IV fluid therapy introduction body physiology history types of ivf iv fluids in detail ivf in critical care NICE guidelines

1. Intravenous Fluid Therapy
Dr Charul Jakhwal
PDCC SR
Dept. of Anaesthesiology and
Critical Care, SMIH

2. Introduction
• Administration of intravenous fluids is routine in the management of
surgical and critically ill patients.1
• Fluid and electrolyte disturbances are extremely common in the
perioperative period. Large volumes of intravenous fluids are frequently
required to correct fluid deficits and compensate for blood loss during
surgery. 4
• Major disturbances in fluid and electrolyte balance can rapidly alter
cardiovascular, neurological, and neuromuscular functions
• In trauma, burn, surgical, and intensive care patients with hypovolaemia,
adequate volume restoration is essential to avoid development of organ
failure. 2
• This manoeuvre is aimed at guaranteeing stable macro- and
microhaemodynamics while avoiding excessive interstitial fluid overload.2
• The choice of fluid engenders much controversy and there is considerable
dispute over the pros and cons of each type.

3. Body Fluid Compartments
• Total Body Water (TBW): 50-70% of total body wt
• Avg. is greater for males
• Decreases with age. Highest in newborn, 75-
80%, By first year of life TBW ~ 65%.
• Most in muscle, less in fat.
• TBW= ECF + ICF
• ICF ~ 2/3 & ECF ~ 1/3
• ECF = Intravascular (1/3) + Interstitial (2/3)

4. 12/17/2020 4

5. Fluid compartments
Total body fluid
(60% of TBW)
ECF
(40% of body
fluid)
Interstitial fluid
(25% of TBW)
Plasma
(5-8%of TBW)
Transcellular
fluid (2% of
TBW)
ICF
(60% of body
fluid)
12/17/2020 5

6. Total body water varies with…
a) Age
b) Gender
c) Body fat (Fat contains less water)
12/17/2020 6

7. 80% 60% 55%

9. Intracellular fluid
• 60% of body fluid
• Rich in :
– Potassium
– Magnesium
– proteins
12/17/2020 9

10. Extracellular fluid
• 40 % of body fluid
• Rich in :
– Sodium
– Chloride
– Bicarbonate
• Interstitial fluid : between cells, low in protein
• Intravascular fluid(Plasma) : High in protein
• Transcellular fluids – CSF, intraocular fluids,
serous membranes (third space)
12/17/2020 10

11. BASIC PHYSIOLOGY OF BODY FLUID
• Water balance=(total input – total output)
• Consider insensible input n output also
• Insensible fluid input – 300 ml oxidation
• Insensible fluid loss – skin(500ml)+lung(400ml)+stool(100ml)=1000ml
• Total balance = -700 ml fluid deficit
• Daily fluid requirement = UO + insensible losses

12. • INSENSIBLE LOSS INCREASE IN
• 500ml in moderate sweating
• 1.0-1.5L in severe sweating/high fever
• 0.5-3L through expose wound surface(burns) and laparotomy
• Water needs increase by 15% for every 1 degree C rise in temp

13. Fluid balance
Average intake Average output
Fluid: 1300 ml Urine: 1500 ml
Water in food: 1000 ml Feces: 150 ml
Water metabolism: 250 ml Lungs: 500 ml
Skin: 400 ml
12/17/2020 13
Total for both is 2550ml

14. Definitions
• Mole : 1 mole is atomic wt or mol wt of that substance in gms
• MW (Molecular Weight) = sum of the weights of atoms in a molecule
• Osmolality : number of osmoles of a chemical compound that contributes
to the solution's osmotic pressure and is expressed as mOsm/kg of solvent
• Osmolarity : number of osmoles of solute particles per unit volume of
solution (mosm/L)
• Osmotic pressure : pressure exerted by osmotically active particles in the
fluid.
depends on number of particles / unit vol

15. Plasma osmolality : determined largely by sodium salts
• Normal plasma osmolality = 275-295 mosm/kg
• Plasma osmolality = 2*Na + glucose/18 + BUN/2.8
• Isotonic(250-375)
• Hypotonic<250
• Hypertonic>375
Effective plasma osmolality : determined by those solutes in plasma which do
not permeate cell wall freely and act to hold water within ECF

16. Fluid Therapy

17. History
• Saline came into being following the ingenious in vitro studies, published in 1883,
performed by the Dutch physiological chemist Hartog Hamburger (1859–1924). He
noted that red blood cells were less likely to lyse in a NaCl solution of 0.9 % than in
more diluted solutions .
• However, the composition of 0.9 % saline largely differs from that of blood. More
physiologic solutions with a salt composition more close to that of blood than 0.9%
saline, subsequently referred to as so-called “balanced” salt crystalloids, were
soon developed.
• Approximately 110 years ago, Sydney Ringer (1834–1910), an Australian physician,
introduced a NaCl solution containing some K+ and Ca++ to promote contraction
of isolated heart.
• Eighty years ago, Alexis Hartmann (1898–1964), an American pediatrician, added
the non–Cl- anion lactate to prevent metabolic acidosis. The solution developed by
A. Hartmann, currently termed either Hartmann’s solution or lactated Ringer’s
solution, eventually replaced the original Ringer’s solution.
• The composition of this solution has been slightly modified over the years (there is
also some variation in its composition as supplied by different manufacturers).

