Prof. Mridul M. Panditrao, has added certain special situations where very specific fluid requirement plays a major role.

1. Fluid (s)
(extended)

2. Prof. Mridul M. Panditrao
Professor, Head & In-Charge of ICU
Dean of Academic Affairs
Department of Anaesthesiology & Intensive Care
Adesh Institute of Medical Sciences & Research
(AIMSR)
Adesh University
Bathinda, Punjab, India

3. Introduction
 Water is life!
 Life on Earth started in Water!
 Journey of Human life starts in Water!!
 Water is also a dramatic Paradox
 Too less or too much = Incompatible with life
 So the life is geared up around maintaining the equilibrium !!
 In Fact entire life of the living thing is spent in maintaining
 The fluid balance
 pH balance

4. Introduction
 Quantitatively most important Body constituent
 Males = 60%
Of the total body weight
 Females 50%
 The lesser percentage in females because of larger fat content.
 Water is found in each and every tissue of the body, including
bones and cartilages!

5. Body
Compartments
Total Body Mass
Total Body Water (TBW)
Extra Cellular Fluid
(ECF)
Intra Cellular Fluid (ICF)
Solid Tissues
Intra Vascular
Fluid Interstitial fluid

6. Distribution of Body water
Intra-Vascular Compartment
5%
Interstitial Compartment
15%
Intra- Cellular Compartment
40%
Tissues
40%
Intra-Vascular Compartment Interstitial Compartment Intra- Cellular Compartment Tissues
Percentage Distribution of Various Body Compartments

7. Definitions
Total Body Water (TBW) :
 The sum of intracellular water and extracellular water (volume)
 The latter consisting of
 the interstitial or tissue fluid
 the intravascular fluid or plasma.
 About 60% of body weight
http://medical-dictionary.thefreedictionary.com/total+body+water
http://www.medilexicon.com/medicaldictionary.php?t=99650

8. Definitions
 The Extra-Cellular Fluid (ECF): The water content found outside the
body cells
 Constitutes two major compartments
Inra-vascular & interstitial
 Also contain the trans-cellular fluids that are formed by active transport
processes
Include the fluids of the eye and the secretory glands e.g. saliva, GIT and sweat
glands
In the cavities and channels of the brain and spinal cord (Cerebrospinal fluid, CSF)
Lymph
In body cavities lined with serous (moisture-exuding) membrane and
In muscular and other body tissues
Ingested water or water produced by the body's metabolic processes (metabolic
water).
http://www.britannica.com/EBchecked/topic/199041/extracellular-fluid

9. Definitions
Intra Cellular Fluid ( ICF):
 a fluid within cell membranes of the tissue cells, throughout most of
the body
 containing dissolved solutes that are essential to electrolytic
balance and to healthy metabolism.
 Also called intracellular water
 constituting about 30–40% of the body weight.
http://medical-dictionary.thefreedictionary.com/
www.medilexicon.com/medicaldictionary.php?t=34113

10. Rule of 1/3
 Out of all the compartments in TBW
 We can manipulate only ECF Compartment
 More specifically only Intra-Vascular Compartment
 Quantity of ECF is 1/3rd of the TBW
 Quantity of Intravascular Compartment is 1/3rd of ECF

11. Intra Vascular Volume: Blood
 Blood Volume: is the volume of blood (both red blood cells and
plasma) in the circulatory system of any individual.
 Effective Circulating Volume: that proportion of Intra- vascular
volume ( thus of ECF) that is effectively perfusing the tissue cells
 It is in direct proportion to the
 ECF
 Solute Content dissolved in it ( esp. Na+ salts)
 Solutes hold the water in ECF

12. Solutes:
Solute: A substance dissolved in another substance or
water
both of in-organic as well as organic origin
Solutes in ECF: by and large of in-organic type
E.g. Na+
, Cl
-
, HCO3
-
,
Solutes in ICF: Mixture of Both
E.g. K+, Organic Phosphate esters( ATP, Creatine Phosphate…
etc.)

