Intravenous fluid therapy .ppt for medicine and nursing students

This PPT is about intravenous fluid therapy. Which fluid in which setting are to be give. Calculation and formulae are also included.

1. Can You Imagine life without water
????

2. INTRAVENOUS FLUID THERAPY
BY-
DR.KISHAN RAO B

3. WATER
Water has many functions in the body !
Essential for Cell life .
Interfere in the Chemical and metabolic reactions .
Nutrients absorption and transport .
Regulate the Body temperature .
Elimination of waste products through urine .

4. How much of us is water?
•Body muscle mass is rich in water, while Adipose Tissue has a
lower percentage of water content. That’s why:
•Overweight or obese people have a lower percentage of water
compared to someone who's lean and muscular.
•Women typically have a lower percentage of total body water
than men due to a higher percentage of body fat.
•Older adults tend to have a lower concentration of water
overall, due to an age-related decrease in muscle mass.
•Childrentend to have a higher percentage of water weight-as
much as 70-80% in a full-term neonate.

5. How much of us is water?
Input and Output of the “Normal” Adult
Minimal Obligatory Daily input:
500mL: Ingested water:
800mL: Water content in food
300mL : Water from oxidation :
TOTAL: 1600mL

6. Minimal Obligatory Daily water output:
•500mL : Urine
•500mL: Skin
•400mL: Respiratory tract
•200mL: Stool
•TOTAL : 1600mL
•On average, an adult input and output is 30-35mL/kg/day
(about 2.4L/day)

7. Water requirements increase with:
•Fever Sweating
•Burns Tachypnea
•Surgical drains Polyuria
•Gastrointestinal losses through Vomiting or diarrhea
Water requirements increase by 100 to 150 mL/day for each C degree
of body temperature elevation.

8. Body fluid compartments

9. Intracellular Fluid
2/3 of the total body water .
Found inside the plasma membrane of
the body's cells. In humans (average 70
KG), the intracellular compartment
contains on average about 28 liters of
fluid .

10. Extracellular Fluid
Accounts for 1/3 of the TBW, either:
Interstitial, Intravascular and 3
rd
space
1-Interstitial compartment
•It the small, narrow spaces between tissues or parts of an organ. It is
filled with what is called interstitial fluid
•When excessive fluid accumulates in the interstitial space, edema
develops. In the average male (70 kg) human body, the interstitial space
has approximately 10.5 liters of fluid( 15% of the TBW)
Importance:
It acts as the microenvironment that allows movement of ions, proteins
and nutrients across the cell barrier .

11. 2-Intravascular compartment
•The main intravascular fluid in humans is blood;
the average volume of blood in humans is
approximately 70-75 ml/kg

12. 3-Third space
•The third space is space in the body where fluid does not
normally collect in larger amounts.
•For examples the peritoneal cavity and pleural cavity are major
examples of the third space.
•Small amount of fluid does exist normally in such spaces, and
function for example as lubricant in the case of pleural fluid .

14. What are Solutes?
A substance dissolved in another substance
•There are many SOLUTES, for example:
Plasma proteins (eg. albumin, globulins, fibrinogen)
Ions (sodium chloride, magnesium, calcium,
bicarbonates)
Food molecules (eg. glucose, amino-acids), waste
products as urea

15. Definitions
•Mole: 1 mole is atomic wt or mol wt of that substance
in gms
•Equivalent: atomic wt (mole) * valence
•Osmolality: number of moles of a chemical compound
that contributes to the solution's osmotic pressure and
is expressed as mOsm/kg of water
•Osmolarity: number of osmolesof 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

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

17. FLUID THERPY
Goals
•Maintenance of normovolemia and
hemodynamic stability
•Acceptable plasma colloid osmotic pressure
•Correction of electrolyte imbalance
•Correction of acid base imbalance
•Adequate urine output( 0.5 to 1 ml/kg/hr)

