2LEARNING OUTCOMES.. By the end of this lecture you will be able to, List different types of IV fluidsIdentify different methods of classifying i.v. fluidsUnderstand differences in fluids in relation to their distribution in different fluid compartments of the bodyDescribe indications for IV therapyOutline complications of IV therapyList constituents of ORS
3FLUID DISTRIBUTION IN THE BODY Total body water (TBW)In males – 60% of body weightIn females – 55% of body weighte.g. In a 60kg male – TBW is 36L
4TBW = 60% OF BODY WEIGHT ICF ECF 05% 40% 15% Plasma Interstitial Fluid Our intravascular compartment holds the smallest amount of water at around 3 litres ( a further 2 litres of red cells makes up our total blood volume ).15%Interstitial Fluid
5TYPES OF I.V. FLUIDS Crystalloids vs. Colloids CRYSTALLOIDS COLLOIDS Normal (0.9%) salineHuman AlbuminRinger's lactate solution (Hartmann's' solution)Gelatin solutions (Haemaccel,Gelafundin )5% DextroseDextranHydroxyethyl starches(Hetastarch)
6TYPES OF I.V. FLUIDS Hypotonic, Isotonic and Hypertonic solutions HYPOTONIC SOLUTIONSISOTONIC SOLUTIONSHYPERTONIC SOLUTIONS0.45% (N/2) SalineNormal (0.9%) saline3% Saline0.18% (N/5) SalineHartmann's' solutionMannitol5% Albumin20% AlbuminTonicity – osmolality of a solution relative to the osmolality of plasma
7TYPES OF I.V. FLUIDS Balanced vs. unbalanced intravenous fluids UNBALANCED SOLUTIONSBALANCED SOLUTIONS0.9% SalineHartmann's' solutionDextranshave a number of additional components to normal saline in an attempt to approximate the composition of the solution to plasma.Balanced colloids are being developed.
8TYPES OF I.V. FLUIDS Natural vs. Synthetic NATURAL SOLUTIONS SYNTHETIC SOLUTIONSHuman AlbuminGelatin solutions (Haemaccel,Gelafundin )Fresh Frozen PlasmaHartmann’s solutionDextran
9CRYSTALLOIDSConsist of inorganic ions and small organic molecules dissolved in waterEither glucose or sodium chloride (saline) based.May be isotonic, hypotonic or hypertonicBoth water and the electrolytes in the crystalloid solution can freely cross the semi permeable membranes of the vessel walls into the interstitial space
10Normal Saline (0.9% NaCl)Contains sodium and chloride ions in water and it is isotonic with extracellular fluidCell membrane is impermeable to Na+ and Cl- ions owing to the presence of the energy dependantNa+ /K+ - ATPaseIntravenous infusion of an isotonic solution of sodium chloride will expand only the extracellular compartment
11Normal Saline (0.9% NaCl)Na+ is the main solute in ECF saline is well suited to replace ECF fluid lossese.g. dehydration due to nausea/vomitingNa+ and Cl- freely moves across vascular membrane into the interstitium.
12Normal Saline (0.9% NaCl)Remain in the intravascular space for only a short period before diffusing across the capillary wall into the interstitial space.1 liter infusion of normal (0.9%) saline will result in~ 250 ml expansion of the circulating volume.Achieve equilibrium in 2-3 hours.
13Normal Saline (0.9% NaCl) Indications: Replacement of fluids in hypovolaemic or dehydrated patients ( Needs 3 blood loss)A small amount of saline as a special adjunct can be used to keep the veins open for medication administrationAs the initial plasma expander in blood loss while blood is typed and matchedIn dengue patients as once hypovolaemia sets in there is circulatory collapse, Some points may apply for other crystalloids
14Normal Saline (0.9% NaCl) Adverse Effects Fluid overload (peripheral and pulmonary oedema)With high volume administration,Dilutional reduction of normal plasma components such as calcium and potassiumDilutional coagulopathyHyperchloraemic acidosisDiuresis.Story about dengue deaths and alkaline diuresis used in Aspirin poisoning earlier, now abondoned due to risk of pul oedema
155% Dextrose Initially behave as an isotonic solution. Glucose is soon metabolized, leaving behind water making the solution hypotonic.Water freely moves between intravascular, interstitial and intracellular fluid compartments till the osmolalities become the same.
165% Dextrose Indications: To maintain water balance ( In pure water deficit and for patients on sodium restriction)To supply calories ( ~ 200kcal/l)An adult require ~2500 kcal/dayHence, glucose alone can’t meet the need.Would need >10 liters of 5% glucose to supply all calories !!Not used for fluid resuscitation. Wernicke’s encephalopathy. The brain is surrounded by a membrane separating it from the vascular space - the blood-brain barrier. This membrane will only allow water to pass through it. Therefore only fluid with the same concentration of sodium as plasma should be given intravenously. Otherwise, the plasma will become more dilute and water will pass from it into the brain, making the brain swell, and thus increase pressure further.Normal Saline (0.9%) has a similar concentration of sodium and therefore is the fluid of choice for the brain. Colloid can be given if required to treat hypovolaemia due by major blood loss.When Dextrose solutions in water (5% Dextrose, Dextrose 4%-Saline 0.18%) are given, the dextrose is metabolised leaving just the water or a very dilute saline solution. This "dilutes" the blood, reducing the concentration of sodium in the plasma. The water then passes into the brain where the concentration of sodium is higher. The brain then swells, and intracranial pressure will rise.