18. • In 1861, Thomas Graham’s investigations on diffusion led him to classify
substances as crystalloids or colloids based on their ability to diffuse
through a parchment membrane. Crystalloids passed readily through the
membrane, whereas colloids (from the Greek word for glue) did not.
• Most crystalloids consist of a non-physiological mixture of electrolytes.
• In the beginning of the 1990s, substantial alterations in acid–base status
were described in patients who had large amounts of saline (NS) infused.
• This has been defined as ‘hyperchloraemic acidosis’.3

19. • Colloids have been shown to be more effective than crystalloids for
correcting intravascular volume deficits. Consequently, colloids are often
preferred for correcting hypovolaemia.
• Almost all colloids [albumin, hydroxyethylstarch (HES), gelatins] are
prepared in nonphysiological solutions and can be defined as ‘unbalanced
colloids’. The use of large amounts of these colloids may be associated
with unwanted electrolyte or acid–base disturbances.
• In order to avoid the complications of normal saline and colloids, the
concept of balanced crystaloid solution took birth.

20. TMC 20
of
Intravenous Fluid
Therapy

21. TMC 21
• in combination
with oxygen
therapy
• in combination
with vasoactive
and/or cardio
active
substances
• electrolytes
• dehydration
• hypovolemia
To
Maintain
or correct
fluid
balance
To Maintain
or correct
plasma
constitution
To Secure
sufficient
oxygen
delivery to
organs
To Secure
sufficient
circulation

22. Intravenous fluid therapy
Indications
• Dehydration and shock
• Hypoglycemia
• Vehicle for – antibiotics, chemotherapy agents
• TPN
• Coma, anaesthesia, Severe vomiting and diarrhoea,
• Critical problems – anaphylaxis, status asthmaticus or epilepticus, cardiac
arrest , forced diuresis in drug overdose, poisoning

23. Advantages
• Accurate , controlled and predictable way of administration
• Immediate response due to direct infusion to intravascular compartment
• Prompt correction of serous fluid and electrolyte disturbances

24. Disadvantages
• More expensive, need asepsis, and under skilled supervision
• Improper selection of type, volume, rate and technique can lead to serious
problems
Contra indications
• Avoided if patient can take oral fluids
• CHF
• Pulmonary edema

25. Complications
• Local : hematoma , infusion phlebitis
• Systemic:
• Large volume can lead to circulatory overload
• Air embolism
• Septicemia
– others – fluid contamination, mixing of incompatible drugs

26. The ideal fluid
• achieves the desired effect with
1. No tissue storage,
2. No adverse electrolyte/acid-base changes,
3. No hematological or immunomodulating effects,
4. Is compatible with other medicines,
5. Is affordable and available,
6. Has long shelf life
7. Reasonable storage requirements.
• However, no fluid currently meets all of these
criteria [3]
Ideal fluid= plasma

27. Plasma composition
(extracellular & intravascular fluid)
• 55% of the body's total blood volume.[5]
• It is the intravascular fluid part of extracellular fluid (all body fluid outside
cells).
• It is mostly water (up to 95% by volume), and contains dissolved proteins
(6–8%) (i.e.—serum albumins, globulins, and fibrinogen)[6]
glucose, clotting factors, electrolytes (Na+, Ca2+, Mg2+, HCO3
−, Cl−,
etc.), hormones, carbon dioxide(plasma being the main medium for
excretory product transportation) and oxygen
• The reference range of serum osmolality is 275–295 mosm/kg(mmol/kg).
(Normal physiologic osmolarity range is 280 to
310 mOsmol/L. )

29. TYPES OF FLUID:
IV Fluid
Crystalloid
Crystalloid solutions are aqueous solutions of ions
(salts) with or without glucose
isotonic saline (e.g., .9% saline, normal saline) or
balanced electrolyte solutions(e.g., Plasmalyte,
Ringer’s lactate)
Colloids
colloid solutions contain high-molecular-
weight substances such as proteins or large
glucose polymers.
(e.g. albumin, Gelatins,
and Synthetic Starches;hydroxyethyl starch)
blood and
blood
products
Intravenous fluid therapy may consist of infusions of crystalloids, colloids, or a
combination of both and blood and blood products

31. Overview of Isotonic, Hypotonic, &
Hypertonic Solutions
• Tonicity is a measure of the effective osmotic pressure gradient, as defined by
the water potential of two solutions separated by a semipermeable membrane.
• Isotonic (Iso: same/equal. Tonic: concentration of a solution)
• The cell has the same concentration on the inside and outside which in normal
conditions the cell’s intracellular and extracellular are both isotonic.
• Isotonic fluids
• 0.9% Saline
• 5% dextrose in water (D5W)
• Lactated Ringer’s
• Isotonic solutions are used: to increase the EXTRACELLULAR fluid volume due
to blood loss, surgery, dehydration, fluid loss that has been loss extracellularly.