18. Indications
•Coma, anaesthesia, Severe vomiting and diarrhoea,
•Dehydration and shock
•Hypoglycemia
•Vehicle for –antibiotics, chemotherapy agents
•TPN
•Critical problems –anaphylaxis, status asthmaticusor
epilepticus, cardiac arrest , forced diuresisin drug overdose,
poisoning

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

20. 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

21. Classification of Fluids
1. Maintenance fluids : replaces insensible fluid losses
5 % dextrose, dextrose with 0.45 % NS
2. Replacement fluids : correct body fluid deficit
gastric drainage, vomiting,diarrhoea, infection ,
trauma, burns
3. Special fluids :
Hypoglycemia–25 % dextrose
Hypokalemia–injKcl
Metabolic acidosis –injsoda bicarb

22. Types of Fluid
The fluids used in clinical practice are usefully classified
into colloids, crystalloidsand blood products
1.Colloid
Solutions that contain large molecules that don't pass
the cell membranes.
When infused, they remain in the intravascular
compartment and expand the intravascular volume and
they draw fluid from extravascular spaces via their
higher oncotic pressure

23. 2.Crystalloid
Solutions that contain small molecules that flow easily across
the cell membranes, allowing for transfer from the
bloodstream into the cells and body tissues.
This will increase fluid volume in both the interstitial and
intravascular spaces (Extracellular)
It is subdivided into:
* Isotonic
* Hypotonic
* Hypertonic

25. When to consider a solution isotonic?
When the concentration of the particles (solutes) is
similar to that of plasma, So it doesn't move into cells
and remains within the extracellular compartment
thus increasing intravascular volume.

26. Types of isotonic solutions include:
0.9% sodium chloride (0.9% NaCl)
lactated Ringer's solution
5% dextrose in water (D5W)
Ringer's solution

27. Normal Saline (0.9%NaCl)
•Composition: Na 154 mEq, Cl154 meq
•Pharmacological basis : provide major EC electrolytes..
corrects both water and electrolyte deficit.
increase the iv volume substantially
Contra indications
•Avoid in pre eclampticpatients, CHF, renal disease and
cirrhosis
•Dehydration with severe hypokalemia–deficit of IC potassium
•Large volume may lead to hyperchloremicacidosis.

28. Indications
•Water and salt depletion –diarrhoea, vomiting, excessive
diuresis
•Hypovolemic shock
•Alkalosis with dehydration
•Severe salt depletion and hyponatremia
•Initial fluid therapy in DKA
•Hypercalcemia
•Fluid challenge in prerenal ARF
•Irrigation –washing of body fluids
•Vehicle for certain drugs

29. TAKE CARE:
Because 0.9% sodium chloride replaces
extracellular fluid, it should be used cautiously
in certain patients (those with cardiac or renal
disease) for fear of fluid volume overload.

30. Ringer’s Lactate (Hartmann solution)
Composition–Na, k , cl, lactate , ca
each 100 ml –sodium lactate 320 mg, Nacl-600mg, kcl-
40mg, calcium chloride 27 mg
Pharmacological basis :
•Most physiological fluid , rapidly expands iv volume..
•Lactate metabolised in liver to bicarbonate providing
buffering capacity
•Acetate instead of lactate advantageous in severe
shock.

31. Indications
•Correction in severe hypovolemia
•Replacing fluid in post op patients, burns
•Diarrhoea induced hypokalemicmetabolic
acidosis
•Fluid of choice in diarrhoea induced
dehydration in paediatrics
•DKA , provides water, correct metabolic acidosis
and supplies potassium
•Maintaining normal ECF fluid and electrolyte
balance

32. Contra indications
•Liver disease, severe hypoxia and shock
•Severe CHF , lactic acidosis takes place
•Addison’s disease
•Vomiting or NGT induced alkalosis
•Simultaneous infusion of RL and blood
•Certain drugs –amphotericin, thiopental,
ampicillin, doxycycline

33. Note:Both 0.9% sodium chloride and RL may be
used in many clinical situations, but patients
requiring electrolyte replacement (such as
surgical or burn patients) will benefit more
from an infusion of RL.

