Crystalloids

crystalloids

1. CRYSTALLOIDS DR.ZIKRULLAH

2. INTRODUCTION Crystalloid solutions are aqueous solutions of low-molecular-weight ions (salts) with or without glucose . May be isotonic, hypertonic or hypotonic salt solutions. Crystalloid solutions are used to provide maintenance water and electrolytes and to maintain intravascular fluid volume. The replacement requirement is threefold to fourfold the volume of blood lost because administered crystalloid is distributed in a ratio 1 : 3 similar to ECF, which is composed of about 3 L intravascularly (plasma) and about 9 L extravascularly (interstitial).

3. Advantage and Disadvantage of Crystalloids Advantages- Crystalloids are inexpensive and non allergic. They are more effective at replacing ECF and are not associated with transmission of infection, impairment of coagulation or cross matching. Disadvantages- Crystalloids exert short lived hemodynamic effect in comparison to colloids. When used for massive fluid resuscitation, they invariably produce peripheral edema and occasionally pulmonary edema.

4. Water+electrolytes high mol wt subs. Osmotic pressure oncotic pressure. Reduced increased. Extravascular sp. Intravascular sp. Transient sustained. 3-4 times of loss equal to loss. No effect interfere. Produce do not. No may occur. Economic costly… Composition Pressure Oncotic press. Distribution Half life . Volume req. X matching. E dema . Anaphylaxis. Cost Differences between crystalloid and colloid solution Crystalloid Colloid

5. CRYSTALLOIDS Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Plasma 7.4 140 4.5 103 5 2 290 0.9% NS 5 154 154 308 0.45% NS 5 77 77 154 3% NS 513 513 1026 0.45%DNS 77 77 50g/L 350 5%DNS 154 154 50g/L 564

6. CRYSTALLOID Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L RL 6.5 130 4 109 3 28 274 5%D 4.2 50g/L 253 Iso -G 63 17 150 50g/L 70 274 Iso -M 40 35 40 50g/L 20 580 Iso -P 25 20 22 50g/L 23 410 Iso - E 140 10 103 5 3 50g/L 47 368

7. ISOTONIC SALINE (0.9% NaCl ) MECHANISM- Principle component is NaCl Na is most abundant extracellular solute. 75-80% of extracellular Na is in interstitial space as the ECF. I.V administered NaCl solutions follow the same principle. 1L of .9%NaCl adds 275 mL to plasma volume and 825 mL to interstitial volume.(total 11oo mL ) Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose/L Acetate/L NH4cl/L Osmolarity mOsm/L 0.9% NS 5 154 154 308

8. INDICATIONS Hypovolemic shock Tt of alkalosis ( vomiting) with dehydration . In hyponatremia . Initial fluid therapy in DKA . Water and salt depletion as in diarrhoea , vomiting , excessive diuresis and perspiration. Tt of hypercalcemia Fluid challenge in prerenal ARF Irrigation for washing of body fluid and cavity .

9. CONTRAINDICATION Cautious use or avoid in hypertensive or preeclamptic patients and in patients with edema due to CHF , renal Disease and cirrhosis. Dehydration with severe hypokalemia :- with severe hypokalemia there is deficit of even ICF potassium so infusion of NaCl without additional Potassium supplement will aggravate electrolyte imbalance of ICF. Infusion of large amount of isotonic saline can produce hyperchloremic metabolic acidosis . 9

10. RINGER’S LACTATE Physiological basis :- Also known as Hartman solution. Ringer lactate is the most physiological fluid as its electrolyte conc. and Osmolality is near to plasma, even in larger amount of RL can be infused without or with minimal electrolyte imbalance. It is also useful in correction of metabolic acidosis . Lactate is used as a buffer instead of bicarbonate because in stored solution lactate is more stable . I t is slightly hypotonic, providing approximately 100 mL of free water per liter and tending to lower serum sodium .