32. Hypertonic
Hyper: excessive
Tonic: concentration of a solution
• will cause the CELL TO SHRINK.
• Hypertonic solutions
• 3% Saline
• 5% Saline
• 5% Dextrose in 0.45% saline
• 5% Dextrose in Lactated Ringer’s
• 10% Dextrose
• 25% Dextrose
• When hypertonic solutions are
used (very cautiously….most likely
to be given in the ICU due to
quickly arising side effects of
pulmonary edema/fluid over
load).
• will cause CELL SWELLING which can
cause the cell to burst or lyses.
• Hypotonic solutions
• 0.45% Saline (1/2 NS)
• 0.225% Saline (1/4 NS)
• 0.33% saline (1/3 NS)
• used when the cell is dehydrated and fluids need
to be put back intracellularly. This happens when
patients develop diabetic ketoacidosis (DKA) or
hyperosmolar hyperglycemia.
• Never give –
increased cranial pressure (can cause fluid
to shift to brain tissue),
extensive burns,
trauma (already hypovolemic) etc. because
you can deplete their fluid volume.
Hypotonic
Hypo: ”under/beneath”
Tonic: concentration of a solution

33. 140.0
5.0
98.0
1.5
27.0
23.0
kabilyte

36. 5 % dextrose
Composition : Glucose 5 g in 100ml
Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L). After consumption
of dextrose, remaining water distruibuted in all compartment of body
proportionately. So best agent to correct intracellular dehydration.
It is selected when there is need of water but not electrolyte.
Indications :
• Prevention and treatment of dehydration
• Pre and post op fluid replacement
• IV administration of various drugs except those which are acid labile eg
penicillin, amphotericin B
• Prevention of ketosis in starvation, vomiting, diarrhea
• Adequate glucose infusion protects liver against toxic substances
• Correction of hypernatremia due to pure water loss DI

37. Contra indications
• Cerebral edema(hypotonic nature aggravate cerebral edema),
• Neurosurgical procedures(increases intracranial pressure, cause damage during
neurosurgery)
• Acute ischaemic stroke(as hyperglycemia aggravates cerebral ischaemic brain
damage)
• Hypovolemic shock as it does not substantially increase the intracellular volume
moreover fast replacement can lead to hyperglycemia and osmotic diuresis
• Hyponatremia , water intoxication
• Same iv line blood transfusion – hemolysis , clumping occurs
• Uncontrolled DM , severe hyperglycemia
Rate of adminstration – 0.5 g/kgBW/hr or
666ml/hr 5 % D or
333ml/hr 10 %D

38. Normal Saline is Not Normal
• One of the most widely used crystalloid fluids is 0.9%
sodium chloride.
• The most popular term for 0.9% NaCL is normal saline,
but this solution is neither chemically nor
physiologically normal.
• It is not normal chemically 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.
• It is not normal physiologically because the
composition of 0.9% NaCL differs from the composition
of extracellular fluid. This is shown in Table 12.1 . When
compared to plasma (extracellular fluid), 0.9% NaCL
has a higher sodium concentration (154 vs. 140 mEq/L),
a much higher chloride concentration (154 vs. 103
mEq/L), a higher osmolality (308 vs. 290 mOsm/L), and
a lower pH (5.7 vs. 7.4).
• These differences can have deleterious effects on fluid
and acid-base balance.

39. • Volume Effects
The effects of 0.9% NaCL on expanding the plasma volume and interstitial fluid volume.
Infusion of one liter of 0.9% NaCL adds 275 mL to the plasma volume and 825 mL to the
interstitial volume
• INTERSTITIAL EDEMA:
• Infusions of 0.9% NaCL promote interstitial edema more than crystalloid fluids with a
lower sodium content (e.g., Ringer’s lactate, Plasma-Lyte). This is related to the
increased sodium load from 0.9% NaCL, which increases the “tonicity” of the interstitial
fluid (as just described) and promotes sodium retention by suppressing the renin-
angiotensin-aldosterone axis.
• Decreases in renal perfusion have also been observed after infusion of 0.9% NaCL,
presumably as a result of chloride mediated renal vasoconstriction. The increase in
interstitial edema with 0.9% NaCL can have a negative influence on clinical outcomes.
• Acid-Base Effect
• Large-volume infusions of 0.9% NaCL produce a metabolic acidosis (7,8), as
demonstrated in Figure 12.3. In this clinical study (7), infusion of isotonic saline (0.9%
NaCL) at a rate of 30 mL/kg/h was accompanied by a progressive decline in the pH of
blood over two hours, while the pH was unchanged when Ringer’s lactate solution was
infused at a similar rate. 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). The close match between the chloride concentration in
Ringer’s lactate solution and plasma explains the lack of a pH effect associated with
large-volume infusion of Ringer’s lactate solution.