34. 5%Dextrose
Composition: Glucose 50 gms
Pharmacological basis :
Corrects dehydration and supplies energy( 170Kcal/L)
Indications:
•Prevention and treatment of dehydration
•Pre and post op fluid replacement
•IV administration of various drugs
•Prevention of ketosis in starvation, vomiting, diarrhea
•Adequate glucose infusion protects liver against toxic substances
•Correction of hypernatremia

35. Contra indications
•Cerebral edema, neurosurgical procedures
•Acute ischaemicstroke
•Hypovolemicshock
•Hyponatremia, water intoxication
•Same iv line blood transfusion –hemolysis,
clumping occurs
•Uncontrolled DM , severe hyperglycemia

36. Take Care !
-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 inisolation 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.
-Not used in the early postoperative period, because the body's reaction to
the surgical stress may cause an increase in antidiuretic hormone secretion

37. Precautions in usage of Isotonic solutions
•Be aware that patients being treated for hypovolemia can
quickly develop hypervolemia (fluid volume overload)
following rapid or overinfusion of isotonic fluids.
•Document baseline vital signs, edema status, lung sounds,
and heart sounds before beginning the infusion, and
continue monitoring during and after the infusion.

38. Precautions in usage of Isotonic solutions
•Frequently assess the patient's response to I.V. therapy,
monitoring for signs and symptoms of hypervolemia such as:
hypertension / bounding pulse / pulmonary crackles /
peripheral edema / dyspnea/ shortness of breath /
jugular venous distention (JVD)
•Monitor intake and output
•Elevate the head of bed at 35 to 45 degrees, unless
contraindicated .
•If edema is present, elevate the patient's legs.

39. •monitor for signs and symptoms of continued hypovolemia,
including:
urine output of less than 0.5 mL/kg /hour /
poor skin turgor
 tachycardia
 weak, threadypulse
 hypotension
•Educate patients and their families about signs and symptoms of
volume overload and dehydration
•instruct patients to notify if they have trouble breathing or notice
any swelling.
•Instruct patients and families to keep the head of the bed
elevated (unless contraindicated).

40. B-HYPOTONIC FLUIDS
•Comparedwithintracellularfluid(aswellascomparedwith
isotonicsolutions),hypotonicsolutionshavealower
concentrationofsolutes(electrolytes).Andosmolalityless
than250mOsm/L.
•Hypotoniccrystalloidsolutionslowerstheserumosmolality
withinthevascularspace,causingfluidtoshiftfromthe
intravascularspacetoboththeintracellularandinterstitial
spaces.
•Thesesolutionswillhydratecells,althoughtheirusemay
depletefluidwithinthecirculatorysystem.

41. TYPES OF HYPOTONIC FLUIDS
•0.45% sodium chloride (0.45% NaCl), 0.33% sodium
chloride, 0.2% sodium chloride, and 2.5% dextrose in
water
•Hypotonic fluids are used to treat patients with
conditions causing intracellular dehydration, when fluid
needs to be shifted into the cell , such as:
1.Hypernatremia
2.Diabetic ketoacidosis
3.Hyperosmolar hyperglycemic state.

42. HYPOTONIC FLUIDS
Precautions with hypotonic solutions
Never give hypotonic solutions to patients who
are at risk for increased ICP because it may
exacerbate cerebral edema
Don't use hypotonic solutions in patients with liver
disease, trauma, or burns due to the potential for
depletion of intravascular fluid volume

43. Precautions with hypotonic solutions
The decrease in vascular bed volume can worsen existing
hypovolemia and hypotensionand cause cardiovascular
collapse
Monitor patients for signs and symptoms of fluid volume
deficit
In older adult patients,confusion may be an indicator of a
fluid volume deficit. Instruct patients to inform you if they
feel dizzy.