13. •Mole - A mole is the amount of a substance that contains the number of
molecules equal to Avogadro's number.
•The mass in grams of one mole of a substance is the same as the number of atomic mass units in one
molecule of that substance.
•i.e. the molecular weight of the substance expressed as grams)
•The mole (symbol: mol) is the base unit in the SI system for the amount of a substance
•Molality of a solution is the number of moles of solute per kilogram of
solvent
•Molarity of a solution is the number of moles of solute per liter of solution
 Avogadro's number - this is the number of molecules in one
mole of a substance (i e 6.022 x 1023)

14. Osmole
The amount of a substance
that yields, in ideal solution
that number of particles = (Avogadro’s number)
that would depress the freezing point of the solvent by 1.86K

15. Osmolality & Osmolarity
 Osmolality: Osmolality is a measure of the number of solute
particles present in solution
 Is independent of the size or weight of the particles
 Expressed as : milliosmoles per kilogram of water ( m Osmol/Kg)
 Osmolality of a solution is the number of osmoles of solute per
kilogram of solvent ( m Osmol/Kg)
 Osmolarity of a solution is the number of osmoles of solute per liter
of solution ( m Osmol/L)
http://www.anaesthesiamcq.com/FluidBook/fl2_3.php

16. Osmolality & Osmolarity
 The value measured in the laboratory is usually referred
to as the ‘osmolality’
 The value calculated from the solute concentrations is
reported by the laboratory as the ‘osmolarity’
 The Osmolar gap is the difference between these two
values

17. Tonicity
 Tonicity is the effective osmolality
 Is equal to the sum of the concentrations of the solutes which have
the capacity to exert an osmotic force across the membrane
 Osmolality is a property of a particular solution and is independent of
any membrane
 Tonicity is a property of a particular solution in reference to a particular
membrane

18. Tonicity
 It is strictly wrong to say this or that fluid is isotonic with plasma
 what should be said is that the particular fluid is isotonic with
plasma in reference to the cell membrane
 By convention, this specification is not needed in practice as it is
understood that the cell membrane is the reference membrane
involved.

19. Tonicity Vs. Osmolality
 refers to the relative concentration
of two solutions.
 hyperosmotic, means the
concentration of solutes outside
the cell is greater than the
concentration inside the cell
• refers to what the cell does in
a certain environment.
• If the environment is
hypertonic, the cell will shrink
due to water leaving the cell.
• Hypotonic means water enters
the cell makes it to expand
and possibly explode.
 Effect is same:
 If a hyperosmolar/ hypertonic solution was administered to a patient,
this would tend to cause water to move out of the cell.

20. Electrolytes: definition
An electrolyte
is a substance that ionizes when dissolved in suitable ionizing
solvents such as water
 This includes most soluble salts, acids, and bases
 Some gases, such as hydrogen chloride, under conditions of high
temperature or low pressure can also function as electrolytes
 Cations: Positively charged e.g. Na+, K+, Ca++, Mg++
 Anions: Negatively Charged e.g. Cl-, HCO-, OH-, HPO4--,SO4--
http://en.wikipedia.org/wiki/Electrolyte

21. Main Electrolytes per Compartment
Electrolytes (mEq/L) ECF: Cations ECF: Anions ICF: Cations ICF: Anions
Sodium Na+ 135 - 145 - 8 -10
Potassium K+ 3.5 - 5.5 148 -152
Calcium Ca++ 7 - 10 0.001
Magnesium Mg++ 1.5 - 4 40
Chloride Cl- 95 -105 1-2
Bicarbonate HCO3 - 20 - 24 4-7
Phosphate HPO4 +
Sulphate SO4
5 - 9 145 - 155

22. Plasma Osmolality
 Plasma or Serum Osmolality is Number of solutes dissolved in
plasma
 Normal range is : 275 -290 m Osmols/ Kg of Plasma
 Equation for calculation:
 Plasma Osmolality = 2x S. Na + S. Glucose/18 + BUN/2.8
 Conversion factor for BUN = B. Urea(mg/dl) /2.14
 P. Osmol = 2x S. Na + S Glucose/18 + B. urea x 2.8/ 2.14

23. Body Water Regulation
Increase in osmolality stimulates osmo-receptors in
antero-lateral hypothalamic nuclei
Thirst
Neuro-hypophysis
ADH & AVP
Decreased excretion through kidneys
by increasing re-absorption.

