IV FLUIDS & PLASMA EXPANDERS PHARMACOLGY.ppt

FLUIDS FOR RESUSCITATION AND LIFE SAVING

2. IV FLUIDS & PLASMA
EXPANDERS

3. • WATER accounts 60% of body weight in normal persons
• It is contained in three comparments namely
• INTRACELLULAR ( 40%)
• INTERSTITIAL (16%)
• Intravascular (4%).
• Interstitial & Intravascular compartment is otherwise called
• as ECF
•Therefore in a 70 kg adult
• TBW - 42 L
•
• INTRACELLULAR WATER – 28 L
• ECF _ 14 L.
•
•
•

4. The activity of particles in a solution is inversly
related to the activity of water molecules in that
solution.
This is called as osmotic activity & is expressed in
terms of “osmoles”. Water moves from side where
the solute concentration is low when they are
separated by a semi pearmeable membrane.
The blood’s osmotic activity determines whether The
IV fluid infuse stay inside the vascular compartment
or moves into interstitial compartment.
Serum osmolality is calculated by formula
Na x 2 + blood glucose + Blood urea nitrogen
18 2.8
Normal serum osmolality =290-300 mosmoles/lit.

5. Normal serum values
 sodium Na - 130-140 Meq/L.
 pottassium K - 3.5- 5 Meq/L.
 chloride Cl - 95- 105 Meq/L.
 blood sugar - 80-120 Mgs% or 5-7
Meq/L.
 Blood urea Nitrogen mg/dl - Blood urea /2.14
mg %


8. Tonicity of a fluid means how much the osmotic
activity of thegiven solution differs from that of
blood.
We have seen blood’s osmolality is near 290
mosmoles/lit.
So when u see for 0.9% saline the
 sodium - 154 meq/l
 chloride – 154 meq/l
So total is 308 meq/l which is approximately as
blood osmolality.so its called ISTONIC FLUID.

9. Step 3: Select Type of Fluid

11. Indications for IV Therapy
Establish or maintain a fluid or electrolyte balance
Administer continuous or intermittent medication
Administer bolus medication
Administer fluid to keep vein open (KVO) (Old
Skool!)
 Administer blood or blood components
Administer intravenous anesthetics
Maintain or correct a patient's nutritional state
Administer diagnostic reagents
Monitor hemodynamic functions

12. Types of IV Fluids
Three main types of IVF:
Isotonic fluids
Hypotonic fluids
Hypertonic Fluids

13. Isotonic Fluids
Osmolarity is similar to that of serum.
These fluids remain intravascularly
mommentarily, thus expanding the volume.
Helpful with patients who are hypotensive or
hypovolemic.
Risk of fluid overloading exists. Therefore, be
careful in patients with left ventricular
dysfunction, history of CHF or hypertension.
Avoid volume hyperexpansion in patients with
intracranial pathology or space occupying lesions.

14. Hypotonic Fluids
Less osmolarity than serum (meaning: in general less sodium
ion concentration than serum)
These fluids DILUTE serum thus decreasing osmolarity.
Water moves from the vascular compartment into the
interstitial fluid compartment  interstitial fluid becomes
diluted osmolarity descreases  water is drawn into
adjacent cells.
These are helpful when cells are dehydrated from conditions
or treatments such as dialysis or diuretics or patients with
DKA (high serum glucose causes fluid to move out of the cells
into the vascular and interstitial compartments).
Caution with use because sudden fluid shifts from the
intravascular space to cells can cause cardiovascular collapse
and increased ICP in certain patients.

15. Hypertonic Fluids
These have a higher osmolarity than serum.
These fluids pull fluid and sometimes electrolytes
from the intracellular/interstitial compartments
into the intravascular compartments.
Useful for increasing urine output, and
decreasing edema.
These can be dangerous in the setting of cell
dehydration.

16. Clear solutions –fluids- made up of water &
electrolyte solutions; small molecules.
These fluids are good for volume expansion.
However, both water & electrolytes will cross a
semi-permeable membrane into the interstitial
space and achieve equilibrium in 2-3 hours.
Remember: 3mL of isotonic crystalloid solution are
needed to replace 1mL of patient blood.
This is because approximately 2/3rds of the solution
will leave the vascular space in approx. 1 hour.
In the management of hemorrhage, initial
replacement should not exceed 3L before you start
using whole blood because of risk of edema,
especially pulmonary edema.

17. Some of the advantages of crystalloids are that they
are inexpensive, easy to store with long shelf life,
readily available with a very low incidence of
adverse reactions, and there are a variety of
formulations that are available that are effective
for use as replacement fluids or maintenance
fluids.
A major disadvantage is that it takes approximately
2-3 x volume of a crystalloid to cause the same
intravascular expansion as a single volume of
colloid.

