A quick overlook about crystalloids used in fluid resuscitation.

1. CRYSTALLOIDS
Presented by,
Rashin

2. BODY FLUID COMPARTMENTS
• TBW: 60% of body weight (42L)
• ICF:
- 40% of body weight (28L)
- 2/3rd ofTBW
• ECF: 20% of body weight (14L)
- Interstitial fluid (15% of body weight, 11L)
- Blood plasma (5% of body weight, 3L)
- 75 to 80% ECF is in interstitial fluid

3. DISTRIBUTION OF ELECTROLYTES AND
SUBTANCES IN BODY FLUIDS
SUBSTANCE PLASMA (mOsm/L H2O) INTERSTITIAL (mOsm/L
H2O)
INTRACELLULAR
(mOsm/L H2O)
Na+ 142 139 14
K+ 4.2 4 140
Ca++ 1.3 1.2 1
Cl- 108 108 4
HCO3- 24 28.3 10
Amino acid 2 2 8
Lactate 1.2 1.2 1.5
Glucose 5.6 5.6 0-20 mg/dL

4. INTRAVENOUSTHERAPY
• Intravenous (IV) therapy is the administration of a fluid
substance (solution) directly into a vein as a therapeutic
treatment.
CLINICAL CLASSIFICATION OF IV FLUIDS:
1) Crystalloids
2) Colloids
3) Blood Products

5. CRYSTALLOIDS
• Crystal + oid (resembling a crystal)
• Electrolyte solutions with small molecules that can diffuse freely throughout the
extracellular space
• Smaller in size than colloid
• Relatively low tendency to stay intravascular
• Principal component is inorganic salt sodium chloride (NaCl)
• 75-80% of infused crystalloid is distributed in interstitial space
• Volume resuscitation with crystalloid fluids expand interstitial volume rather than
plasma volume
• Eg: Isotonic saline, Lactated Ringer’s solution, etc.,

6. TYPES OF CRYSTALLOIDS
1. Isotonic crystalloids:
When the concentration of the particles (solutes) is similar to that of plasma, it doesn't move
into cells and remains within the extracellular compartment thus increasing intravascular volume.
Eg: 0.9% NaCl, Ringer’s lactate, D5W
2. Hypotonic solutions:
Compared with intracellular fluid (as well as compared with isotonic solutions), hypotonic
solutions have a lower concentration of solutes (electrolytes). These solutions will hydrate cells,
although their use may deplete fluid within the circulatory system.
Eg: 0.45% sodium chloride (0.45% NaCl), 0.33% sodium chloride, 0.2% sodium chloride, and 2.5%
dextrose in water
3. Hypertonic solutions:
Solution that have a higher tonicity or solute concentration. The osmotic pressure gradient
draws water out of the intracellular space, increasing extracellular fluid volume, so they are used
as volume expanders.
Eg: 3% NaCl, D5NS

7. FLUID Na+ Cl- K+ Ca++ pH GLUCOSE BUFFER OSMOLAR
ITY
TONICITY TYPICAL
INDICATION
NORMAL
PLASMA
142 108 4.2 1.3 7.4 ~0.85 HCO3-
~24 mEq/L
~290 N/A N/A
NORMAL
SALINE
154 154 0 0 5.7 0 0 308 Isotonic Resuscitation
RINGER’S
LACTATE
130 109 4 3 6.4 0 Lactate
28 mEq/L
273 Isotonic Resuscitation
D5W 0 0 0 0 0 50 0 252 Hypotonic Hypernatremia,
Hypoglycemia

8. ISOTONIC SALINE (Normal saline/NS)
• Prototype crystalloid fluid is 0.9% NaCl
• 9 grams of NaCl per liter
• It's called "normal saline solution" because the percentage
of sodium chloride in the solution is approximate to the
concentration of sodium and chloride in the intravascular
space.
FEATURES:-
Na+ = 154 mEq/L
Cl- = 154 mEq/L
pH= 5.7
Osmolarity = 308 mOsm/L

9. WHEN TO BE GIVEN?
1) To treat low extracellular fluid, as in fluid volume deficit from
Hemorrhage, Severe vomiting or diarrhea, Heavy drainage from GI suction
2) Shock
3) Mild hyponatremia
4) Metabolic acidosis (such as diabetic ketoacidosis)
5) It’s the fluid of choice for resuscitation efforts.
6) It's the only fluid used with administration of blood products.
DISADVANTAGE:-
• Metabolic acidosis – due to high chloride concentration (Hyperchloremic acidosis)
• Intraoperative infusion of isotonic saline at the rate of 30 ml/kg/h causes a drop in
serum pH from 7.41 to 7.28 after 2 hours

10. RINGER’S LACTATE (HARTMANN’S SOLUTION)
FEATURES:-
Na+ = 130 mEq/L
Cl- = 109 mEq/L
K+ = 4 mEq/L
Ca++ = 3 mEq/L
pH= 6.4
Lactate = 28 mEq/L
Osmolarity = 273 mOs/L
• K+ and Ca++ ion concentration are in appropriate concentrations of plasma
• Na+ concentration is reduced for electrical neutrality
• Lactate addition requires reduction in chloride concentration which is a close approximation of plasma
chloride concentration
• Thus the risk of hyperchloremic acidosis with large volume infusion of RL is eliminated

11. USES:-
• The most physiologically adaptable fluid because its electrolyte content is
most closely related to the composition of the body's blood serum and
plasma.
• Another choice for first-line fluid resuscitation for certain patients, such as
those with burn injuries.
When to be used?
To replace GI tract fluid losses ( Diarrhea or vomiting )
Fluid losses due to burns and trauma
Patients experiencing acute blood loss or hypovolemia

12. DISADVANTAGES:-
• Ca++ in RL can bind with certain drugs and inactivate or reduce their
effectiveness
• Drugs to be not infused with RL are:
Aminocaproic acid (Amicar)
Amphotericin
Ampicillin
Thiopental
• LR is metabolized in the liver, which converts the lactate to bicarbonate. LR is
administered to patients who have metabolic acidosis not patients with lactic
acidosis
• Not given to patients with liver disease as they can't metabolize lactate

13. D5W (5% of dextrose in water)
• 1 gram dextrose = 3.4 kcal  50 grams = 170 kcal/L
• Osmolarity = 252 mOsm/L
• It is considered an isotonic solution, but when the
dextrose is metabolized, the solution actually
becomes hypotonic and causes fluid to shift into
cells.
• <10% of infused volume of D5W remains
intravascularly
• 2/3rd of infused volume ends up inside cells
• Predominant effect is cellular swelling

14. How does it work?
• D5W provides free water that pass through membrane pores to
both intracellular and extracellular spaces. Its smaller size allows
the molecules to pass more freely between compartments, thus
expanding both compartments simultaneously
• It provides 170 calories per liter, but it doesn't replace
electrolytes.
• The supplied calories doesn't provide enough nutrition for
prolonged use.

15. DISAVANTAGES:-
- D5W is not good for patients with renal failure or cardiac problems since
it could cause fluid overload.
- patients at risk for intracranial pressure should not receive D5W since it
could increase cerebral edema
- D5W shouldn't be used in isolation to treat fluid volume deficit because it
dilutes plasma electrolyte concentrations
- Never mix dextrose with blood as it causes blood to hemolyze.
- Not used for resuscitation, because the solution won't remain in the
intravascular space.