24. Insensible water loss
Skin = 400 - 450 ml/day
RS = 400 - 500 ml/day
GIT (Stool) = 100-200ml/daay
Sweat is not insensible loss
Total Minimal loss around 1L/day

25. Calculation
 Daily Total imperative requirement in a surgical patient/ person is
= absolutely required minimal Urine output + 800-1000 ml
 In a 60 kg male
 i.e. 0.6-0.7ml/kg/hr + 800-1000 ml
 40ml/hr = 1000ml + 1000 ml
 2000ml/24 hrs = 80 – 100ml/hr

26. Classification of I V Fluids
Blood and Products
I V Fluids
Non blood I V Fluids
Crystalloids Colloids
Glucose Containing
Electrolyte solutions
Mixed
Proteinous Non proteinous
Polygelins
• Haemaccel
• Gelofusin
Albumin 20%
& 5%
Starches Dextrans
 HES
 PentaStarch
 Tetrastarch
Lomodex (Dextran 40)
Macrodex (Dextran 70)
Rheomacrodex (Dextran
110)

27. Relative tonicity
 Isotonic : R L, 1N NaCl,D5W (inside body becomes hypotonic)
 Hypertonic: 5DNS, 5D in RL, 5D in ½ N NaCl, 3% NaCl
 Hypotonic: ½ N NaCl
 20% Albumin has osmotic effect 5 times its volume
i.e. 100 ml will increase plasma volume by 400-500ml
Given at the rate of 1-2 ml/min
Correcting fluid deficit is absolutely imperative
5% will increase only by 100 ml ( 0.5-1 ml/min)

28. Crystalloids!
 first-line choice for fluid
resuscitation in
hypovolemia
hemorrhage
sepsis
dehydration
 To achieve the goals:
 as a solution for intravenous
medication delivery
 to deliver maintenance fluid in
patients with limited or no
enteral nutrition
 blood pressure management
 to increase diuresis to avoid
nephrotoxic drug or toxin-
mediated end-organ damage.

29. Various Crystalloids
 Normal Saline (0.9% NaCl solution)
 Lactated Ringers/Hartman's solution (lactate buffered solution)
 Acetate buffered solution
 Acetate and lactate buffered solution
 Acetate and gluconate buffered solution
 0.45% NaCl (hypotonic solution)
 3% NaCl (hypertonic solution)
 5% Dextrose in water
 10% Dextrose in water

30. How Do They Act?: Proposed Mechanism of Action
 A crystalloid is an aqueous solution of mineral salts and other small, water-
soluble molecules
 Most commercially available crystalloids are isotonic to human plasma
 They approximate concentrations of various solutes found in plasma
do not exert an osmotic effect in vivo
 Crystalloid fluids function to expand intravascular volume
without disturbing ion concentration or
causing significant fluid shifts between intracellular, intravascular, and
interstitial compartments

31. How Do they Act?
 Hypertonic solutions
 such as 3% saline solutions contain higher concentrations of
solutes than those found in human serum/plasma
 As a result of this discrepancy in concentration,
these fluids are osmotically active and
therefore, will cause fluid shifts
 Their primary indication is for emergent replacement of serum
solutes,
such as in hyponatremia with neurologic symptoms.

32. How Do they Act?
 Buffered solutions contain molecules that metabolize in vivo to
bicarbonate
 These solutions were designed to sustain a normal physiologic
plasma pH
 The three commonly used molecules are lactate, acetate, and
gluconate
 Lactate and gluconate are hepatically metabolized to bicarbonate
 while acetate is predominantly metabolized peripherally by skeletal
muscle.