18. Crystalloids – Saline Solutions
0.9% Normal Saline – Basically ‘Salt and Water’
Principal fluid used for IV resuscitation and replacement of salt loss e.g V/D
Contains: Na+ 154 mmol/l, K+ - Nil, Cl
-
- 154 mmol/l; But K+ is often added
ISOOsmolar compared to normal plasma
Distribution: Stays almost entirely in the Extracellular space
So for 100ml blood loss  need to give 300-400ml NS[only 1/3 remains intravascular]
0.45% Normal saline = ‘Half’ Normal Saline = HYPOtonic saline
Can be used in severe hyperosmolar states E.g. H.O.N.K and dehydration
Leads to HYPOnatraemia if plasma sodium is normal (dilution if unchecked)
May cause rapid reduction in serum sodium if used in excess or infused too rapidly. This
may lead to cerebral oedema and rarely, central pontine demyelinosis ; Use with caution!
1.8, 3.0, 7.0, 7.5 and 10% Saline = HYPERtonic saline
Reserved for plasma expansion with colloids or acute hyponatrema
In practice rarely used in general wards; Reserved for high dependency, specialist areas
Distributed almost entirely in the ECF and intravascular space an osmotic gradient
between the ECF and ICFpassage of fluid into the EC space.
This fluid distributes itself evenly across the ECF and intravascualr space, in turn leading
to intravascular repletion.
Large volumes will cause HYPERnatraemia and IC dehydration.

19. Crystalloids – Dextrose Solutions
5% Dextrose (often written D5W) – Sugar and Water’
Primarily used to maintain water balance in patients who are not able to take
anything by mouth; Commonly used post-operatively in conjuction with salt
retaining fluids ie saline; Often prescribed as 2L D5W: 1L N.Saline
[‘Physiological replacement’ of water and Na+ losses]
Provides some calories [ approximately 10% of daily requirements]
Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium, Chloride or
Calcium
Distribution: <10% Intravascular; > 66% intracellular
When infused, is rapidly redistributed into the intracellular space; Less than
10% stays in the intravascular space therefore it is of limited use in fluid
resuscitation.
For every 100ml blood loss – need 1000ml dextrose replacement [10% retained
in intravascular space
Common cause of iatrogenic hyponatraemia in surgical patient
Dextrose saline – Think of it as ‘a bit of salt and sugar’
Similar indications to 5% dextrose; Provides Na+ 30mmol/l and Cl
-
30mmol/l Ie a
sprinkling of salt and sugar!
Primarily used to replace water losses post-operatively
Limited indications outside of post-operative replacement – ‘Neither really
saline or dextrose’; Advantage – doesn’t commonly cause water or salt overload.

20. The 4 Types of Patients
When considering appropriate IV fluids as you are
writing admission order, keep in mind that in
general, there are 4 types of medical patients
when it comes to administering IV fluids:
Hypovolemic Patient
Pneumonia, Sepsis, Hemorrhage,
Gastroenteritis
Hypervolemic Patient
CHF, renal failure, cirrohsis
NPO Patient, surgical patient, euvolemic
Awaiting surgery, unsafe swallow
Eating/drinking normally

21. Colloids
Colloids are large molecular weight solutions (nominally
MW > 30,000 daltons)> These solutes are macormolecular
substances made of gelatinous solutions which have
particles suspended in solution and do NOT readily cross
semi-permeable membranes or form sediments.
Because of their high osmolarities, these are important in
capillary fluid dynamics because they are the only
constituents which are effective at exerting an osmotic
force across the wall of the capillaries.
These work well in reducing edema because they draw
fluid from the interstitial and intracellular compartments
into the vascular compartments.
Initially these fluids stay almost entirely in the
intravascular space for a prolonged period of time
compared to crystalloids.
These will leak out of the intravascular space when the
capillary permeability is deranged or leaky.

22. Colloids Continued
Albumin solutions are available for use as colloids
for volume expansion in the setting of CHF however
albumin is in short supply right now.
There are other solutions containing artificial
colloids available.
The general problems with colloid solutions are:
Much higher cost than crystalloid solutions
Small but significant incidence of adverse reactions
Because of gelatinous properties, these can cause
platelet dysfunction and interfere with fibrinolysis
and coagulation factors thus possibly causing
coagulopathy in large volumes.
These fluids can cause dramatic fluid shifts which
can be dangerous if they are not administered in a
controlled setting.

23. 23
Colloids
Types
Albumin: e.g. 4.5-5%, 20-25% human albumin solution
Dextran: e.g. 6% Dextran 70
Gelatin: e.g. 3.5% polygeline (Haemaccel), 4% succinylated gelatin
(Gelofusion)
Hydroxyethyl starch: e.g. 6% hetastarch (Elo-HAES, Hespan), 6 & 10
pentastarch (Pentaspain, HAES-steril)
Uses
Used for maintenance of plasma volume and acute replacement of
plasma volume deficit.
Short term volume expansion (gelatin, dextran)
Medium term volume expansion (albumin, pentastarch)
Long term volume expansion (hetastarch)
Routes
IV
Side effects
Dilution coagulopathy
Anaphylaxis
Interference with blood cross matching (Dextran 70)

24. 24
Unique features of albumin
Transport of various molecules
Free radical scavenging
Binding of toxins
Inhibition of platelet aggregation
Relative persistence of colloid effect
Albumin +++
Dextran 70 ++
Gelofusin +
Haemaccel +
Hespan ++++
Pentaspan ++
Elo-HAES ++++
HAES-Steril ++
Presistence is dependent on molecular size and protection from
metabolism.
All artificial colloids are polydisperse (i.e. there is a range of
molecular sizes).

26. RAJ DRd KUMAR
.K