40. STRONG ION DIFFERENCE
The influence of crystalloid fluids on acid-base balance can be explained
using the strong ion difference (SID), which is the difference between readily
dissociated (strong) cations and anions in extracellular fluid
Roughly equivalent to the plasma [Na] – plasma [CL] since
Principle of electrical neutrality SID + [H+]-[OH-]=0
Since the [OH–] is negligible in the physiologic pH range=>SID + [H+]=0
• According to this relationship, a change in SID must be accompanied by a
reciprocal change in [H+] (or a proportional change in pH) to maintain
electrical neutrality.
With normal protein levels, [SID] is about 40mEq/L.

41. • 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 increase
the H+ inon concentration and thus reduce the plasma pH.
• The SID of Ringer’s lactate fluid is 28 mEq/L
• (Na + K + Ca – CL=130 + 4 + 3 – 109=28)
This SID is not far removed from the normal SID of plasma, so Ringer’s lactate
infusions will have less of an influence on plasma pH than 0.9% NaCL.
.

42. Ringer’s Fluids
• Ringer’s Lactate
• In the early 1930’s, an American pediatrician named Alexis Hartmann added
sodium lactate to Ringer’s solution to provide a buffer for the treatment of
metabolic acidosis. This solution was originally called Hartmann’s solution, and is
now known as Ringer’s lactate solution.
• The sodium concentration in Ringer’s lactate is reduced to compensate for the
sodium released from sodium lactate, and the chloride concentration is reduced to
compensate for the negatively-charged lactate molecule; both changes result in an
electrically neutral salt solution.
• Ringer’s Acetate
• Because of concerns that large-volume infusions of Ringer’s lactate solution could
increase plasma lactate levels in patients with impaired lactate clearance (e.g.,
from liver disease), the lactate buffer was replaced by acetate to create Ringer’s
acetate solution.
• Acetate is metabolized in muscle rather than liver, which makes Ringer’s acetate a
reasonable alternative to Ringer’s lactate in patients with liver failure. The
composition of Ringer’s acetate and Ringer’s lactate solutions is almost identical
with the exception of the added buffer.

43. RL
Lactated Ringer's is composed of
• sodium chloride 6 g/L,
• sodium lactate 3.1 g/L,
• potassium chloride 0.3 g/L, and
• calcium chloride 0.2 g/L.
Lactated Ringer's contains ions of
• sodium 130 mEq/L,
• potassium 4 mEq/L,
• calcium 2.7 mEq/L,
• chloride 109 mEq/L, and
• lactate 28 mEq/L.

44. Advantages & Disadvantages
• The principal advantage of Ringer’s lactate and Ringer’s acetate over
isotonic saline (0.9% NaCL) is the lack of a significant effect on acid-base
balance.
• The principal disadvantage of Ringer’s solutions is the calcium content;
i.e., the ionized calcium in Ringer’s solutions can bind to the citrated
anticoagulant in stored RBCs and promote clot formation.
• For this reason, Ringer’s solutions are contraindicated as diluent fluids for
the transfusion of erythrocyte concentrates (packed red blood cells).
• However, clot formation does not occur if the volume of Ringer’s solution
does not exceed 50% of the volume of packed RBCs.

45. Other Balanced Salt Solutions
• Newer solutions contain magnesium instead of calcium, and
contain both acetate and gluconate buffers to achieve a pH of
7.4.
• The absence of calcium makes them suitable as diluents for
RBC transfusions.
• They shown less of a tendency to promote interstitial edema
when compared with isotonic saline.

46. Balanced crystalloid solutions
• Recently, research regarding optimal fluid therapy has focused on the use of
balanced crystalloid solutions (e.g., Ringer’s acetate, Plasmalyte) in comparison
with normal saline as a result of concerns regarding the deleterious effects of
administration of normal saline, particularly in relation to metabolic,
gastrointestinal, renal, and coagulation side effects.
• Crystalloids with a chemical composition that approximates extracellular fluid have
been termed “balanced” or “physiologic” solutions and are derivatives of the
original Hartmann’s and Ringer’s solutions. However, none of the proprietary
solutions are either truly balanced or physiologic
Balanced Solutions
• They have electrolyte compositions similar to that of plasma
• the ionic composition of “balanced” crystalloids closely mimics the ionic make-up
of the aqueous fraction of blood
• Ringer acetate
• Plasmalyte A
• Kabilyte
• Sterofundin
• Normosol