33. How to administer?
Fluid Resuscitation:
In an acute setting, rapid infusion of crystalloid may be
indicated
To be administered via a Large bore peripheral line (18gauge or larger)
Through Central venous cannula ( Blood/ products also can be)
It may require a pressure apparatus to the bag of fluid to
achieve a higher infusion rate

34. How to administer?
Maintenance Fluids:
 In 1957 Holliday and Segar determined that
 The fluid requirements of patients was related to their caloric
requirements
 Since this time, their initial formula has been modified to provide
clinicians with guidelines for the administration of maintenance
crystalloid fluids.
 The mass-based formula uses what is known as the "4-2-1" rule:
 0-10 kg: +4 mL/kg/hr
 10-20 kg: +2 mL/kg/hr
 >20 kg: +1 mL/kg/hr
 Example: 70 kg patient: 20 kg (40 + 20 mL/hr) + 50 kg (50 mL/hr) =
100 - 110 mL/hr

35. Adverse Effects?
Volume expansion with crystalloids
 may cause iatrogenic fluid overload
 The risk becomes particularly elevated in patients with
impaired kidney function (acute kidney injury, chronic kidney
disease, etc.),
 these patients should, therefore, receive treatment with judicious
use of intravenous fluids.
 Patients with congestive heart failure are at increased risk
Fluid overload can cause life-threatening pulmonary edema and
the worsening of a diastolic or systolic heart failure
leading to end-organ damage or even death.
 Imperative to monitor these patients carefully and to administer
the minimum required volume to maintain volume homeostasis.

36. Adverse Effects?
Normal saline (0.9% Saline)
 has a higher concentration of chloride ions (154 mmol/L) than is found in human serum
(98 to 106 mmol/L)
 With the administration of large volumes of normal saline, hyperchloremia occurs
 Possible explanation to exact mechanism of this pH disturbance,
 the increase in chloride concentration adjusts the substantial ion difference in plasma
 resulting in more free water in the intravascular space
 As a result, the hydrogen ion concentration in the serum would increase to maintain
electrochemical neutrality
 Excessive renal bicarbonate excretion can occur, resulting in metabolic acidosis.
 The dilution of serum bicarbonate through non-buffered crystalloids (e.g., normal
saline) may also contribute to acidosis.
 In addition, high volumes of normal saline can cause hyperchloremia-induced renal
afferent arteriole constriction,
 which can cause a decrease in the glomerular filtration rate

37. Adverse Effects?
 Acetate buffered crystalloid solutions controversial
 Studies performed on dogs have shown that even small volumes of
acetate containing crystalloids can significantly increase the serum
concentration of acetate to 10 to 40 times the physiologic level
 It is proposed that acetate may potentiate hemodynamic instability
by decreasing both myocardial contractility and blood pressure
 Unlike acetate buffered solutions, lactated crystalloid fluids can
induce hyperglycemia
 Lactate is a metabolically active compound that is utilized during the
gluconeogenesis to produce glucose
 Hence, excessive administration of lactated crystalloids may be of
concern in diabetic patients.

38. Contraindications
 Patients who are fluid-overloaded should not receive crystalloid fluids.
 Special care is prudent when administering fluids to patients with
congestive heart failure or those with significant renal impairment (e.g.,
CKD-V dialysis-dependent patients)
 Hypertonic saline is contraindicated in all clinical settings except in
patients with severe hyponatremia and neurologic sequelae.
 Rapid correction of hyponatremia may cause central pontine myelinolysis,
a devastating neurologic condition
 Hypotonic solutions are also contraindicated in patients with or at risk of
developing cerebral edema.

39. Contraindications
 Crystalloids containing potassium (Lactate ringers, Hartman’s
solution, etc.) are relatively contraindicated in hyperkalemic patients
 can lead to ventricular dysrhythmias.
 avoid using crystalloids containing dextrose (D5%W, D10%W, D5%
0.45% NS, etc.) in patients with hyperglycemia.
 Ringer Lactate solution contains calcium ions.
 Calcium can induce coagulation of the blood products in the IV
tubing and therefore inhibit their effective delivery.
 blood products should utilize a separate IV setup.

40. Monitoring
Patients should undergo assessment for signs and symptoms of dehydration and
fluid overload.
 Indications that a patient may receive inadequate volume include elevated lactate
and creatinine concentrations in the absence of an alternate cause.
 The urine output also requires monitoring. An ideal urine output target of 0.5 – 0.6
mL/kg/hr indicates adequate hydration
 but may not be useful to assess volume status in patients with renal impairment.
 To monitor for fluid overload, patients receive frequent re-evaluation.
 Clinically assess for new or worsening crackles.
 These sounds may indicate pulmonary edema secondary to volume overload.
 Additionally, any new or worsening peripheral edema in the extremities is also a
potential complication of excessive crystalloid fluid administration.

