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IV fluids

Pediatric Surgery
by

sami aswad

on 7 February 2014

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Transcript of IV fluids

IV Fluids
prepared by:
Sami Ibrahim Aswad

supervised by:
Dr. Muhammed Hazim


Classification


IV fluids come in four different forms:
• Colloids
• Crystalloids
• Blood and blood products
• Oxygen-carrying solutions
Why is IV therapy important?
As many as 75% of patients admitted to the hospital receive some type of IV therapy.
Did you know
50-70% of the average human body is comprised of body fluid
1/3 Extracellular
Interstitial fluid
Plasma
2/3 Intracellular
Red Blood Cells
Other cells
ECF
15 L
ICF
30 L
Plasma (25%)
ISF (75%)
We use

intravenous therapy
in the hospital to:
establish or maintain a fluid electrolyte balance
administer continuous, intermittent, or bolus medication
administer fluid to keep vein open
administer blood or blood components
administer IV anesthetics
maintain or correct a patient's nutritional state
Colloid solutions are IV fluids that contain solutes in the form of large proteins or other similarly sized molecules.



The pro- teins and molecules are so large that they cannot pass through the walls of the capillaries and onto the cells. Always hypertonic

Crystalloids contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids.
Isotonic crystalloids
have a tonicity equal to the body plasma.
e.g D5W, Normal saline, lactated Ringer's solution
Hypertonic crystalloids
have a tonicity higher than the body plasma.
e.g: 3% sodium chloride solution
dextrose 5% in NS soulution
dextrose 5% in half normal saline solution
dextrose 10% in normal saline solution
Hypotonic crystalloids
have a tonicity lower than the body plasma.
e.g half normal saline solution (0.45% sodium)
Commonly used colloid solutions include:
plasma protein fraction
salt poor albumin
dextran
hetastarch
Crystalloids
vs
Colloids
Definition:
Is the infusion of liquid substances directly into a vein.
Colloid solutions
Crystalloids come in many preparations and are classified according to their “tonicity.”:
Isotonic
Hypotonic
Hypertonic
Crystalloids
Indications

1. Bleeding or potential bleeding from traumatic or non-traumatic causes
2. Shock
3. Hypotension/dehydration
4. Burn
5. Diabetics with BS > 240 mg/dL, with signs of dehydration or when it is unclear if the situation is diabetic ketone acidosis
6. Hyponatremia
7. Gastric or NG loss
8. Pyloric obstruction
9. Hypercalcemia
10. Blood transfusion
11. Cleaning: diagnostic peritoneal lavage, abdominal trauma, burst abdomen, cleaning the wounds
12. For irrigation in TURP, prostatectomy, nephrostomy
13. Filling hydatid cyst sac
Normal Saline Solution
NS should be given cautiously or may be
contraindicated
in :
1) Heart failure
2) Hypertension
3) Impaired renal function and
4) Pulmonary edema

Side effects
1. Hypernatremia
2. Hypokalemia
3. Acidosis
4. Circulatory overload
0.9% Sodium Chloride Solution
• It contains 9 g/L Sodium Chloride with an osmolarity of 286 mOsmol/L.
• It contains 154 mEq/L Sodium and Chloride
Indications:
1. Burn
2. 3rd space fluid shift: pancreatic and biliary loss, intestinal obstruction
3. Ileostomy and colostomy loss
4. Metabolic acidosis: sodium lactate in ringer's lactate solution is metabolized in
x
the liver to bicarbonate makes it useful in correction of metabolic acidosis
5. Shock
6. Trauma
Hartmann's solution
or
lactated ringer's solution
One litre of Hartmann's solution contains:
• 131 mEq of sodium ion = 131 mmol/L.
• 111 mEq of chloride ion = 111 mmol/L.
• 29 mEq of lactate = 29 mmol/L.
• 5 mEq of potassium ion = 5 mmol/L.
• 4 mEq of calcium ion = 2 mmol/L .

