INTRAVENOUS FLUID

THERAPY
Anaesthesiology and Intensive Care Department
Hospital Raja Permaisuri Bainun, Ipoh

Fluid Compartment
TOTAL BODY WATER = 60% Body Weight
42L
40%
20%
Intracellular Extracellular
28L
14L
5%
15%
IntravascularInterstitial
4.6L

9.4L

*Based on a 70kg man

Total body water may vary with age, gender and body habitus

Types of fluid
Crystalloids
Hypertonic
eg. Hypertonic
saline

Hypotonic/Isoosmolar
eg. 0.18-0.45%saline
With dextrose solution,
Dextrose 5%

Isotonic
eg. 0.9% Saline,
Hartmann solution,
Sterofundin

Colloids
Natural

Synthetic

Albumin and
Blood products

Gelatin

Starch

eg. Gelafusin, eg. Haesteril,

Haemacel
Voluven,
Volulytes,
Venofundin,
Tetraspan,
Dextran 40/70

Crystalloids

Solutions with low molecular weight particles/

solutes (<30kDa) either ionic (electrolytes) or
non-ionic (mannitol, glucose)
Colloid oncotic pressure is by definition zero.
Hence, passes freely across capillary
membranes with distribution determined by its
tonicity (mainly Na content of the fluid).
Used as either maintenance or resuscitation
fluid

Isotonic crystalloids

Fluid infused distribute in the extracellular

compartment ( intravascular and
interstitial) hence requiring 3-4 times the
volume to resuscitate the intravascular
compartment.

Eg. Normal Saline (0.9% NaCl), Balance

solution- Hartmanns, sterofundin

Isotonic crystalloids
NS due to the high chloride content has a potential to induce
hyperchloraemic acidosis when infused in large volume.
The balance solutions are mildly hypotonic but is considered
as part of the isotonic family
Lactate or acetate is added to balance solution to counter the
development of acidosis
Lactate Metabolism dependent on functional capacity of
kidneys and liver
Acetate Metabolised by all tissues. May be advantageous
in shock state

Isotonic crystalloids are effective as:

Maintenance fluid
Plasma expander

Hypotonic crystalliods

Containing free water rendering it hypotonic

Eg 0.45% Saline, 0.18%Saline Detrose 5%,

Dextrose solutions.

Glucose substrate is rapidly metabolised leaving a

hypotonic solution that freely equilibrate
throughout total body water content.
Eg. 1Litre Dextrose solutions will provide 1 L free
water that will equilibrate leaving only 1/12 of
the infused volume in intravascular space
(83.3mls)
Commonly used as part of maintenance fluid in
ward or as correction for hypertonic
dehydration.

Hypertonic crystalloids

Salinity ranging from 1.5 7.5% (480

2400mOsm/L)

3% saline is commonly used for correction of

severe hyponatremia

7.5% saline provides rapid volume expansion

by mobilising the extravascular fluid into the IV
compartment in small volume resuscitation
concept.

HS benefit goes beyond intravascular volume

expansion.
- helps improve cardiac contractility through
improvement in the myocardial oedema
sustained during the shock period.
- helps restore urine output through natiuresis
Also used in traumatic brain injury for ICP
reduction where it acts as an osmotic agent

Colloids

Solutions with high molecular weight solutes (usually

> 30kDa) that remains in the intravascular
compartment, generating an oncotic pressure,
effectively giving it a longer intravascular persistence
as compared to crystalloids.
The degree of volume expansion is dependent on
the MW but is generally accepted as 1:1

Used for rapid volume expansion

General problems include cost, allergic reaction and

coagulopathy

Albumin Use controversial

Dextran

Risk of anaphylactoid reaction 0.275%

Affected coagulation in various ways:

Reduce platelet adhesion

Induce fibrinolysis

Decrease fibrinogen

Lower blood viscosity

Gelatins:
Haemacel (Urea-bridged), Gelafusin
(Succinyllated)
Relatively low MW, hence rapidly excreted
through kidneys.
Anaphylactoid reaction incidence - 0.375%

Starches Modified glycopectin with addition of

hydroxyethyl group to resist degradation by
endogenous amylase.
Newer generation of starches usually has a lower
MW (140kDa), degree of substitution ( 0.4/ 0.42)
and C2/C6 ratio giving it a shorter t and less
risk of accumulation, hence increasing its
recommended daily volume to 50mls/kg
Much lower incidence of anaphylactoid reaction