41. Colloids: Dextrans
 Dextrans are branched polymers of Glucose molecule
 40, 70 and 110 are, mol. Wts : 40000, 70000 and 110000 Daltons
 40 is 10% while 70 is 6%
 Act as Antithrombotic, by decreasing RBC aggregation
 Total dose not more than 20ml/kg in 24 hrs
 Hyperglycemic effect
 Not commonly used nowadays

42. Colloids : starches
 Excellent Volume expanders
 All of the volume remains inside Intra vascular compartment
 Effect lasts for 4-6 hours
 Interference with platelet aggregation: HES> Penta> tetra,
Least
 Increase the volume by nearly 100 to 150 % depending upon %
conc.
 Tetrastarch: Voluven Better of all
 Made from corn starch: least antigenic
 Up to 35ml – 50 ml/ kg/ 24 hours can be given

43. Colloids: Polygelins
 Modified: degraded gelatin polymers
 Derived from animal bones
 Can expand plasma by 50%
 Do not have any interference with agglutination, platelet
aggregation
 Have been found have variety of allergic reactions : minor to
anaphylaxis
 Have been implicated in transmission of Creutzfeldt-Jakob’s
disease (Mad Cow disease) to humans
 Slowly becoming obsolete

44. Fluids: In Special Situations!

45. Chronic Liver Disease/ Cirrhosis of Liver
 A large amount of extracellular fluid may be stored in the
extravascular compartment in these patients
 as evidenced by the presence of ascites and edema
 Patients may seem fluid overloaded while intravascularly volume
depleted and at risk of renal failure
 Over-resuscitation with intravenous (IV) fluids in a fluid-overloaded
patient in shock may worsen the clinical situation by fueling
ascites, hyponatremia, and edema.
 Excessive fluid therapy may also increase PH and increase the risk
of hemorrhage in the setting of variceal bleeding

46. Chronic Liver Disease/ Cirrhosis of Liver
 crystalloids should be used as first-line treatment
 Recently, some evidence suggested that, among crystalloids, balanced salt
solutions should be preferred to normal saline, as the risk of hyperchloremic
acidosis and subsequent adverse kidney events may be decreased.
 The use of colloid solutions in resuscitation from shock has been more
controversial.
 Hydroxyethyl starch, one of the frequently administered colloid solutions, may have
an unacceptable safety profile, notably by inducing potential nephrotoxicity, while
offering no benefits other than a clinically unimportant volume-sparing effect
 Some evidence supports the specific use of albumin for volume loading in ACLF
patients. Indeed, albumin offers numerous advantages over crystalloids beyond the
simple volume expansion in patients with cirrhosis.

47. Chronic Liver Disease/ Cirrhosis of Liver
 Albumin is recommended as the first-line volume therapy for 48 hours
in cases of Kidney Disease Improving Global Outcomes stage 2 and in
combination with vasoconstrictors in the treatment of hepatorenal
syndrome
 Finally, albumin was also proven to be superior to other fluids in the
prevention of postparacentesis circulatory dysfunction and related
renal vasoconstriction.
 The ANSWER trial very recently showed that weekly IV albumin
infusions reduced 18-month mortality in patients with decompensated
cirrhosis and persistent ascites despite diuretic therapy

48. Supportive therapy
 Fluid restriction: to less than 1000 mL/ day
 Salt restriction: 2 Gm or less /day
 Diuretics: combination of the aldosterone antagonist ( to combat the
secondary hyperaldosteronism) + Loop (to avoid the hyperkalemia)
 Spironolactone 80-100 mg + frusemide 20-40 mg/ day ( up to 400 mg+ 160
mg/day maximum)
 if required Peritoneal tap
 To achieve the target weight loss 1-5 kg/day depending upon the symptomatic
fluid retention
 If ascites and peripheral edema present : 1 kg/day
 If only ascites : 5 Kg/day