47. Normosol-R
Normosol-R is a sterile, nonpyrogenic isotonic solution
of balanced electrolytes in water for injection. The
solution is administered by intravenous infusion for
parenteral replacement of acute losses of extracellular
fluid.
Each 100 mL of Normosol-R contains sodium chloride,
526 mg; sodium acetate, 222 mg; sodium gluconate,
502 mg; potassium chloride, 37 mg; magnesium
chloride hexahydrate, 30 mg. May contain HCl and/or
NaOH for pH adjustment. pH 6.6 (4.0 to 8.0); 294
mOsmol/liter (calc.).
Electrolytes per 1000 mL (not including pH adjustment):
Sodium 140 mEq;
potassium 5 mEq;
magnesium 3 mEq;
chloride 98 mEq;
acetate 27 mEq;
gluconate 23 mEq.

48. PLASMA-LYTE A
PLASMA-LYTE A Injection pH 7.4 (Multiple
Electrolytes Injection, Type 1, USP) is a sterile,
nonpyrogenic isotonic solution in a single dose
container for intravenous administration.
Indicated as a source of water and electrolytes or
as an alkalinizing agent.
Is compatible with blood or blood components. It
may be administered prior to or following the
infusion of blood through the same administration
set (i.e., as a priming solution), added to or infused
concurrently with blood components, or used as a
diluent in the transfusion of packed erythrocytes.

49. Composition
One liter has an ionic concentration of
• 140 mEq sodium,
• 5 mEq potassium,
• 3 mEq magnesium,
• 98 mEq chloride,
• 27 mEq acetate, and
• 23 mEq gluconate.
• The osmolarity is 294 mOsmol/L (calc).
The caloric content is 21 lcal/L.

50. Sterofundin
This product is an isotonic electrolyte solution with electrolyte
concentrations adapted to plasma electrolyte concentrations. It is
used to correct extracellular fluid losses (i.e. losses of water and
electrolytes in proportional amounts). The supply of the solution
is aimed to restore as well as maintain normal osmotic conditions
in the extracellular and intracellular space. The anion pattern
represents a balanced combination of chloride, acetate, and
malate which counteracts metabolic acidosis

51. QUALITATIVE AND QUANTITATIVE
COMPOSITION
• Sodium chloride 6.80 g
• Potassium chloride 0.30 g
• Magnesium chloride hexahydrate 0.20 g
• Calcium chloride dihydrate 0.37 g
• Sodium acetate trihydrate 3.27 g
• Malic acid 0.67 g
Electrolyte concentrations:
• Sodium 145.0 mmol/l
• Potassium 4.0 mmol/l
• Calcium 2.5 mmol/l
• Chloride 127.0 mmol/l
• Magnesium 1.0 mmol/l
• Acetate 24.0 mmol/l
• Malate 5.0 mmol/
• A clear, colourless aqueous solution
• pH: 5.1 – 5.9
• Theoretical osmolarity: 309 mosm/l

52. kabilyte
KABILYTETM (Multiple Electrolytes Injection Type 1 USP)
is a sterile, non-pyrogenic isotonic solution in a single
dose container for intravenous administration. has value
as a source of water and electrolytes.
• KABILYTE is indicated as a source of water and
electrolytes or as an alkalinizing agent.
• compatible with blood or blood components. It may
be administered prior to or following the infusion of
blood through the same administration set (i.e., as a
priming solution), added to or infused concurrently
with blood components, or used as a diluent in the
transfusion of packed erythrocytes.
Packaging
KABILYTE (Multiple Electrolytes Injection Type 1 USP) in a
Freeflex container available in 500 and 1000ml pack size

53. kabilyte
• Composition
•
• Each 100 ml. contains :
• Sodium Chloride IP 0.526 g.
• Sodium Gluconate USP 0.502 g.
• Sodium Acetate Trihydrate IP 0.368 g.
• Potassium Chloride IP 0.037 g,
• Magnesium Chloride Hexahydrate IP 0.030 g,
• Water for Injections IP q.s.
• It may contain Sodium Hydroxide IP or Hydrochloric Acid IP to adjust the pH.
• Concentration of Electrolytes (mmoles /L)
• Sodium 140.0
• Potassium 5.0
• Chloride 98.0
• Magnesium 1.5
• Acetate 27.0
• Gluconate 23.0
• Osmolarity : 294mOsm/L (Calc)
• pH : 7.4(6.5 - 8.0)

54. Isolyte fluids
Isolyte G Isolyte M Isolyte P Isolyte E
dextrose 50 50 50 50
Na
K
Cl
63
17
150
40
35
40
25
20
22
140
10
103
Acetate
Lactate
NH4Cl
---
---
70
20
---
---
23
---
---
47
---
---
Ca
Mg
---
---
---
---
---
---
5
3
HPO4 --- 15 3 ---
Citrate --- --- 3 8
Mosm/L 580 410 368 595
Decreasing use….

