Crystalloid

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) - 2/3 rd of TBW 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. INTRAVENOUS THERAPY Intravenous (IV) therapy  is the administration of a fluid substance (solution) directly into a vein as a therapeutic treatment. CLINICAL CLASSIFICATION OF IV FLUIDS: Crystalloids Colloids 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 OSMOLARITY 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 5.7 308 Isotonic Resuscitation RINGER’S LACTATE 130 109 4 3 6.4 Lactate 28 mEq/L 273 Isotonic Resuscitation D5W 50 252 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 2/3 rd 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.