49. Supportive therapy
 If no improvement in spite of high dose diuretic therapy, then it
considered, refractory ascites
 Large volume paracentesis may have to be implemented.
 PT, INR to be monitored
 Vit K
 FFPs
 Rarely rFVIIa (Novoseven) may have to be administered.
 Anti hepatic encephalopathy treatment has to be administered
 Betablocker: propranoloi for hypertension.
 Contraindicated: Sedatives, hypnotics, NSAIDS,
 Avoid High protein diet, hypovolemis, hyponatremia and hypokalemia

50. TREATMENT GUIDELINES FOR ESTABLISHED ARF
 Discontinue all potentially nephrotoxic drugs Consider induction of
emesis and administration of activated charcoal and sodium sulfate to
decrease further absorption of ingested toxicant
 Obtain baseline data (body weight, PCV, total protein, urinalysis, serum
biochemistry profile, and blood gas analysis) prior to initiating fluid
therapy
 Identify and correct any pre- or postrenal complications
 Initiate intravenous fluid therapy with 0.9% or 0.45% saline with 2.5%
dextrose-replacedeficits within 6 hours and provide maintenance and
continuing loss fluid needsQuantitate urine output
 Assess and correct any acid-base and electrolyte abnormalities Rule
out potential treatable causes of the renal failure (e.g., hypercalcemia,
pyelonephritis, and Leptospirosis)

51. TREATMENT GUIDELINES FOR ESTABLISHED
ARF Provide mild volume expansion and/or administer diuretics and vasodilators if patient
remains oliguric
 -mannitol
 -furosemide and dopamine
 Adjust maintenance fluid requirements based on urine output
 Recheck baseline data at least daily during fluid therapy. Change fluid type and/or
supplement with potassium as necessary.
 Consider peritoneal dialysis if no response to above treatments after 3 days-obtain a
kidney biopsy at the time of dialysis catheter placement
 Control vomiting and gastroenteritis
 -metoclopramide
 -H2 receptor blockers
 Provide caloric requirements (70-100 kcal/kg/day) if possible
 Control hyperphosphatemia with phosphate-restricted diet and enteric phosphate binders
if necessary

52.  Strict Fluid restriction: daily intake of less than 1 liter/day
 Salt Restriction : 2-3 gm/day
 Protein restriction 0.6 g/kg/day
 Phosphorus Management: blood level to be kept less than 4.6 mg/dl, before
dialysis and less than 5.5 mg/dl when on dialysis
 Restriction to less that 1000mg/dl
 Oral phosphorus binders like, aluminium hydroxide, calcium carbonate or
calcium acetate three to four times aday
 Low potassium diet potassium binder sodium polystyrene sulphonate
 Calcium supplementation as well as Vit D supplement
 Renal replacement therapy
 Hemodialysis
Fluid Management of CRF

53. Hypovolemia
Extra renal
Hemorrhage
Gastro-intestinal
Skin
Renal
Diabetes insipidus
Diabetes mellitus
Drugs: Diuretics
Hypoaldosteronism
Salt wasting
nephropathies
ECF Volume Reduced

54. Hypovolemia
 Decreased Cardiac Output
CCF
 Redistribution of Fluid
Decreased PCOP
Cirrhosis
Nephrotic Syndrome
Capillary leak
Ischemic Bowel: Third space loss
Ac. Pancreatitis
 Increased Venous Capacitance
Anaphylaxis
 Mixed of all
SEPSIS
ECF Volume increased ( Low circulatory/Intra-Vascular volume)

55. Diagnostic Criteria
 S. Na: Low if both Na+H2O, High if only H2O
 BUN/ S. Creatinine raised & BUN: Creatinine ratio > 20:1
:: .. If Pre-Renal azotemia
 CVP: 2 tests
 Lower than normal (8 – 10 CM H2O) = In IPPV patient deduct PEEP of more than 5 cm H2O :
 Volume Challenge: 250-500 ml of rapid infusion RL/NS will increase CVP, but cannot sustain it more
than 10 minutes.
 USG & IVC = correlation between
IVC size, Respiration & CVP
 IVC size decreases with respiration
IVC Size Respiratory
change
CVP cm
H2O
<1.5 Total Collapse 0-5
1.5 -2.5 >50% Collapse 6-10
1.5 -2.5 < 50% Collapse 11-15
>2.5 <50% Collapse 16-20
>2.5 No Change >20