175% Dextrose Adverse effects: Causes red cell clumping (cannot be given with blood).May cause water intoxicationCan cause hyponatraemia
18Ringer’s Lactate A balanced isotonic electrolyte solution. Similar to 0.9% saline in all aspects except,Contains sodium, chloride, potassium, calcium and lactate in water. ( “physiological”)Prevents dilutional reduction of normal plasma components such as calcium and potassiumAvoids hyperchloraemic acidosis ( Lactate converted to bicarbonate in liver.) Preferred to normal saline when large quantities of volume infused rapidly
19COLLOIDSColloids contain large molecules such as proteins that do not readily pass through the capillary membraneRemain in the intravascular space for extended periodsThese large molecules also increase the osmotic pressure in the intravascular spaceCause fluid to move from the interstitial and intracellular space to the intravascular space Often referred to as volume expanders
20COLLOIDSColloids stay in the vascular compartment for a longer time compared to crystalloidsAdministered in a volume equal to the volume of blood lost.COLLOIDSNORMAL SALINEHALF LIFE IN INTRAVASCULAR COMPARTMENT3-6 hrs20-30 min
21INDICATIONS When rapid expansion of plasma volume is desirable e.g. in haemorrhage prior to blood transfusionFor fluid resuscitation in the presence of hypoalbuminaemiaIn large protein losses e.g. in burnsUsually both colloids and crystalloids used to expand both vascular and interstitial compartments in resuscitation.
22Gelatins Prepared by hydrolysis of bovine collagen. a). Gelafusine - succinylated gelatin in isotonic salineb). Haemaccel - urea-linked gelatin and polygelinein an isotonic solution of sodium chloride withpotassium and calcium.Theoretical risk of transmitting bovine spongiform encephalopathy. (new-variant Creutzfeldt-Jakob disease)Volume expanding effect lasts 2-3 hrs.Because of the significant calcium content of Haemaccel, blood should not beinfused through a giving set that has been previously used for this product.
23DextransHigh molecular weight D-glucose polymers prepared from the juice of sugar beets.Preparations of different molecular weightse.g. Dextran 40 (MW 40,000)Dextran 70 (MW 70,000)Volume expanding effect lasts 5-6 hrs.
24Dextrans Causes haemostatic derangements Factor VIII activity is reducedplasminogen activation and fibrinolysis is increasedplatelet function impairedInterfere with blood cross matchingAlter laboratory testse.g. Plasma glucose, plasma proteinsIn patients whose haemostatic function is normal prior to infusion a maximum dose of 1.5 g/kg is oftenrecommended to avoid risk of bleeding complications.
25Hydroxyethyl starches Synthesized from amylopectin(a D-glucose polymer with a branching structure) derived from maize or sorghum.The larger molecular size leads to prolonged intravascular retention compared to other colloids.e.g. Hetastarch, PentastarchEven more than albumin
26Human AlbuminTwo preparations 5% albumin (isotonic) and 25% albumin (Hypertonic)20% albumin expands the plasma volume up to five times the volume infused.Heat treated - no risk of transmitting viral infections.Reduce ionized calcium level.Even more than albumin
27PHYSIOLOGYWater is transported paracellularly as a result of the osmotic gradient.- Water is absorbed along the osmotic gradient created by shift of electrolytes mainly Na+ and Cl-- One form of sodium absorption occurs coupled to glucose.
28In Diarrhoea……..Imbalance between absorption and secretion of fluid and electrolytes.Prompt fluid replacement can prevent dehydration and mortality( esp. in children)Na+ - K+ ATPaseNa+ - Glucose co-transport unaffectedIt is estimated that in the 1990s, more than 1 million deaths related to diarrhoea may have been prevented each year, largely attributable to the promotion and use of ORT and ORS.unaffected
29THE “NEW” WHO/UNICEF ORS FORMULA A reduced osmolarity formula.Contains reduced amounts of glucose and sodium.Further reduces….- stool out put- vomiting- unscheduled supplemental intravenous therapyAssociated with increased risk of hyponatraemia
30WHO/UNICEF LOW OSMOLARITY ORS FORMULA Anhydrous Glucose13.5 g/lSodium chloride2.6 g/lPotassium chloride1.5 g/lSodium citrate2.9 g/lCereal bases ORS better than glucose based ORS. Why?Continuous slow releasing source of glucoseColonic bacteria produce short chain fatty acids which further enhance colonic sodium and water absorption.