This amounts to an osmolarity of 279 mOsm/L
Contraindications :
1. D.M
2. CHF
3. Ischemic stroke
4. Liver disease
5. Severe reduction in renal function
6. Blood transfusion
Does not contain lactate
It contains:
1. Na: 147 mmol/L
2. Cl: 156 mmol/L
3. K: 4 mmol/L
4. Ca: 4.5 mmol/L

With osmolality of 309 mosmol/L

Ringer's solution
Indications
1. To replace fluid deficits with no significant loss of electrolytes:
• Coma ,dysphagia
• Hyperthyroidism
• Hypocalcaemia
• Diabetic insipidus
2. For replacing insensible fluid losses e.g high grade fever
3. For emergency management of hyperkalemia used with calcium gluconate, bicarbonate and insulin during treatment of diabetic ketoacidosis
4. For correction of hypernatremia by giving D5W with furosemide which will promote Na excretion
5. in patients with burns on the second post-burn day
6. preparation of jaundiced patients for surgery
7. post-operative nutrition (NPO for long time)
8. during treatment of diabetic ketoacidosis, when they must be accompanied by continuing insulin infusion
9. Vehicle for mixing medications for I.V. delivery for all age groups except penicillin, amphotricin B and phenytoin
D5W (dextrose 5% in water)
50 grams of dextrose per liter with osmolality of 277 mosmol/L
5 gm of dextrose per in each 100 ml of water so each pint of GW which is 500 ml contains 25 gm of dextrose
1 gm of dextrose = 4 kcal…. 1 pint = 25 *4= 100 kcal of energy
It corrects dehydration and supplies energy
It is fluid of choice for patients who need more water and fewer electrolytes, it is idea fluid for correction of intracellular dehydration

Safe rate of administration
1. Can be given safely at a rate of 0.5 gm/kg/hour without causing glycosuria
2. If it is given rapidly it will cause osmotic dieresis and dehydration


Metabolism
• Dextrose is metabolized leaving free water
• The proportion of dextrose load that contributes to lactate formation can increase from 5% in healthy subject
x

x
to 85% in critically ill patient this is why the routine use of D5W has been abandoned in critically ill patient
Advantages
1. Fluid of choice for those who are likely to retain Na and those who are at risk of heart failure
2. During first 24 hr after surgery where Na retention is common and also in patients with impaired kidney function
3. Adequate dextrose infusion protects liver against toxic substance

Disadvantages
1. May cause local pain, venous irritation and thrombophelbitis
2. Prolonged administration can give rise to hypomagnesaemia, hypophosphatemia and hypokalemia
3. Undesirable effects of dextrose in critically ill patients include enhanced production of CO2 and lactate and
x x x x
aggravation of ischemic brain injury

Contraindications
1. Hypovolemic shock
2. Neurosurgical procedure
3. Cerebral edema
4. Acute ischemic stroke
5. Blood transfusion
6. Uncontrolled diabetes and severe hyperglycemia
7. Hponatremia and water intoxication
8. Hyerpnatremia (if given rapidly )
• It has advantages of both D5W and NS
• Dextrose provides energy, saline provides electrolytes (sodium and chloride) along
x
with fluid to correct dehydration


Indication

1. Combined water and Na depletion
2. Dehydration with hpovolemic shock provided correction is not needed rapidly
3. Compatible with blood transfusion
4. Fluid of choice in vomiting, nasogastric aspiration in these patients it will correct
x x
hypovolemia, salt depletion, and also supply energy

Precaution:
1. Patients with edema due to any cause: cardiac, hepatic and renal disease
2. Severe hypovolemic shock where rapid correction is needed

Dextrose saline (5% dextrose and 0.9 NaCl)
Side effects
1. Fever and chills
2. Thrombophelbitis
3. Explosion when cautery is used in endoluminal surgery
4. Pulmonary congestion,
5. fluid and electrolyte imbalance,
6. acidosis
7. dehydration
8. urticaria
Manitol
* It is an osmotic diuretic
* Hypertonic solution
*Available in concentration of (5%, 10%, 15%, 20%, 25%)
*Administration by intravenous infusion only