56. Hemorrhagic Hypovolemia: Surgical
 Calculate Estimated Blood Volume (EBV): approx. 75-80 ml/ Kg
 Categorize the blood loss: Fromme - Boezaart Surgical Field Grading
Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional
endoscopic sinus surgery. Canadian Journal of Anaesthesia 1995; 42: 373-6
F-B
Grade
% age of
EBV
Fluid to be
transfused
1 - 2 Less than
10
Maintenance with
NaCl/ RL= 1ml/kg/hr
3 10 - 20 Increase the rate of
Crystalloid =
2ml/kg/hr
4 20 – 25% Colloid
5 25% or
more
Stat Blood
transfusion

57. Management : Non-Hemorrhagic Hypovolemia
 Intra-Venous Fluids : Irrespective of Na level.. Initial fluid is NS
 If Na low– 0.9% N NaCl
 If Hypernatremia : ½ N NaCl
 Strict I/O chart with Hourly urine record
 Choice of I V fluid as per I-V Compartment stay : 1 Liter
Type of fluid Intra vascular in
ml
Interstitium in ml Intra cellular in
ml
5% D/W 75-100 (10%) 230 - 260 ( 20-
23%)
670 (67%)
1 N NaCl 300 (30%) 700 (70%) 0 (0%)
1/2N NaCl 170 (17%) 500 (50%) 330 (33%)
Colloids 1000 (100%) 0 (0%) 0(0%)

58. According to indication
Pathology Choice of IV Fluid
Non-Hemorrhagic hypovolemic shock NaCl/RL/Colloids
Diarrhea RL/ NaCl
Vomiting Isolyte G, NaCl
DKA NaCl
Burns RL
Starvation 5% D/W
Maintenance Adult Isolute M
Maintenance Pediatric Isolyte P
Required Na = desired Na – actual Na x ( 0.6 x Body weight in Kg.): 0.5 females

59. Protocol
 Impossible to measure exactly the total deficit
 Empirically : RL or NaCl at the rate of 30ml/Kg bolus
 RL is preferred as less chances of Hyperchloremic metabolic acidosis
 Strict watch on: vitals, CVP, Urine output, GCS, ABG
 Maintain CVP 8-12cm H2O
 Urine 0.5-0.6ml/kg/hr
 Improved sensorium
 Decreased Hematocrit and BUN: creatinine ration> 20:1
 Decreased Metabolic Acidosis

60. Syndrome of Inappropriate ADH (SIADH)
 Syndrome of impaired water excretion with retention of water
leading to increase in TBW, hyponatremia but NO CLINICAL
OEDEMA
 Multiple aetio-pathgeneses: stress, surgery, anesthesia, pain,
sepsis, inflammatory process, tumors, CNS disorders
 Low Na: 130, low osmolality < 270 mosm/L ,but normovolemia
 Increased urine osmolality>100mosm/L, urine Na> 40mEq/L
 Normal renal, endocrine, K levels and acid-base balance

61. Correct underlying cause
Fluid restriction: < 800ml/day
Loop Diuretic
Hypertonic (3%) NaCl
High Protein diet will increase renal water excretion
SIADH

62. Diabetic Keto Acidosis (DKA)
 Triad: Hyperglycemia, Dehydration and Hyperketonemia with Metabolic acidosis
 Deficit levels in DKA
 Fluid deficit: 100ml/Kg---- 50% replace with NaCl (ECF)
---- 50% replace with dextrose (ICF)
 Na 7-10 mEq/Kg
 K 3-5 mEq/kg
 PO4 5-7
 Ca 1-2
 Mg 1-2
 ABG: severe acidosis with HCO3 grossly reduced

63. DKA: Management
 A,B, C
 Fluid Therapy
 NaCl: 10-15ml/Kg/hr. up to 50ml/kg in first 4 hours
 1000ml in first 30 min : next 1000 in 1hour: next 1000 in next 2 hours: next 1000
in next 2-4 hours
 When Blood sugar to 250mg/dl: D5W 1000ml/ 8hourly : continue with NaCl and
D5W 1000 ml every 12 hours
 Nearly 6 liters fluid in first 24 hours
 Strict watch on CVP, I/O, urine, ABG(acidosis), sensorium, S. Na levels
 Strict watch On S. K levels.