11. REABSORPTION INDICATION Replacement fluid in perioperative period, burn and fracture. Diarrhoea induced hypovolemia with hypokalemic metabolc acidosis. For maintaining normal ECF and electrolyte during and after surgery. Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose/L Acetate/L NH4cl/L Osmolarity mOsm/L RL 6.5 130 4 109 3 28 274

12. CONTRAINDICATIONS Liver disease , severe hypoxia and shock - lactate metabolism is severely impaired. RL infusion can lead to lactic acidosis in such patients. CHF- lactic acidosis takes place , which is more in heart tissue. Lactate given can’t be utilized, so it ppt condition . Vomiting or continuous NG aspiration – here hypovolemia is associated with metabolic alkalosis , as RL provide bicarb so its worsen alkalosis. Calcium in RL- bind with citrate (CPDA) in blood transfusion and this can inactivate the anticoagulant and promote the formation of clot in donor blood . Calcium in RL- binds with certain drugs (thiopental, doxycycline , ampicillin , aminocaproic acid) and reduce their effectiveness.

13. DEXTROSE - 5% PHARMACOLOGICAL BASIS:- C orrects cellular dehydration and supplies energy- After consumption of dextrose , remaining water distributed in all compartment of body proportionately and less than 10% of the volume remains in the vascular compartment . Therefore D-5% is best agent to correct intracellular dehydration . D-5 % is selected when there is need of water but no electrolyte 1 gm dextrose provide 3.4 kcal energy( 170 kcal/L ). Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose/L Acetate/L NH4cl/L Osmolarity mOsm/L 5%D 4.2 50g/L 253

14. For treatment of ketosis in starvation , diarrhoea , vomiting , high grade fever. Adequate glucose infusion protects the liver against toxic substances. Correction of hypernatremia due to pure water loss ( eg DI ). Cerebral edema Neurosurgical procedure Acute ischaemic stroke Hypovolemic shock :- as it doesn’t substantially increase intravascular volume .moreover fast replacement can lead to hyperglycemia and osmotic diuresis . Hyponatremia and water intoxication. Blood transfusion :-not given with same I.V line as hemolysis and clumping can occur. DEXTROSE - 5% INDICATIONS:- CONTRAINDICATION

15. DNS (5% dextrose with 0.9 % NaCl ) PHARMACOLOGICAL BASIS :- DNS has advantage of providing both 5% dextrose ( for energy ) and NaCl (for salt ). So DNS is useful to supply major E.C. electrolyte and energy along with fluid to correct dehydration . As DNS increase only ECF volume , it can be consider in treatment of hypovolemia . But like D-5 % , faster infusion of larger volume of DNS will lead to large glucose load (> 25 gm / hr), leading to hyperglycemia induced osmotic diuresis . Unlike D-5 %, DNS is not hypotonic ( due to NaCl ) and hence it is compatible with blood transfusion .

16. INDICATIONS Correction of salt depletion and hypovolemia with supply of energy . Correction of vomiting or NG aspiration induced alkalosis and hypochloremia along with supply of calories. Fluid compatible with blood product. Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L 5%DNS 154 154 50g/L 564

17. CONTRAINDICATION Cautious use in cardiac , renal disease . Hypovolemic shock:- not preferred in severe hypovolemic shock , when rapid replacement with larger volume of fluid is required . Rapid infusion of DNS can cause hyperglycemia and osmotic diuresis . It can result in metabolic acid production instead of metabolic energy production.

18. HYPERTONIC SALINE(3% NaCl ) INDICATIONS- In severe salt depletion when rapid electrolyte restoration is of paramount importance. Cerebral and pulmonary edema . CONTRAINDICATIONS should be used with great care, if at all, in patients with congestive heart failure, severe renal insufficiency, and in clinical states in which there is sodium retention with edema .

19. PHARMACOLOGICAL BASIS :- I.V. fluid which fulfill maintenance requirement of children. As compare to adult , children need more water and same electrolyte . So it contains double water but same electrolyte as ISO-M. ISO – P Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -P 25 20 22 50g/L 23 410

20. INDICATION Chiefly used as maintenance fluid in infant and children to provide daily water and electrolyte . Excessive water loss or inability to concentrate urine ( DI) CONTRAINDICATION HYPONATREMIA ( low Na+) RENAL FAILURE ( high K+) HYPOVOLEMIC SHOCK :-isolyte –P is not suitable to correct hypovolemic shock (diarrhoea, vomiting) because low Na+ , high K+ in oliguric state in not safe . And rapid infusion of large ISO-P can cause hyperglycemia and osmotic diuresis. ISO - P

