1. E Stanton RN MSN/ED, CEN, CCRN, CFRN
IV FLUIDS
E Stanton RN MSN/ED, CEN, CCRN, CFRN

2. There are three main types of fluids
ISOTONIC
HYPOTONIC
HYPERTONIC

3. Isotonic fluids 
Close to the same osmolarity as serum. They stay inside the intravascular compartment, thus expanding it. Can be helpful in hypotensive or hypovolemic patients. Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension. Isotonic fluids contain an approximately equal number of molecules (blue dots) SEE NEXT SLIDE as serum so the fluid stays within the intravascular space. Remember that fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into or out of the intravascular space.

4. Examples: Lactated Ringer's (LR), 0.9 NS

5. Hypotonic fluids 
Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells.  Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients

6. D5NS.45 (5% dextrose in 1/2 normal saline).
Hypotonic fluids contain a lower number of molecules than serum so the fluid shifts
from the intravascular space to the interstitial space (represented by the green arrows).
This decreases the interstitial space osmolarity (because of the increase of fluid
and constant number of molecules within it), which then causes fluid to move into the
cellSsNote that the green arrows represent fluid movement, not molecule movement.

7. Hypertonic fluids 
Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema.  Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration.

8. Table of Commonly Used IV Solutions (MOST COMMON HIGHLIGHTED IN YELLOW)

9. Name of Solution
Type of Solution
Ingredients in
1-Liter
Uses
Complications
0.45% Sodium Chloride
Shorthand Notation:
½NS
Hypotonic
pH 5.6
77 mEq Sodium
77 mEq Chloride
hypotonic hydration; replace sodium and chloride; hyperosmolar diabetes
if too much is mixed with blood cells during transfusions, the cells will pull water into them and rupture
0.9% Sodium Chloride NS
Isotonic
pH 5.7
154 mEq Sodium
154 mEq Chloride
isotonic hydration; replace sodium and chloride; alkalosis; blood transfusions (will not hemolyze blood cells)
VOLUME OVERLOAD

10. 5% Dextrose in Water
Shorthand Notation:
D5W
Isotonic
pH 5.0
5 grams dextrose
(170 calories/liter)
isotonic hydration; provides some calories
water intoxication and dilution of body's electrolytes with long, continuous infusions
RARELY USED
10% Dextrose in Water
D10W
Hypertonic
pH 4.3
10 grams dextrose
(340 calories/liter)
may be infused peripherally;
hypertonic hydration; provides some calories
5% Dextrose in 1/4 Strength (or 0.25%) Saline
D5¼NS
pH 4.4
5 grams Dextrose
34 mEq Sodium
34 mEq Chloride
fluid replacement; replacement of sodium, chloride and some calories
vein irritation because of acidic pH, causes agglomeration (clustering) if used with blood transfusions; hyperglycemia with rapid infusion leading to osmotic diuresis

11. 5% Dextrose in 0.45 Sodium Chloride
Shorthand Notation:
D5½NS
Hypertonic
pH 4.4
5 grams Dextrose
77 mEq Sodium
77 mEq Chloride
hypertonic fluid replacement; replace sodium, chloride, and some calories
5% Dextrose in Normal Saline
D5NS
154 mEq Sodium
154 mEq Chloride
hypertonic fluid replacement; replace sodium, chloride and some calories
Ringer’s Injection, U.S.P.
Isotonic
pH 5.8
147 mEq Sodium
4 mEq Potassium
4 mEq Calcium
155 mEq Chloride
electrolyte replacement; hydration; often used to replace extracellular fluid losses
rapid administration leads to excessive introduction of electrolytes and leads to fluid overload and congestive conditions; provides no calories and is not an adequate maintenance solution if abnormal fluid losses are present

12. 5% Dextrose in Lactated Ringer’s Injection
Shorthand Notation: LR
Isotonic
pH 6.6
130 mEq Sodium
4 mEq Potassium
3 mEq Calcium
109 mEq Chloride
28 mEq Sodium Lactate (provides 9 calories/liter)
isotonic hydration; replace electrolytes and extra-
cellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis)
TRAUMA FLUID- USED IN OPERATING ROOM ALWAYS
not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is present
5% Dextrose in Lactated Ringer’s Injection
D5LR
Hypertonic
pH 4.9
5 grams Dextrose
(170 calories/liter)
hypertonic hydration; provides some calories; replace electrolytes and extra-
cellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion

13. Examples: 9.0% NS, blood products, and albumin.*
Hypertonic fluids
Contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.