1. 수액 요법의 내과적 원칙
경희대학교 동서신의학병원 신장내과 문 주 영

2. 내용
1. 수액용법의 목적
2. 수액 치료 목적에 따른 수액제의 선택
3. 수액제의 종류
4. 수액요법의 원칙과 단계

3. 단위 정리 1mol =(Molecular weight, MW)g mmol/L = mg/dL x 10/ MW
Na+ 1mol = 23g, Na+ 1M (molarity, 몰농도) = 23g/L
1 mol Na+ (23g) + 1 mol Cl- (35.5g)= 1 mol NaCl (58.5g)
NaCl 1g = NaCl 17 mmol
mmol/L = mg/dL x 10/ MW
mEq/L = mmol/L x valence
msoml/kg = n x mmol/L
(n=number of particles per unit volume of solvent)
Substance
Atomic or molecular weight
mmol
mEq
mosmol
Na+ 23 1
Cl-
35.5
NaCl
58.5 2
1.75
CaCl2
111 4 3
Glucose
180

4. 60kg 인 28세 남성에서의 intravascular volume의 량은?
Total body water = 60 x 0.6 =36L
Intravascular volume = 36 x 1/12 = 3L

5. Total Body Water and Fluid Compartments
ECF
ECF IV IV
ISF
ICF
ISF
ICF 1 1
Plasma(Colloid) 4 4 8
Sodium(Crystalloid) 12 12
Water (Dextrose in water)

6. Barriers of Fluid Compartments
(ECF) IV
ISF
ICF
H2O, urea
H2O, urea
Na+ = mEq/L
K+ = mEq/L
Cl-
HCO3-
K+ = mEq/L
Na+ = mEq/L
Phosphate-
2K+
Na-K
ATPase
RBC
3Na+
albumin
Semipermeable cell membrane
Basement memb + Endothelial cell

7. Distribution of 1,000ml Infusion of Each Solution
Replacement
amount
of volume deficit
Volume added(ml)
Solution Distribution
IV ISF ICF
5% Dextrose water Water space X 8-12
0.9% Saline ECF X
0.45% Saline X 5-6
500ml water Water space
500ml 0.9% saline ECF
Plasmanate IV , X 1

8. 그러면 serum albumin =2.0g/dL 인 환자에서albumin 한 병이 증가시키는 intravascular volume은?
20% albumin 100cc = 20g/dL 의 albumin 함유
따라서 1000 cc 의 intravascular volume 증가

9. Tonicity (Osmotic Forces) by Effective Osmoles
pressure
Na+ +
H2O
Urea
urea
Ineffective osmole
Effective osmole
총 혈장 삼투압 = 2x혈장 나트륨농도 + 포도당 농도(mg/dL)/18+ BUN(mg/dL)/2.8
유효 혈장 삼투압 = 2x혈장 나트륨농도 + 포도당 농도(mg/dL)/18
혈장 삼투압 = 2x혈장 나트륨농도

10. Sodium concentration =
Water Balance
Sodium content
Sodium concentration =
Water volume
1. Water gain : hyponatremia
2. Water loss : hypernatremia

11. Sodium Balance ECF volume
Sodium gain : ECF  ) Sodium gain> Water gain: intravascular volume 
hypertension
2) Water gain > Sodium gain : ISF , IV edema, hyponatremia
2. Sodium loss : ECF  (volume depletion, hypotension)
1) Sodium loss > Water loss : hyponatremia
2) Water loss > Sodium loss : hypernatremia

12. Volume Depletion vs Dehydration
Volume depletion (hypovolemia)
- extracellular volume depletion
- most often due to sodium loss >> water loss
Dehydration
- presence of hypernatremia due to pure water loss

13. 1. 수액요법의 목적 1. 체액량의 유지 (Volume replacement)
2. 결핍이 있거나 부족한 전해질이나 수분의 보충
(Deficit replacement)
3. 매일 필요한 생리적 요구량의 수분 및 전해질 공급
(Maintenance replacement)

14. 2. 수액 치료 목적에 따른 수액제의 선택 체액량의 유지 (Volume replacement)
유지 수액 요법 (Maintenance replacement)

15. 체액량의 유지 (Volume replacement)
1. Saline
Isotonic saline (0.9% NaCl)
Hartmann’s solution
2. Blood component
Whole blood
Plasma
Albumin
3. Colloidal solution
Dextran, Starches

16. 유지 수액 요법 (Maintenance replacement)
1. Water : 30 ml/kg (2,000 ml/day)
Fever : % ↑ / 1C ↑
2. Sodium : 100 – 150 mmol (6 – 9 g NaCl)
Sweating : ⅓ 0.9% saline
⅔ dextrose water
3. Potassium : 40 – 80 mmol (3 – 6 g KCl)
4. Glucose : 100 – 150 g
Reduction of protein breakdown

17. Water Losses in a NPO patient
Daily Average (mL)
Range (mL) Medium Maximum
A. Sensible loss
Urine
Feces
B. Insensible loss
Lungs
Sweat
Total water loss
C. Catabolism= water gain
Overall loss
1, ,400
≒ 30 mL/kg of ideal body weight