Assessing Fluid Status

Patients more likely to have deranged fluid balance:
Extremes of ages
Patients with abnormal losses such as blood/ plasma loss, loss
from GIT (vomiting, diarrhoea, NGT aspirate, stoma losses),
diuresis and perspiration.
Patients with reduced intake debilitated, cachexic or comatose
and GIT pathology
Patients at risk of fluid overloading such as CCF, ESRF
Diabetics with poor sugar control

Assessing Fluid Status

Clinical assessment:
Clinical history of poor intake or excessive fluid
loss associated with patients' pathological
conditions.
Physical examination will usually elicit the
degree of dehydration

Degree of dehydration
Signs

Mild (5% body

weight)

Moderate (10%)

Severe (>15%)

Mucous membrane

Dry

Very Dry

Parched

Sensorium

Normal

Lethargic

Obtunded

Postural Changes in
heart rate and blood
pressure

Absent or Mild

Present

Marked

Urine Output

Mildly decreased

Decreased

Markedly Decreased

Pulse rate

Normal or increased

Increased

Markedly increased

Mildly decreased

Decreased

Blood Pressure

Normal

Other signs to watch for: Skin turgor, Anterior fontanelle tension, pulse volume,
capillary reperfusion time

Laboratory investigations:
Gives added values to physical examination but
it should not cause delay in much needed fluid
resuscitation.
Full blood count Hb, Hct
BUSE Disproportionate rise in urea, deranged sodium level
ABG Metabolic Acidosis, Lactate level
Urine SG > 1.010 or [Na]urine < 20 mmol/l indicating water
conservation

Invasive Haemodynamic Monitoring:

Central venous pressure:
Measures the right atrial pressure to imply the left
ventricular filling pressure (LVEDP)
Accurate at extreme of values ( <2mmHg indicates
undervolume and >15mmHg overvolume in a normal heart)
Serial reading is more useful to assess adequacy of fluid
therapy
CVP changes
after 250mls
fluid challenge

< 3mmHg

3-5mmHg

> 5mmHg

Volume Status

Undervolume

Adequately filled

Over-volume

Pulmonary artery wedge pressure:

Static measurement to imply LVEDP hence
LVEDV
Serial measurement provides more useful
information
Other parameters may be measured to optimise
shock state resuscitation

Other useful monitoring tools

Arterial blood pressure
Waveform may be analysed to give an indication
of the intravascular volume status.(respiratory
swing usually indicates hypovolaemia)
Pulse contour analysis relates stroke volume
assessment to measurement of haemodynamic
parameters
Transoesophageal doppler
ECHO and IVC USG imaging

Fluid Therapy During the

Perioperative Period
Total Fluid =
Maintenance
+
Deficit
+
On-going loss

Maintenance Fluid
Replaces daily losses through urine, gastrointestinal
tract, respiratory tract and skin.

Estimation of total maintenance by 4-2-1 rule:

First 10kg: 4mls/kg/hr
Second 10kg: 2mls/kg/hr
Subsequent kg: 1ml/kg/hr
Maintenance requirement may need to be
increased in patients with excessive GI/GU loss,
fever, hypermetabolic states or tachypnoea.

Deficit

Deficit may be estimated through clinical

assessment as demonstrated earlier.

In patients who are fasted in preparation for

surgery, the deficit is calculated by the hours
of fasting multiplied by the maintenance
volume per hour

Replacement of deficit may need to be guided

by invasive monitoring in severely dehydrated
and ill patients

On-Going Loss
Includes:

blood loss

drainage of ascitic or cystic fluid

gastric fluid aspirated through NGT

Evaporative loss through exposed surgical

field

Type of fluid given should reflect the nature of

loss.

Evaporative loss may be estimated based on the

degree of surgical site exposure:
Superficial 1-2mls/kg/hr
Moderate 3-4mls/kg/hr
Severe
6-8mls/kg/hr
Invasive haemodynamic monitoring should be
used in major surgery with expected massive
fluid shift and blood loss.
Close monitoring and repeated assessment is
required to ensure adequate intravascular
volume and hence vital organs perfusion.

Postoperative fluid therapy

Oral intake should be resumed as soon as
possible
If the surgery involves gastrointestinal tract,
current recommendation would still be early
feeding but decision will usually be at the
discretion of the operating surgical team.
Patients who are unlikely to resume oral intake
should be placed on maintenance fluid of
crystalloids.