55. Colloids
Colloids : large molecular weight substances that largely
remains in the intravascular compartment thereby generating
oncotic pressure
• 3 times more potent
• 1 ml blood loss = 1ml colloid = 3ml crystalloids

56. colloids…

57. Type of fluid Effective plasma volume
expansion/100ml
duration
5% albumin 70 – 130 ml 16 hrs
25% albumin 400 – 500 ml 16 hrs
6% hetastarch 100 – 130 ml 24 hrs
10% pentastarch 150 ml 8 hrs
10% dextran 40 100 – 150 ml 6 hrs
6% dextran 70 80 ml 12 hrs

58. Albumin
• One of the orginal plasma expanders.
• Accounts for 60% -80% of normal plasma oncotic pressure
• Dervied from pooled human plasma
• Available as albusol in 4% and 20% solutions
• Levels are mostly used as prognostic indicators.
• Blood derived product which has its own problems.
• High cost
• Availability
• General scarcity of blood products at blood bank level.
• Risk of transmission of infections.

59. Indications :
• Plasma volume expansion in acute hypovolemic shock, burns, severe
hypoalbuminemia
• Hypoproteinemia – liver disease, Diuretic resistant nephrotic syndrome
• In therapeutic plasmapheresis , as an exchange fluid
Contra indications :
• Severe anaemia, cardiac failure(as it may lead to cardiac decompensaition
when infused rapidly)
• Hypersensitive reaction

61. DEXTRAN
• Branched-chain polysaccharides produced by bacterium (Leuconostoc)
incubated in sucrose medium.
• May produce plasma expansion by a colloidal osmotic effect.
• Has been mostly used in restoring intravascular volume in the treatment
of shock or impending shock as a result of haemorrhage and burns.
• 2 preparations include:
• -dextran 70, 6% (Macrodex®)MW 70000
• -dextran 40, 10% (Rheomacrodex®)MW 40000
• Both are in a 0.9% saline solution.
• 50-70% excreted unchanged in the urine. The rest is metabolised in the
liver into water and CO2

62. • Advantages:
1.↓blood viscosity.2.↓platelet adhesiveness. 3.↓RBC aggregation (anti-thrombotic).
4.Improve blood flow through the microcirculation.
5.Also implicated in suppressing excessive platelet-leukocyte-endothelial interaction.
• Clinical advantages and uses include:1.Plastic surgery, especially flaps to maintain
and assist in perseverance of pedicle vascular integrity.
• 2.Improve peripheral blood flow in the treatment and prevention of
thromboembolic disease associated with surgery.
• 3.Peripheral vascular disease to improve the microcirculation, especially peri-
operatively.
• 4.Useful in the prevention of excessive platelet activation and release of
microemboli during enarterectomy, stent grafting and other vascular procedures

63. Disadvantages:
1.Much briefer volume expansion effect compared to the starches and gelatins(due to rapid
clearance and small MW).
2.One of the highest risk of anaphylaxis amongst all the colloids, including hypersensitivity
reactions. Ranges from rash, pruritis and hypotension to full blown anaphylaxis. The rash, pruritis
and hypotension are mostly due to its potential antigenicity.
3.Severe risk of bleeding following usage, may prolong bleeding time.
4.Can interfere with blood typing(cross matching and grouping). Always take a blood sample prior
to administration of a Dextran.
5.Antiplatelet
6.Can be associated, or worsen renal failure/compromise
7.If Heparin is used concurrently, recommendation is to decrease the dosage by 35-70% due to
synergistic effect on the coagulation
8.Watch for and correct any dehydration due to the increase in viscosity of fluid in the renal
tubules due to the Dextran
9.Patient’s have to be watched carefully for post-operative bleeding due to the improved
microcirculation

64. Administration :
• Adult patient in shock – rapid 500 ml iv infusion
• First 24 hrs – dose should not exceed 20ml/kg
• Next 5 days – 10 ml/kg/ day

65. GELATINS
Second most commonly used plasma expanders (colloid) after the
hydroxyethyl starches.
2 different formulations:
1.4% modified (succinylated) fluid gelatin -Gelofusine®
2.3,5% polygeline -Haemaccel®. Degraded gelatin polypeptides, cross-linked
via urea bridges
The succinylation of the Gelofusin® results in a negative charge, which
supposedly spreads out the molecule. This results in the shape filling the
required volume greater then the non-succinylated gelatines of the same
molecular weight.

66. Gelatins
• Neither of the two formulations contain any preservatives in their
manufacture.
• The average MW is between 30000 and 35000 daltons.
• Rapid excretion from the body via the urine, with complete plasma
clearance within 3 days and complete excretion from the body in one
week.
• Up to 50% removed within the first 4-8 hours following administration.
• Only about 1% is metabolized of the infused amount.
• No storage within the RES.
• They claim to have no effects on coagulation with disturbances, unless due
to dilution and ↓the thrombin levels.