44. C-HYPERTONIC SOLUTIONS
•What is hypertonic solutions?
•Solution that have a higher tonicity or solute
concentration. Hypertonic fluids have an
osmolarityof 375 mOsm/L or higher
•The osmotic pressure gradient drawswater
outof the intracellular space, increasing
extracellular fluid volume, so they are used as
volume expanders.

45. HYPERTONIC SOLUTIONS
Some examples and Indications:
1-3% sodium chloride (3% NaCl):
•May be prescribed for patients in critical situations
of severe hyponatremia.
•Patients with cerebral edema may benefit from an
infusion of hypertonic sodium chloride
2-5% Dextrose with normal saline (D5NS): which
replaces sodium, chloride and some calories

46. DNS
Composition : Na Cl–154 mEq, glucose 50 gm
Pharmacological basis :
•Supply major EC electrolytes, energy and fluid to correct
dehydration
Indications :
•Conditions with salt depletion ,hypovolemia
•Correction of vomiting or NGT aspiration induced alkalosis and
hypochloremia
Contra indications :
•Anasarca–cardiac, hepatic or renal
•Severe hypovolemicshock

47. Precautions with hypertonic fluids:
Maintain vigilance when administering hypertonic saline solutions because
of their potential for causing intravascular fluid volume overload and
pulmonary edema.
Prescriptions for their use should state the specific hypertonic fluid to be
infused, the total volume to be infused and infusion rate, or the length of
time to continue the infusion .

48. Isolyte fluids
IsolyteG IsolyteM IsolyteP IsolyteE
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

49. IsolyteP
•Maintenance fluid for children –as they require less
electrolytes and more water
•Excessive water loss or inability to concentrate urine
•Contraindications : hyponatremia, renal failure
IsolyteE
•Extracellular replacement solution, additional K and
acetate (47mEq)
•Only iv fluid to correct Mg deficiency
•Treatment of diarrhoea, metabolic acidosis
•Contraindications–metabolic alkalosis

50. IsolyteG:
•Vomiting or NGT induced hypochloremic, hypokalemic
metabolic alkalosis
•NH4 gets converted to H+ and urea in liver
•Treatment of metabolic alkalosis
•Contraindications : Hepatic failure, renal failure, metabolic
acidosis
IsolyteM
•Richest source of potassium (35 mEq)
•Ideal fluid for maintenance
•Correction of hypokalemia
•Contraindications : Renal failure, burns, adrenocortical
insufficiency

51. Colloid solutions
How does it work?
•It expand the intravascular volume by drawing fluid from
the interstitial spaces into the intravascular compartment
through their higher oncotic pressure.
•1 ml blood loss = 1ml colloid = 3ml crystalloids
•the same effect as hypertonic crystalloids solutions but it
requires administration of less total volumeand have a
longer duration of actionbecausethe molecules remain
within the intravascular space longer.
•Its effect can last for several days if capillary wall linings
are intact and working properly.

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

53. Albumin
•Maintain plasma oncotic pressure –80 %
•Heat treated preparation of albumin –5%, 20% and 25%
commercially available
Pharmacalogicalbasis :
•5% albumin –COP of 20 mmHg
•25% albumin –COP of 70mmHg ,expands plasma
volume to 4-5 times the volume infused
Rate of infusion :
•Adults –initial infusion of 25 gm
•1 to 2 ml/min –5% albumin
•1 ml/min -25% albumin

54. Indications:
•Plasma volume expansion in acute hypovolemic
shock, burns, severe hypo albuminemia
•Hypo proteinemia–liver disease, Diuretic resistant
nephroticsyndrome
•In therapeutic plasmapheresis, as an exchange
fluid
Contra indications :
•Severe anaemia, cardiac failure
•Hypersensitive reaction