18. 2 L half-saline (77 mmol/L x 2) /day
Daily Sodium Loss
Most important cation of the ECF
loss of Na in the urine= 100 –140 mmol/day
2 L half-saline (77 mmol/L x 2) /day
Daily Potassium Loss
Most important cation of the ICF
Need to supply K to meet obligatory urine loss (40-80 mmol/d)
20 – 40 mmol KCl / L of IV fluid
Daily Chloride Loss
Determined by Cl intake, pH, HCO3
Not need to calculate the Cl requirements when usually given in IV fluids
as NaCl and KCl

19. Maintenance Fluid Therapy
Stable NPO state, fever(-), drainage(-)
Water : 30 ml/kg (2,000 ml)
5 % D/W x 2L
Glucose : 100 g
Sodium : 100 – 150 mmol mmol/L x 2L
Potassium : – 80 mmol – 40 mmol/L x 2L
D5Na77K30 (NAK1) or D5Na77K20 (NAK2): 2,000ml
10%DW 1L + (NS 1L + KCL 40mEq)

20. Average Electrolyte Contents of GI Secretions (mmol/L)
Source Na K Cl HCO H+
Stomach
Duodenum
Jejunum/ileum
Bile
Pancreas
Colon

21. Replacement of GI Loss
1. Stomach : 5% dextrose + ½ saline with 20 mmol KCl/L
2. Small intestine, biliary tract, pancreas :
Ringer’s lactate (Hartmann solution) +
1) 20 mmol NaHCO3/L : duodenal loss
2) 50 mmol NaHCO3/L : pancreatic loss
3. Colon : half saline with 20 mmol K acetate/L

22. 3. 수액제의 종류 1. Glucose solutions (carbohydrate in water) 2. Saline
3. 수액제의 종류
1. Glucose solutions (carbohydrate in water)
2. Saline
isotonic and hypotonic saline
hypertonic saline
3. Ringer’s and Hartmann’s solution
4. Potassium solution
5. Colloidal solutions

23. Glucose Solutions (Carbohydrate in Water)
Physiological properties
1) Water supply (water ml/g glucose)
2) Calorie supply (4.1 kcal/g)
3) Reduction of protein breakdown
** Never for volume replacement !!
2. Solutions Dextrose in water (D/W) : 5, 10, 20, 50 %
3. Caution : thrombophlebitis
4. Rate of administration with normal insulin
- Glucose : 0.5 g/Kg/hr

24. For replacement for water deficit
TBW1 X Osm1 = TBW2 X Osm2
TBW1 X 2[Na]1 = TBW2 X 2[Na]2
[Na]2
[Na]1
TBW1 = X TBW2
Water deficit = TBW1 - TBW2
= [ Na]2/ [ Na ] 1 X TBW2 - TBW2
[Na]2
140
= ( ) X BW X 0.6
Hct2 45
= ( ) X BW X 0.6

25. Saline (NaCl ) Solutions
Physiologic Properties
1) Sodium (volume) supply
2) More chloride than plasma (dilutional acidosis)
** Never for water supply !!
2. Solutions
- Isotonic saline : volume replacement
- Hypotonic saline : hyperosmolar condition
ex) diabetic coma, diuretic phase of renal failure
- Hypertonic saline : severe hyponatremia
(remove water from brain cells)

26. Rate of Administration of Isotonic Saline
1. Volume replacement – 500 ml/hour 2. Volume challenge ml/15-30 min - maximum : 2,000 ml/hour

27. Correction of Severe Hyponatremia by 3% Saline
1. Target
1) Serum sodium : 120 – 125 mmol/L
2) Loss of symptoms and signs
2. Rate of correction
1) Raise serum sodium < 0.5 – 1 mmol/L/hour
2) Raise serum sodium < 12 mmol/L/24 hours < 18 mmol/L/48 hours
3) Maximum : 200 – 250 ml/hour

28. Ringer’s and Lactated Ringer(Hartmann)’s Solution
1. Ringer’s solution : normal saline + KCl + CaCl2
2. Lactated Ringer’s solution (Hartmann's solution)
- sodium lactate for Cl- overload
- no definite beneficial effect of buffer action
Compositions (mmol/L)
Na Cl HCO K Ca
Ringer’s Solution
Hartmann’s Solution

29. Potassium Solutions
1. Physiologic properties Mixed to the basic solution Never mix to D/W in severe hypokalemia
2. Rate Concentration : mEq/L (saline) Rate : 10 – 20 mEq/hour (rapid correction 시) Amount : 80 – 160 mEq/24 hours
3. Monitoring : ECG, serum K, ionized Ca, Mg

30. Concentration(mmol/L)
Colloidal Solutions
Concentration(mmol/L)
Na K Cl
Whole Blood
Packed RBC
Plasma
20% Albumin
Dextran in isotonic saline

31. Colloids Indications Safe? Effective? Volume deficit Major hypovolemia
For tissue perfusion
When increased capillary permeability
Safe? Effective?