67. Indications:
• 1.Prevention and treatment of hypovolaemia:
• -Following shock due to haemorrhage or trauma.
• -Peri-operative blood loss.
• -Burns.
• -Sepsis.
• -Epidural/spinal anaesthesia.
• 2.Haemodilution.

68. Advantages :
• Does not interfere with coagulation, blood grouping(rapid
clearance)
• Remains in blood for 4 to 5 hrs
• Infusion of 1000ml expands plasma volume by 300 to 350 ml
Side effects :
• Hypersensitivity reaction
• Should not be mixed with citrated blood

70. HYDROXYETHYL STARCHES
• First developed in the 1960’s as an alternative to the traditional plasma
expanders at that time viz. Albumin and Dextrans.
• Have progressed tremendously over the years from their beginnings in the
60’s.
• Started off with very high molecular weight entities and is continually
changing and adapting to suit the need for lower weighted fluids with
maximum benefits

72. HYDROXYETHYL STARCHES
• All derived from amylopectin, which is chemically modified.
• Found in wax corn starch
• Natural, non-synthetic product
• Available in isotonic solutions
• Osmolarity in the 310 mOsm/l range (close to normal physiological
osmolarity)
• Concentration 6% & 10%
• Approximate pH 5.5.
• In a 0,9% Saline solution (9g NaCl & 60g starch)

73. • Benefits of Hydroxyethyl Starches
• Very good plateau effect of up to 4 hours.
• Relatively short intravascular half-life of 2-3 hours.
• Volume efficacy of 1:1 with duration varying from 4-8 hours.
• Broken down by amylase in the plasma.
• Essentially removed by:
• 1.Renal excretion (particles < 50 after degradation).
• 2.Redistribution.
• Rapid excretion with 70% eliminated within the first 24 hours and >85%
after the first 7 days.
• Extremely low incidence of anaphylaxis reactions compared to other
colloids (lowest incidence of reactions amongst ALL

74. • The volume effect, duration of action and elimination as well as effect on
coagulation is dependant on various factors:
• 1.Molecular weight size.
• 2.Degree of substitution.
• 3.Ratio of substitution.

75. MOLECULAR WEIGHT
• The starches vary in size from 450 Daltons down to the medium to low
range (200 and 130 Daltons)
• The molecular weight is responsible for the degree of elimination, as well
as the effect on coagulation.
• The lower the MW, the less the effect on the coagulation.
• Trend is towards the lower the MW

76. DEGREE OF SUBSTITUTION
• Relates to the number hydroxyethyl molecules substituted on the carbon skeleton
of the glucose pectin entity.
• Expressed as a ratio.
• Of what relevance is this?
• The higher the degree of substitution, the more the degradation of the starch by
serum amylase is resisted.
• This relates into a longer duration of action and volume effect.
• By having this delayed breakdown and elimination, sufficient quantities remain in
the plasma to effect an effective volume effect with the least amount of colloid
infused.
• Ideally, one can then get a 1:1 volume effect.
• This compares to gelatins, which due to their more rapid elimination, have a
lower duration and volume effect. As a result, one often needs appreciably more
volume to maintain the desired volume effect

77. SUBSTITUTION PATTERN
• Worked on a C2 to C6 ratio.
• The relative ratio of the hydroxyethyl starch substitutions at the carbon
level.
• The relevance is related to the effect on coagulation.
• Studies have shown that the higher the C2/C6 ratio, the increase in the
negative effect on coagulation
• Ultimately, all colloids have a possible negative effect on coagulation, be
it from:
– 1.Direct effect on clotting factors, especially FVII and VWF.
– 2.Direct effects on platelet function and kinetics.
– 3.Dilutional effect on coagulation

78. Advantages :
• Non antigenic
• Does not interfere with blood grouping
• Greater plasma volume expansion
• Preserve intestinal micro vascular perfusion in endotoxaemia
• Duration – 24 hrs
Disadvantages :
• Affects coagulation by prolonging PTT, PT and bleeding time by lowering
fibrinogen
• Decrease platelet aggregation , VWF , factor VIII
• Nephrotoxicity
• Hyperamylasemia

79. Contra indications :
• Bleeding disorders , CHF
• Impaired renal function
Administration :
• Adult dose 6% solution – 500ml to 1 lit
• Total daily dose should not exceed 20ml/kg

81. Stay updated…

84. • Holliday and segar for adults
• Adults
• 4:2:1
• mL/hr =
• (4 x first 10kg) +
• (2 x second 10kg) +
• (1 x every 1kg after)
• For pediatric age group
Pediatric age group
Intraoperative 20-30ml/kg
Post operative 2 : 1 : 0.5

