IV FLUIDS AND FLUID

MANAGEMENT
MODERATOR- DR.RUPSI
PRESENTOR-DR.RAMANI GORLA
CLINICAL SCENARIO
You attended a call from ER,
Pt came with multiple episodes of vomitings, watery and with food
particles as content.
Severe dehydration+, pulse feeble+
Peripheral pulses not palpable
ABG-pH:7.52, Cl-82, HCO3-32.6, k-2.2
RBS-68
ER doctor has given 1000ml DNS.
NICE GUIDELINES
• WATER:20-30ML/KG/DAY
• SODIUM/POTASSIUM/CHLORIDE: 1m.mol/kg/day
• GLUCOSE: 50-100g/day.

• Fluid loss per day is approximately 700ml.

TYPES OF IV FLUIDS
CRYSTALLOIDS: COLLOIDs: contributes for plasma
fluids with electrolytes mixed with water. does oncotic pressure
not contribute for plasma oncotic pressure
PROTEIN
BALANCED: • Albumin
• Ringer lactate • Gelatin
• plasmalyte
• Gelaspan
UNBALANCED:
• Normal saline NON PROTEIN
• DNS • Dextran
• 5% dextrose
• Starch
Based on tonicity
• ISOTONIC: stays inside blood stream
NS, RL
• HYPOTONIC: draws fluid from vessels into cells
5% DEXTROSE, 0.45% SALINE
• HYPERTONIC: draws fluid out of cells.
3%NS, 5% NS
NORMAL SALINE
COMP0SITION- sodium-154 meq , chloride-154meq
INDICATIONS-
• Water and salt depletion as in diarrhoea, vomiting, excessive diuresis and
excessive perspiration
• Treatment of hypovolemic shock.
• Initial fluid therapy in diabetic ketoacidosis
• Treatment of hypercalcemia
• Irrigation of washing od body fluids like RT drainage
• As a vehicle of certain drugs-
eg.inj.monocef 2g IV in 100ml NS over 4 hours.
CONTRAINDICATIONS:
• Cautious use in hypertensive, preeclamptic patients
• In patients with edema, congestive heart failure.
• Renal diseases and cirrhosis
• In dehydration with severe hypokalemia.
5% DEXTROSE
• COMPOSITION: glucose 50g
• Provides 170kcal of energy per lite
INDICATIONS:
• To prevent ketosis in starvation, diarrhoea, vomiting
• Correction of hypernatremia due to pure water loss as in diabetis
insipidus- used along with frusemide.
CONTRAINDICATIONS:
• Cerebral edema
• Neurological procedures.
25% DEXTROSE
• Contains 25g glucose in 100ml 25D
• Used in rapid correction of hypoglycemia
• For treatment of hyperkalemia- aong with insulin
CONTRAINDICATIONS:
• Dehydrated patient with anuria
• Intracranial, intraspinal hemorrhage.
RINGER LACTATE
COMPOSITION: sodium-130meq. Chloride-109meq. Bicarbonate-
28meq. Calicium-3meq. Potassium-4meq
INDICATIONS:
• Correction of hypovolemia with large fluid volume
• Replacing fluid in postoperative patients.
• Burns, fractures
• Peritoneal irrigation.
• Diarrhoea induced hypovolemia with hypokalemic metabolic acidosis.
CONTRAINDICATIONS:
• In conditions where lactate metabolism is impaired- as in liver disease,
severe hypoxia and shock.
It causes lactic acidosis in such conditions.
• In severe congestive heart failure
• Severe metabolic acidosis
• long with blood transfusion- calcium binds to citrate(anticoagulant)
• With certain drugs- amphotericin b, ampicillin, doxycycline.
DEXTROSE NORMAL SALINE
COMPOSITION: Sodium-154meq. Chloride-154meq. Glucose-50grams.
• Provides energy along with fluid correction.
• Compatible with blood transfusion.
CONTRAINDICATIONS:
• Not preferred in hypovolemic shock- as it causes osmotic diuresis.
PLASMALYTE
• COMPOSITION: sodium-140meq, potassium-5meq, MG-3meq, Cl-
99meq, gluconate-23meq, acetate-27meq.
• Osmolality-294mOsm/l
• pH-7.40
• Most physiological fluid till date-pH and osmolarity close to plasma
ISOLYTE-G
COMPOSITION: Glucose-50meq. Chloride-150meq. sodium-65meq. Ammonium-
69meq. Potassium-17meq
It is equivalent to gastric juice.
INDICATIONS:
• Vomiting and continuous gastric aspiration.
• Metabolic alkalosis due to excess soda bicarb/diuretic therapy.
CONTRAINDICATIONS:
• Hepatic failure- due to ammonia
• Renal failures- aggravates uremic acidosis
• Metabolic acidosis
• Severe vomiting with shock
 ISOLYTE-M
Ideal as maintenance fluid. rich in potassium
COMPOSITION: Glucose-50meq. Chloride-40meq. Chloride-38meq.
Phosphate-15meq. Acetate-20meq. Potassium-35meq.
INDICATIONS:
• For parenteral fluid therapy as maintenance fluid.
• To correct hypokalemia secondary to prolonged infusion of potassium
free IV fluids.
CONTRAINDICATIONS:
• Renal failure
• Hyponatremia- as it has low sodium
• Adrenocortical insufficiency, burns- due to high potassium.
ISOLYTE-P
COMPOSITION: Glucose-50meq. Acetate-23meq. Sodium-25meq.
HPO4-3meq. Potassium-20meq. Mg-3meq. Cl-22meq.
Children need more water than adults. Hence ideal for children.
Contraindications:
Hyponatremia- due to excess fluid
Renal failure- due to high potassium
Hypovolemic shock-as it has low sodium, glucose causes osmotic
diuresis, oliguric child can have hyperkalemia.
ISOLYTE-E
• Extracellular replacement solution.
COMPOSITION: Glucose-50meq. Acetae-47meq. Sosium-140meq. Ca-
5meq. K-10meq. Mg-3meq. Cl- 103meq. Citrate-8meq.
• Only fluid with magnesium
• Maximum acetate- provides maximum bicarbonate
CONTRAINDICATIONS:
• Metabolic alkalosis
ALBUMIN
INDICATIONS:
• Correction of hypoproteinemia
• As an exchange fluid in therapeutic plasmapheresis
CONTRAINDICATIONS:
• Pulmonary edema
• Severe anemia, cardiac failure
ADVERSE EFFECTS:
• Analphylaxis, allergic reactions
EVALUATION NEEDED FOR
APPROPRIATE FLUID MANAGEMENT