55. Dextran
•Dextran are glucose polymers produced by
bacteria(leuconostocmesenteroides)
2 forms : dextran 70(MW 70,000) and dextran
40(40,000)
Pharmacological basis :
•Effectively expand iv volume
•Dextran 40 as 10% sol greater expansion , short
duration( 6hrs) –rapid renal excretion
•Anti thrombotic , inhibits platelet aggregation
•Improves micro circulatory flow

56. Indications :
•Hypovolemiacorrection
•Prophylaxis of DVT and post operative thromboembolism
•Improves blood flow and micro circulation in threatened
vascular gangrene
•Myocardial ischemia, cerebral ischemia, PVD and
maintaining vaculargraft patency
•Priming in ECC
Adverse effects
•Acute renal failure
•Interfere with blood grouping and cross matching
•Hypersensitive reaction

57. Precautions/CI :
•Severe oligo-anuria
•CHF, circulatory overload
•Bleeding disorders like thrombocytopenia.
•Severe dehydration
•Anticoagulant effect of heparin enhanced
•Hypersensitive to dextran
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

58. Gelatin polymers( haemaccel)
•Sterile, pyrogenfree 3.5 % solution
•Polymer of degraded gelatinwith electrolytes
•2 types
•Succinylatedgelatin(modified fluid gelatin)
•Urea cross linked gelatin( polygeline)
Composition : Na Cl145 mEq, Ca12.5 mEq,
potassium 5.1 mEq
Indications :
•Rapid plasma volume expansion in hypovolemia
•Volume pre loading in regional anesthesia
•Priming of heart lung machines

59. Advantages :
•Does not interfere with coagulation, blood
grouping
•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

60. Hydroxyethyl starch
Hetastarch:
•It is composed of more than 90% esterified
amylopectine.
•Esterification retards degradation leading to
longer plasma expansion
•6% starch -MW 4,50,000
Pharmacological basis :
•Osmolality –310 mosm/L
•Higher colloidal osmotic pressure
•LMW substances excreted in urine in 24 hrs

61. Physiochemical characteristics :
•Substitution of hydroxyethyl groups at C2, C3 and C6
•Concentration : low( 6%), high(10%)
•MW : Low( <70kDa), med and high(>450kDa)
•Degree of substitution : low(0.45 –0.58),
high( 0.62 –0.70)
•C2/C6 : low(<8) , high(>8)
Metabolism:
Rapid amylase dependent breakdown and renal
excretion upto50% in 24 hrs

62. Advantages :
•Non antigenic
•Does not interfere with blood grouping
•Greater plasma volume expansion
•Preserve intestinal micro vascular perfusion in
endotoxaemia
•Duration –24 hrs
Disadvantages:
•Increase in S amylase concentration upto5 days after
discontinuation
•Affects coagulation by prolonging PTT, PT and bleeding
time by lowering fibrinogen
•Decrease platelet aggregation , VWF , factor VIII

63. 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

64. Precautions when using Colloid solutions:
1)The patient is at risk for developing fluid volume overload
2)As for blood products, use an 18-gauge or larger needle to
infuse colloids.
3)Monitor the patient for signs and symptoms of
hypervolemia, including:
•Increased BP
•Dyspnea or crackles in the lungs
•edema.

65. 4)Closely monitor intake and output.
5)Colloid solutions can interfere with platelet function and increase
bleeding times, so monitor the patient's coagulation indexes.
6)Elevate the head of bed unless contraindicated.
7)Anaphylactoid reactions are a rare but potentially lethal adverse
reaction to colloids. Take a careful allergy history from patients
receiving colloids (or any other drug or fluid), asking specifically if
they've ever had a reaction to an I.V. infusion

66. What to do if you suspect transfusion reaction
•Sings of transfusion reaction may include:
fever, flank pain, vital sign changes, nausea, headache, urticaria,
dyspnea, and broncho spasm.
•If you suspect a transfusion reaction, take these immediate
actions:
1.Stop the transfusion.
2.Keep the I.V. line open with normal saline solution.
3.Notify the blood bank incharge.
4.Intervene for signs and symptoms as appropriate.
5.Monitor the patients vital signs.