85. In terms of blood loss replacement
• Crystalloids
Volume of infusion = 3 x Volume of blood loss
• Colloids
Volume of infusion = Volume of blood loss
ERAS protocols to find the term
“intraoperative fluid restriction” or “zero
balance”Protocols advocate the infusion of balanced crystalloid of 1–3 ml/kg/h and to
give additional boluses of fluid only to match needs judged by either
measured volumes lost during surgery, or the assessment of peripheral
perfusion

86. INTRAVENOUS FLUID THERAPY IN
CRITICALLY ILL

88. The four Ds of fluid
management
• Similarly to antibiotics, the 4 Ds of fluid therapy need to be considered
1. Drug
• Fluids are drugs with indications, contraindications, and side effects.
Different indications need different types of fluids, e.g.,
– resuscitation fluids should focus on rapid restoration of circulating volume;
– replacement fluids must mimic the fluid that has been lost;
– maintenance fluids must deliver basic electrolytes and glucose for metabolic needs.
2. Dosing
• In contrast to most drugs, there is no standard therapeutic dose for fluids.
3. Duration
• The duration of fluid therapy is crucial and volume must be tapered when
shock is resolved. “starting triggers” &“stopping triggers”
4. De-escalation
• The final step in fluid therapy is to withhold/withdraw fluids when they are no
longer required, thus reducing the risk of fluid overload and related
deleterious effects.

89. • Optimal fluid management should thus target efficient central
hemodynamics and tissue perfusion while avoiding positive net fluid
balance.
• Annane et al (2013) ; Large multinational randomized trial performed in
critically ill patients with acute hypovolemia, colloids reduced
vasopressor and ventilator dependency when compared to
crystalloids.
• CHEST / CRISTAL/ FLASH TRIALS

90. THE PROBLEM WITH FLUID OVERLOAD IN
THE INTENSIVE CARE UNIT
• Fluid overload is particularly likely to arise in conditions when capillary
permeability is altered due to an inflammatory response, such as during
sepsis.
• In patients with septic shock, fluid administration and positive fluid balance
were independently associated with increased mortality rates.
• In patients admitted to the ICU after major surgery, fluid balance was an
independent risk factor for death.
• Inadequate resuscitation due to insufficient fluid administration may result in
poorer tissue perfusion and hence organ dysfunction and failure, particularly
in the early phase of treatment.
• As such, fluids must be prescribed on an individual patient basis; the prescription
should be regularly reviewed and tailored to the evolving clinical stage.

91. Stay updated…
2017
Principles and protocols for intravenous fluid therapy -
• Provide intravenous (IV) fluid therapy only for patients whose needs cannot be met by oral or
enteral routes, and stop as soon as possible.
• Skilled and competent healthcare professionals should prescribe and administer IV fluids, and
assess and monitor patients receiving IV fluids
• When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine maintenance,
Replacement, Redistribution and Reassessment.
• Offer IV fluid therapy as part of a protocol.

92. Assess patients' fluid
and electrolyte needs
following Algorithm 1:
If patients need
IV fluids for fluid
resuscitation,
follow Algorithm
2
If patients need IV
fluids for routine
maintenance, follow
Algorithm 3
If patients need IV fluids to
address existing deficits or
excesses, ongoing abnormal
losses or abnormal fluid
distribution, follow
Algorithm 4

96. References
• 1] Sara J. Allen, FANZCA, FCICM. Fluid Therapy and Outcome: Balance Is Best. JECT.
2014;46:28–32
• 2] British Journal of Anaesthesia 99 (3): 312–15 (2007)doi:10.1093/bja/aem219
• 3] Russell L, McLean AS. The ideal fluid. Curr Opin Crit Care. 2014;20:360–5.
• 4] marino
• 5]Dennis O'Neil (1999). "Blood Components". Palomar College. Archived from the
original on June 5, 2013.
• 6] Jump up^ Tuskegee University (May 29, 2013). "Chapter 9 Blood". tuskegee.edu.
Archived from the original on December 28, 2013.
• 7] Scheingraber S, Rehm M, Schmisch C, Finsterer U. Rapid saline infusion
produces hyperchloremic acidosis in patients undergoing gynecologic surgery.
Anesthesiology 1999; 90:1265–1270.
• 8]. Prough DS, Bidani A. Hyperchloremic metabolic acidosis is a predictable
consequence of intraoperative infusion of 0.9% saline. Anesthesiology 1999;
90:1247–1249.

97. Crystalloids or colloids…???
• Crystalloids – recommended as the initial fluid of
choice in resuscitating patients from hemorrhagic
shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after surgery for hip fracture.
Canadian journal of anesthesia 1999 ; 46 : 133 - 141
• COCHRANE Collaboration in critically ill patients –
“ No evidence from RCT that resuscitation with colloids
reduces the risk of death, compared with crystalloids in
patients with trauma or burns after surgery”
Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for fluid
resuscitation in critically ill patients.. Cochrane Database Syst Rev(4) : CD
000567, 2004

98. Thank you