64. DKA : Insulin
Role of Insulin: if K > 3.3 mEq/Lit
 After initial NaCl infusion has started
 Initial Infusion of 0.15 Unit/Kg regular = 10 units/ hr
 Or Add 50 units in 50 ml NaCl
 6units/hr infusion initially
 Reduce to 5 units/hr when glucose < 500mg/dl
 Reduce to 4 units/hr when glucose < 400 mg/dl
 Reduce to 3 units/hr when glucose < 300 mg/dl
 Reduce to 2 units/hr when glucose < 200 mg/dl
 Maintain on 0.05-0.1unit/kg/ hr infusion
 Switch over to sub cutaneous once sugar <200, HCO3 >18

65. DKA: Potassium Replacement
 Despite total Body K deficit S.K is normal
 With Volume replacement the K level drops
 K <3.5 = KCl 40 mEq/L : Give 1 L of NaCl
 K 3.5- 5 = KCl 20 mEq/L :Give 1 L of NaCl
 K > 5 or Anuria NO KCl to be given
 EKG:
Tall Ts HyperKalemia &
Flat Ts and Us HypoKalemia

66. FLUID THERAPY POTASSIUM SUPPLEMENTATION
GUIDELINESMeasured Serum Potassium Concentration
(mEq/L)
Amount of Potassium Chloride (mEq)
to be Added to Each Liter of Fluid*
3.0-3.5 28
2.5 -3.0 40
2.0-2.5 60
<2.0 80
*Do not exceed a rate of 0.5 mEq/kg/hour.

67. DKA: HCO3
 Not Recommended routinely
 Only if
pH <7, Shock/ Coma, CVS/RS , Hyper Kalemia
 If ABG not available:
 (24 - pt’s HCO3) x (0.5 x Wt. in Kgs.)
 If ABG available:
HCO3 required = BE x 1/3 of Body Wt. in Kg. & ½ correction

68. DKA : Supportive T/t
 O2 By mask/ Venti-Mask / ETT & IPPV
 CVP
 N G / Urinary Catheter = I/O Balance
 Colloid If MAP< 60 mmHg/ Syst BP< 90mm Hg
 Antibiotics/Gastric Prophylaxis/
 Mg and PO4 correction if required

69. Burns : Fluid Therapy
Goals:
 To Maintain tissue perfusion : confirmed by hrly urine output
 To reduce the rate of catabolism or
 To overcome the negative effects of Catabolism
 If less than 20% burns = Oral fluids.. Exceptions facial, hand and
genital burns
 If more : Parkland’s formula = total vol. in first 24 hours.

70. Parkland’s Formula
 4ml/Kg/% burn for adult & 3ml/Kg/% burn for children
 Ringer’s Lactate only
 Total calculation to be transfused in first 24 hours
 50%( half the volume) given in first 8 hours
 Remaining 50% ( half) in next 16 hours
 Children:
4 ml/kg/% burn in 0 – 10 kg
40 ml/hr + 2ml/hr for 10 – 20 kg
60 ml/ hr + 1ml/kg/hr for more than 20 kg

71. Next24 hours: No crystalloids, 5% Albumin (Colloid)
Up to 60% of estimated Plasma Volume
D5W as maintenance for urine: 0.5 – 1 ml/hour
Modified Parkland formula
Initial 24 hours R L 4ml/kg/ % burn
Next 24 hours Colloid infusion 5% albumin 0.3 -1 ml/kg/%
burns
Parkland’s formula

72. Conclusion
Fluid Therapy is the ‘ Make’ or ‘Break’ for many patients.
Especially in evolving/ imminent or existing Crisis
Understanding and executing appropriate fluid therapy is
the most essential duty of a clinician
A small oversight or miscalculation can cause a major
disaster for the patient
Continuous updating of our knowledge is most essential

73. Thank You!