Colloid?Sukanya Mitra1, Purva Khandelwal2
• British Journal of Anaesthesia : Pendulum swings again: crystalloid or colloid fluid therapy 113
(3): 335–7 (2014) Advance Access publication 14 March 2014 . doi:10.1093/bja/aeu015 M. C. Kelleher1* and D. J. Buggy1,21 Department of
Anaesthesia, Mater Misericordiae University Hospital&School of Medicine&Medical Science, University College Dublin, Ireland 2 Outcomes
Research Consortium, Cleveland Clinic, OH, USA.
• Honore et al. Ann. Intensive Care (2016) 6:120 DOI 10.1186/s13613-016-0227-4 Normal saline as
resuscitation fluid in critically ill patients: not dead yet! Patrick M. Honore*, Rita Jacobs and Herbert D.
Spapen