32. Albumin 1. Advantage 2. Disadvantage 3. Albumin usage only in
Natural colloid
Less anaphylaxis
2. Disadvantage
Risk of increased interstitial edema
No advantages over crystalloid
No advantages in hypoalbuminemia
3. Albumin usage only in
Large volume paracentesis (in liver cirrhosis)
Spontaneous bacterial peritonitis
Nephrotic syndrome (resistant to diuretics)
Plasmapheresis

33. Dextran 1. Advantage 2. Disadvantage - Tissue perfusion in stroke (?)
- Volume effect and duration
- Tissue perfusion in stroke (?)
2. Disadvantage
Acute renal failure : critically ill patients
Uterine hypertension
: contraindicated to hypovolemia in pregnancy!

34. Hydroxyethyl Starch(HES)
1. Advantage (Best)
- Volume effect and duration
- Involving inflammatory process
- “Seal the leak”
Improved microcirculation
2. Disadvantage
Coagulation abnormalities, platelet dysfunction
↓vWF, ↑aPTT : rare

35. Colloids Maximal volume effect (%) Duration of volume effect (hr)
COP (mmHg)
Dose limit (ml/kg/day)
Daily Use
Amount
Crystalloid 25
0.5
Albumin 5% 4 20
None
Albumin 20%
> 400%
4 – 6 74
None
Gelatin MF 3%
100
1 – 2 24
None
Dextran 60, 6%
130
4 – 6 26 20
1.5L
Dextran 40, 10%
175
3 – 4
170 20
1.5L
HES 200/0.5, 6%
100 4 26 33 2L
HES 200/0.5, 10%
150 4 64 20
1.5L
HES 200/0.62, 6%
110 6 28 20 2L

36. 4. 수액 요법의 원칙과 단계 1. Avoid unnecessary fluid
2. Stabilize volume status (vital signs)
3. Determine the type of deficit : water vs sodium
4. Maintain daily requirement, and replace continuing loss
5. Monitoring adequacy and complications of fluid therapy
Daily body weight
Intake and output
Urine volume, electrolytes and osmolality
Serum BUN, creatinine, glucose, electrolytes,total CO2 and osmolality
IV sites (thrombophlebitis)

37. 46-year old male with many bruises on the head
and unconsciousness
- BW 60 kg, BP 140/80 mmHg, PR 75/min, RR 15/min,
BT 36.8 C
- Skull X-ray : skull base fracture
Chest PA : pneumonia on right middle lobe
- Hb 14 g/dL, Hct 45 %, Na 172 mmol/L, K 4.2 mmol/L,
Cl 132 mmol/L, BUN 46 mg/dL, Glucose 108 mg/dL

38. 1. Type of deficit
Water
2. Amount of water deficit
0.6 X 60 X ( /172) = 8.2 L
3. Choice of Fluid therapy
5% DW
4. Rate of correction
Decrease serum Na = 0.5 – 1 mmol/L/hour

39. 52-year old male who has been treated with hydrochlorthiazide and on a low Na+ diet for hypertension.
10 days after the therapy, nausea, fatigue, postural dizziness and muscle clamp were developed.
- BW 70 kg, BP 130/80(supine) 100/70 mmHg(sitting),
PR 100/min, JVP < 4 cmH2O, poor skin turgor
- Hb 17 g/dL, Na 118 mmol/L, K 2.5 mmol/L, Cl 86 mmol/L,
BUN 42 mg/dL, Glucose 110 mg/dL, urine Na 8 mmol/L

40. 1. Type of deficit
Sodium deficit, relative water excess
2. Amount of sodium deficit
0.6 X 70 X ( ) = 924 mmol
3. Choice of fluid therapy
(1) Isotonic saline ( >> hypertonic saline)
Never use hypotonic saline or D/W
(2) KCI

41. 58-year old male with severe diarrhea after two weeks broad-spectrum antibiotics treatment for pneumonia
- Confused state
- Dry skin, axillae, decreased skin turgor
- BW 70 kg, BP 110/70 mmHg, PR 95/min, RR 18/min,
BT 37 C
- Hb 17 g/dL, Hct 50%, Na 158 mmol/L, K 4.0 mmol/L,
Cl 128 mmol/L, Glucose 100 mg/dL, Creatinine 1.3 mg/dL

42. 1. Type of deficit
Water > Sodium
2. Amount of water deficit
0.6 X 70 X (1-140/158) = 4.6L
0.6 X 70 X (1-45/50) = 4.2L
3. First fluid
5% D/W till serum Na < 155 mmol/L
4. Second fluid
Isotonic or 1/2 saline

43. Clinical Conditions and Choice of Fluids
1. Volume depletion, hyponatremia sodium deficit > water excess isotonic >> hypertonic saline
2. Volume depletion, hypernatremia
- sodium deficit < water deficit % D/W till serum sodium < 155 mmol/L hypotonic or isotonic saline
3. Volume excess, hyponatremia sodium excess < water excess restrict water and salt hypertonic saline