• Etiology of fluid deficit and type of electrolyte balance

• Associated illness-DM, HTN, IHD, renal, hepatic conditons
• Clinical status- hydration, urine output.
HYPOVOLEMIA
ASSESMENT OF HYPOVOLEMIA
• MILD: thirst, concentrated urine
• MODERATE: dizziness, weakness, oliguria, postural hypotension, low
JVP
• SEVERE: confusion, stupor, systolic bp<100, tachycardia, low pulse
volume, cold extremities, poor capillary return, reduced skin turgor.

FLUID DEFICIT IN LITRES= 0.2× lean body wt × (current hct/normal hct-1)

• Initial fluid of choice is NS. Why?
• Once the urine output is maintained, start with RL as it is the more
physiological fluid. Why?
• Correct electrolyte abnormalities associates.
Eg- vomiting-hypokalemic hypochloremic metabolic alkalosis
Diarrhoea- hypokalemic hyperchloremic metabolic acidosis.

ASSESMENT OF TREATMENT- improvement in clinical symptoms and

correction of acid and electrolyte abnormalities.
CENTRAL VENOUS PRESSURE
• Pressure of blood measured at junction of SVC, right atrium
• Normal value: 2-14 cm
• Low cvp in hypovolemia, relative hypovolemia due to peripheral
vasodilation as in spinal anesthesia, septicemia, anaphylaxis.
• High cvp in cardiac overload, congestive heart failure, cardiac
tamponade
ACUTE PANCREATITIS
• Fluid of choice-ringer lactate
• Rate of fluid infusion-bolus of fluid with 15-20ml/kg i.e 1000-1400ml.
f/b. 2-3ml/kg/hour i.e 200-250ml/hour.
• Urine output to be maintained >0.5mg/kg/hour.
• Decrease in hematocrit and BUN after 12-24 hours is an indicator for
adequate fluid therapy.
DIABETIC KETOACIDOSIS
• Fluid loss is present- so aggressive fluid therapy and insulin should be
given
• Non glucose fluids commonly used fluids like NS,RL becomes fluids of
choice
• Patients require 5-8L fluid resuscitation based on severity of
dehydration.
• Rate: first 1L in 1 hour followed by 500ml/hour in first 4 hours
followed by 250ml/hour.
HEPATIC CONDITIONS
• Salt restriction
• Fluid restriction to less than 1 litre per day
• Use of diuretics( spironolactone)

CARDIAC CONDITIONS

• Reduce fluid intake

• Monitor cardiac overload signs and symptoms
RENAL CONDITIONS
• Fluid restriction
• Diuretics
• Potassium restruction
• Salt restrction
GOLDEN RULES TO BE
REMEMBERED IN CLINICAL PRACTISE
• ALWAYS TRY TO AVOID IV FLUIDS IF PATIENT CAN TAKE ORALLY.
• Shift to balanced fluids once the clinical status of patient is
established.
• Always keep in mind about the underlying cause, associated
conditions, electrolyte and acid-base abnormalities.
• Monitor clinical signs and laboratory investigations accordingly.
• Aminosteril belongs to a group of drugs that help regulate water -
electrolytes and support acid-base balance. The drug is packaged in
the form of a bottle of infusion solution, with 2 main types, including:
Aminosteril 10 (250ml) and Aminosteril n-hepa 8 (500ml).
REFERENCES
• Harrisons text book of internal medicine 21st edition
• Millers text book of anesthesia 8th edition
• Guyton and hall textbook of physiology 13th edition.
• Practical guidelines on fluid therapy by Dr.Sanjay pandya 2nd edition.
THANK YOU🙏