* When administered intravenously mannitol is confined to the extracellular
x
space, only slightly metabolized and rapidly excreted by the kidney.
* It is widely used in head injury management, has significant beneficial
x x x x X
effects on ICP, cerebral blood flow and metabolism
Indications
Therapeutic use
1. To decrease ICP ( head injury, ICB, cerebral edema, brain mass )
2. Reduction of high intraocular pressure when the pressure cannot be lowered by other means.
3. Promotion of diuresis in the prevention or treatment of the oliguric phase of acute renal failure
X X
before irreversible renal failure becomes established
4. Promotion of urinary excretion of toxic materials.
5. Blood transfusion reaction (Prophylactic measures to reduce the risk of renal failure)
6. Pre-operative preparation of jaundiced patient
7. Pre-operative bowel preparation
8. Crush syndrome to prevent hepatorenal shutdown
9. Electrical burn
10. Tourniquet for long time

Diagnostic Use
Measurement of glomerular filtration rate.
Contraindication
1. Hypersensitivity to mannitol
2. Pulmonary edema
3. Congestive heart failure
4. Severe dehydration
5. Well established anuria due to severe renal disease.
6. Progressive renal damage or dysfunction after institution of mannitol therapy,
X
including increasing oliguria and azotemia.
7. Active intracranial bleeding except during craniotomy.
Indication
1. replacement until blood is prepared in severely injured patients
2. in conjunction with crystalloid if fluid load exceeds 3-4 L prior to transfusion
3. emergency treatment of shock especially due to loss of plasma
4. conditions associated with large protein loss such as acute management of burn (3rd post-burn day )
5. clinical situation of hypoalbuminemia:
• Parascentesis
• Pancreatitis
• Liver cirrhosis
• After Liver transplantation
6. Septicemia
7. In critically ill patient, when volume is critical, and crystalloid use would be excessive,
x x x x
e.g: pulmonary edema, congestive heart failure, renal conditions

Contraindications:
1. Hypervolemia
2. Hypertension
3. Dehydration
4. Severe anemia
5. Hypersensitivity
6. Severe heart failure
7. Renal failure with oliguria or anuria

Colloids
Fluids and body requirements
• Sensible loss (urine, feces )
• Insensible loss (respiration, sweating)
The minimum daily water loss in an adult is about 1700 ml.
So daily fluid requirement is :1700-2500 1700-2500/70 = 25-35 ml/kg/day

• Water requirements increase with: fever, sweating, burns, tachypnea, surgical drains, polyuria, or ongoing significant gastrointestinal losses.

• For example, water requirements increase by 100 to 150 mL/day for each C degree of body temperature elevation.

• Male, muscular person, diseased patients need more fluid than female, obese person and healthy ones
Assessment of hydration status

1. Urine output
2. Weight of the patient
3. Sensorial level
4. Vital signs: BP, PR, RR, Temp.
5. Capillary refilling
6. Skin turgor
7. Mucus membrane
Lab evaluation
1. Urea
2. Creatinine
3. Hb, PCV
4. S. electrolytes
5. GUE
6. Blood glucose
Fluids and body requirements
Hypertonic (406 mOsmol) but upon administration it becomes hypotonic that is because dextrose is metabolized by the body and only 0.45% NS remains which is hypotonic

Content:
5 grams Dextrose
77 mEq Sodium
77 mEq Chloride
It replaces water and electrolytes and provides nutrients in the form of dextrose

Indications
1. Heat-related Emergencies
2. Diabetic disorders
3. Can be used as keep open IV solution for patients with impaired renal and cardiac function
4. Patients who are prolonged NPO

Contraindication
Do not use in patients who require rapid fluid resuscitation

5% Dextrose in 0.45 Sodium Chloride (D5½NS)
5% Dextrose in 0.33 Sodium Chloride

hypertonic solution
It contains 56 mEq/L of Na and chloride with 5 gram of dextrose
Approach to IV fluid therapy

Maintenance fluid:
Fluid and electrolyte needs from basal metabolism, it is amount of fluid lost normally (sensible and insensible losses) .

Ongoing loss:
it is loss from sources other than evaporative and urinary losses from NGT, stoma, fistula,

Deficit fluid:
means the fluid lost through abnormal ways like diarrhea, vomiting
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