isolyte and preperations

crystalloids and isolyte and their preperations and use in anesthesia

1. CRYSTALLOIDS-2 ( Isolyte and other preparations) Presenter : Dr Isha Bhagat No of slides : 27 Date : 21/10/2020 1

2. Contents: Composition, Pharmacological basis, Indication and Contraindications of: Isolyte G Isolyte- M Isolyte-P Isolyte - E Plasmalyte Conclusion and summary 2

3. Objective of class? By the end of the class we should be able to tell the: Contents of Isolyte and their preparations. pharmacological basis of Isolyte and their preparations. Indications of Isolyte and their preparations. contraindications of Isolyte and their preparations. 3

4. 1) ISOLYTE-G COMPOSITION : One litre of fluid supplies: Conten t Quantity Glucose 50gms Sodium 65mEq Potassium 17 mEq Chloride 150 mEq Ammonium 69 mEq 4

5. Physiological Basis : During vomiting or continuous Gastric Aspiration there is loss of gastric juice. Gastric juice contains 60 mEq /L sodium, 10 mEq /L Potassium and 130 mEq /L chloride along with acidic content. So vomiting or continuous gastric aspiration will lead to Hypochloraemic , Hypokalemic Metabloic Alkalosis. Isloyte -G is gastric replacement solution. It provides all electrolytes lost by gastric juice, corrects alkalosis and provides calories. Ammonium ions in Isolyte -G are converted into urea and Hydrogen ion by liver. H + ion produced will replace the deficit of H+ ion caused by loss of gastric juice . ISOLYTE-G IS THE ONLY I.V FLUID WHICH DIRECTLY CORRECTS METABLOIC ALKALOSIS OF ANY NATURE. 5

6. INDICATIONS : In vomiting and continuous gastric aspiration to replace loss of gastric juice. In treatment of Metabolic Alkalosis due to excessive administration of sodium bicarbonate or aggressive diuretic therapy. 6

7. CONTRAINDICATIONS : 1 ) HEPATIC FAILURE- in severe liver disease ammonium ions in Isolyte -G will not be converted into H+ ion. Accumulation of such unchanged ammonium ions may precipitate hepatic pre-coma in severe liver disease. Moreover, this process of conversion of ammonium ions into H+ ions will be an additional load to the already sick liver cells. 2 ) RENAL FAILURE : Isolyte -G may aggravate Uremic Acidosis ( due to addition of H+ ions) and may lead to Hyperkalaemia in renal failure. 3 ) METABLOIC ACIDOSIS : By providing H+ ions, Isolyte -G will aggravate MA. 4 ) SEVERE VOMITING WITH SHOCK : it carries the risk of Hyperkalaemia due to its high K+ concentration and poor ability to raise BP due to comparatively low Na+ Concentration. 7

8. ISOLYTE- M (MAINTAINANCE SOLUTION WITH 5% dextrose) COMPOSTION : 1 litre of fluid supplies : Glucose – 50 mg Sodium- 40 mEq Potassium- 35mEq Chloride- 38 mEq Phosphate-15 mEq Acetate- 20 mEq 8

9. Pharmacological basis : Isolyte-M is the richest source of Potassium (35mEq), so very useful to treat hypokalaemia. However, always ensure good urine output or normal renal status before its infusion. Proportion of electrolytes in Isolyte-M is almost similar to the maintenance requirements of the body. Additionally, it corrects acidosis and supplies energy. So this fluid fulfils the needs of the body electrolytes, pH maintenance, caloric supply and water replacement and so it is ideal fluid for maintenance fluid therapy. As concentration of Sodium is low ( 40 mEq /L) ,it should be avoided in Hyponatraemia . It is not preferred IV fluid in patients with significant salt and water depletion . M  Maintenance 9

10. Indications : 1 ) F or parenteral fluid therapy, it’s the ideal maintenance fluid. 2) To correct hypokalaemia (k+=35meq) secondary to Diarrhoea, bilious vomiting, prolonged infusion of potassium free IV fluids, ulcerative colitis etc. 10

11. Contraindications : RENAL FAILURE : cautiously used or totally avoided in presence of significant renal failure( ARF/ CRF) due to potential risk of hyperkalaemia. HYPONATREMIA AND WATER INTOXICATION: As Na+ concentration of Isolyte-M is much low, it should be avoided. ADRENOCORTICAL INSUFFICIENCY : These patients have abnormally high potassium concentration and therefore should not receive fluids with high potassium. BURNS : In patients with severe burns potassium concentration may be abnormally high due to tissue destruction and Acidosis. (Moreover, such patients require fluid with high Sodium concentration such as RL rather than hypotonic fluids like Isolyte-M) 11

12. ISOLYTE-P COMPOSITION : ONE litre fluid contains : Glucose- 50gm Sodium-25meq Potassium -20 meq Chloride- 22meq Acetate- 23 meq HPO4- 3meq Magnesium- 3 meq 12