67. Maintenance therapy
How to calculate maintenance fluid flow rates?
The most commonly used formula is (4/2/1) ,which is used for both
adults and pediatrics.
4/2/1 rule
•4ml/kg/hrfor first 10 kg (=40ml/hr)
•then 2 ml/kg/hrfor next 10 kg (=20ml/hr)
•then 1ml/kg/hrfor any kgsover that
This always gives 60ml/hrfor first 20 kg
then you add 1 ml/kg/hrfor each kg over 20 kg
So: Weight in kg + 40 = Maintenance IV rate/hour
For any person weighing more than 20kg

68. Holiday Segar Method

69. Fluid Resuscitation
Correction of existing abnormalities in volume status or serum
electrolytes (as in hypovolemic shock)
What is the Parameters used to assess volume deficit?
1-Blood pressure
2-Urine output
3-Jugular venous pressure
4-Urine sodium concentration

70. How to know that the patient has Hypovolemic Shock?
The patient has the following sings and symptoms:
1-Anxiety or agitation 2-Cool, Pale skin
3-Confusion 4-Decreased or no urine output
5-Rapid breathing 6-Disturbed consciousness
7-Low blood pressure 8-Low body temperature
9-Rapid pulse, often weak and
thready

71. Rate of Repletion of Fluid deficit:
1-Severe volume depletion or hypovolemic shock:
Rapid infusion of 1-2L of isotonic saline (0.9% NS) as rapidly as
possible to restore tissue perfusion
2-Mild to moderate hypovolemia:
Choose a rate that is 50-100mL/h greater than estimated fluid
losses. calculating fluid loss as follows:
Urine output= 50ml/h
Insensible losses = 30ml/h
Additional loss such as Vomiting or Diarrhea or high fever (additional
100-150 ml/day for each degree of temp >37 C)

72. FLUID OVERLOAD (HYPERVOLEMIA)
It is excessive accumulation of fluid in the body,
due to:
1-Excessive parenteral infusion
2-Deficiencies in cardiovascular or renal fluid
volume regulation

73. Signs and Symptoms
They are not always typical but most commonly are:
1-Edema (swelling) -particularly feet, and ankles
2-Difficulty breathing while lying down
3-Crackles on auscultation
4-High blood pressure
5-Irritated cough
6-Jugular vein distension
7-Shortness of breath (dyspnea)
8-Strong, rapid pulse

74. Management of Hypervolemia
1-Prevention is the best way
2-Sodium restriction
3-Fluid restriction
4-Diuretics
5-Dialysis

75. How to calculate IV flow rates !
What is a drop factor?
Drop factor is the number of drops in one milliliter
used in IV fluid administration (also called drip
factor). A number of different drop factors are
available but the Commonest are:
1-10 drops/ml (blood set)
2-15 drops / ml (regular set)
3-60 drops / ml (microdrop, burette)

76. How to calculate IV flow rates ?
The formula for working out flow rates is:
Example:
1500 ml IV Saline is ordered over 12 hours. Using a drop factor of 15 drops /
ml, how many drops per minute need to be delivered?
volume (ml) X drop factor (gtts/ ml)
---------------------------------------------
time (min)
= gtts/ min
(flow rate)
1500 (ml) X 15 (drop / ml)
---------------------------------------------------
12 x 60 (gives us total minutes)
= 31 drop/ minute

77. Crystalloids or colloids…???
•Crystalloids –recommended as the initial fluid of
choice in resuscitating patients from hemorrhagic
shock
“ No evidence from RCT that resuscitation with
colloids reduces the risk of death, compared with
crystalloids in patients with trauma or burns after
surgery”

78. Last Slide
It’s Over
THANK YOU !