21. ISO - E PHARMACOLOGICAL BASIS: ISO-E is extracellular replacement solution. Electrolyte are similar to ECF except that it has double the concentration of K+ and acetate. So this fluid provide all ECF electrolyte , supply energy , replace water deficit . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso - E 140 10 103 5 3 50g/L 47 368

22. ISO–M PHARMACOLOGICAL BASIS :-ISO- M is richest source of K+ . So very useful to treat hypokalemia . Before adm . ensure good urine output and renal function . As it contain low Na+( 40 mEq /L),so should be avoided in hyponatremia . Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -M 40 35 40 50g/L 20 580

23. ISO – G PHARMACOLOGICAL BASIS :- During vomiting or continuous NG aspiration there is loss of gastric juice , which lead to hypochloraemic , hypokalemic metabolic alkalosis. ISO-G is gastric replacement solution . It provide all electrolytes lost by gastric juice, corrects alkalosis and provides calories. Ammonium ions in ISO-G are converted into urea and hydrogen ion in liver. So ISO-G only fluid which directly correct metabolic alkalosis if any. Electrolytes pH Na mEq/L K mEq/L Cl mEq/L Ca mEq/L Mg mEq/L Lact. mEq/L Glucose acetate NH4cl Osmolarity mOsm/L Iso -G 63 17 150 50g/L 70 274

24. Which fluid to give and how fast ? Fluid depends on nature of loss , hemodynamics & electrolyte and underlying disease. Fluid should be which correct volume and electrolyte abnormality. Elderly and anemic patient require slower and more careful correction and monitoring.

25. Hypotonic fluids (0.45%ns,0.33%NS,5%D) Maintenance, intracellular dehydration Avoid –head injury, trauma, burns Isotonic fluids (RL, 0.9%NS) Hypovolemic patients Hypertonic fluids (3%NS, 5%DNS,10%D) Hypovolemia Nutrition, electrolyte disturbances Hypertonic saline in cerebral and pulmonary edema. Use with caution- impaired renal and cardiac function Avoid in cellular dehydration Choice of fluids

26. GOAL OF FLUID Maintain normovolemia Hemodynamic stability Maintain electrolytemia Maintain tissue perfusion Maintain adequate urine output Avoid fluid overload and deficit

27. Prevention of contrast induced nephropathy – Hydration with normal saline at 100-150ml/hr. Reduce intake in patients who are oliguric Avoid K containing solution Use hypertonic solutions with caution. In polyuric phase – replacement with NS. Rate equal to previous hours urine output. Monitor electrolytes. Liver failure - use dextrose, avoid RL Renal failure and liver failure

28. Resuscitate with isotonic fluids preferably NS. Avoid synthetic colloid in patients with head injury or intracranial bleeding. Avoid dextrose containing solutions Avoid hypotonic solutions There is no advantage in hypertonic fluids with brain injury. Mannitol effective only if BBB intact Avoid electrolyte disturbances Trauma patients with head injury

29. Loss of Na and water in first 6-8hrs and continues for 48hrs Initial resuscitation –Parkland formula First 24 h: RL at 4ml/kg/% TBSA; give half in first 8 h & the remaining over next 16 h Second 24 h: colloid at 20-60% of calculated plasma volume to maintain adequate urinary output After initial resuscitation use a combination fluid infusion of albumin and 5%D. From 3 rd day reduce intake as there is sodium and water reabsorption . Burns

30. Water and electrolyte loss due to osmotic diuresis Hyperkalemia due to acidosis. However there is total body potassium deficit Initial resuscitation with isotonic saline or RL along with IV insulin 0.1units/kg/hr After 3-4L of NS give 0.45%NS to avoid hyperchloremic acidosis. Give 0.45%DNS when blood sugar is <200mg/dl 20-30mEq/L K + to be added if Sr K + <5.3 and patient has good urine output Diabetic ketoacidosis

31. Treat IV fluids as “prescription” like any other medication. Determine if patient needs maintenance or resuscitation. Choose fluid type based on co-existing and anticipated electrolyte disturbances. Choose rate of fluid administration based on weight and minimal daily requirements. Monitor electrolytes. Always reassess whether the patient continues to require IVF. Summary

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