13. PHARMACOLOGICAL BASIS : Isolyte-P is designed to suit maintenance fluid requirement of children. It provides electrolytes, maintains pH, supplies calories and replaces water deficit. As compared to adults, children need more water and same electrolytes. So Isolyte-P provides almost double water but same electrolytes as Isolyte-M. Roughly, Isolyte-P has half concentration of electrolytes as compared to Isolyte-M. Isolyte-P can be used in adults when there is chiefly water loss and only small loss of electrolytes. (e.g.- hypernatremia) isolyteP  Pediatric 13

14. Indications : 1 ) Chiefly, used as a maintenance fluid in infants and children to provide daily water and electrolytes. 2) Excessive water loss or inability to concentrate urine ( e.g.- diabetes insipidus) 14

15. Contraindications : 1) H yponatremia : Among all Sodium containing IV fluids, Isolyte-P has least concentration of Sodium(20meq/l) so it will aggravate hyponatraemia . 2 ) Renal Failure : Cautiously used In RF due to high concentration of Potassium (20meq/l) 3) Hypovolemic shock: Isolyte-P is not the suitable i.v fluid to correct hypovolemic shock ( as with diarrhoea and vomiting) due to low Na+ concentration, ability of isolyte -P to correct intravascular volume and hypotension is poor In oliguric child, high K+ concentration is not safe. Rapid infusion of large volume of Isolyte -P can cause Hyperglycemia and osmotic Diuresis even in child with fluid deficit, which is not desirable. 15

16. ISOLYTE- E ( Extracellular replacement solution) COMPOSTION : 1 LITRE OF FLUID SUPPLIES : GLUCOSE – 50 GM SODIUM- 140 MEQ POTASSIUM- 10 MEQ CHLORIDE- 103 MEQ ACETATE- 47 MEQ CALCIUM- 5 MEQ MAGNESIUM- 3 MEQ CITRATE- 8 MEQ 16

17. PHARMACOLOGICAL BASIS : Isolyte- E is an E xtracellular replacement solution. It has electrolytes similar to ECF except that it has double the concentration of potassium and acetate ( which will get converted into bicarbonate). Patients on long term fluid therapy may develop magnesium deficiency. So Isolyte -E is the only IV fluid available which will correct MAGNESIUM deficiency. So isolyte -E provides all ECF electrolytes, additional potassium and acetate for maximum capacity to correct metabolic acidosis, supplies energy and replaces water deficit. 17

18. Indications : 1- Diarrhoea 2- Metabolic acidosis 3- In maintenance of ECF volume preoperatively. 18

19. Contraindications : 1- Vomiting or continuous nasogastric aspiration will lead to metabolic alkalosis due to to loss of H+ ions in gastric juice. As isolyte -E provides maximum bicarbonate (acetate 47meq/l) among all commercially available IV fluids, it will significantly aggravate metabolic alkalosis. 2- Metabolic alkalosis due to diuretics or sodium bicarbonate. 19

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21. REMEMBER : RENAL FAILURE : ISOLYTE G/M/P are all AVOIDED METABLOIC ALKALOSIS : I SOLYTE-G IS THE FLUID OF CHOICE ISOLYTE E IS CONTRAINDICATED IN IT METABLOIC ACIDOSIS: ISOLYTE G IS CONTRAINDICATED 21

22. Conclusion 22 Same in all Highest Na, Acetate, Mg and Cl in Isolyte E Highest Highest Osmolality

23. Summary : 23

24. Crystalloid vs colloid replacement : Because crystalloids are distributed in the ratio of 1:3 between intravascular and extravascular space , therefore replaced in a ratio of 3-4 times of lost fluid. So for every 100 ml loss of blood 300ml of crystalloid will be required. Replaced in a ratio of 1:1 . So for every 100 ml loss of blood , 100 ml of colloid is sufficient. CRYSTALLOID COLLOID 24

25. Redistribution and evaporative surgical fluid losses: 25 Degree of tissue trauma Additional fluid requirement Minimal ( eg - herrniorrhaphy ) 0-2ml/kg Moderate( eg - open cholecystectomy ) 2-4ml/kg Severe( eg -open bowel resection) 4-8ml/kg Pediatric : 10 ml/kg ( throughout the duration of the surgery )

26. Q) Why are vasopressors diluted in 5% dextrose? Firstly, we dilute vasopressors to prevent intense vasoconstriction during drug infusion. vasopressors are added with 5%D to limit the significant loss of potency through oxidation. It’s not mixed with an alkaline solution. ( rememeber : pH of D5 is the closest to the pH of ADR) 26

27. THANKYOU  SOURCE: PRACTICAL GUIDELINES ON FLUID THERAPY (2 ND EDITION) BY DR. SANJAY PANDYA 27