INTRAVENOUS FLUID THERAPY IN THE CRITICALLY ILL

1. Presented By
DR.SAQBA ALAM
BDS-FCPS (I)
ORAL AND MAXILLOFACIAL SURGERY

2. INTRAVENOUS THERAPY OR IV
THERAPY
“Intravenous therapy also referred as IV therapy
constitutes the administration of liquid substances
directly into a vein and the general circulation through
venepuncture” (Mosby 1998)

3. REASONS FOR INFUSION:
A/c to Brooker(2007) and Martin (2003) Intravenous fluid
therapy may be used to:
 Replace fluids and replace imbalances.
 Maintain fluid, electrolyte and acid-base balance.
 Administer blood and blood products
 Administer medication
 Provide parenteral nutrition
 Monitor cardiac function
 Immediate results
 To provide avenue for diagnostic testing
 Predictable therapeutic effects
 There are more than 200 types of commercially prepared IV
fluids.

4. BODY
COMPARTMENTS
INTRACELLULAR EXTRACELLULAR

5. EXTRACELLULAR
INTRAVASCULAR INTERSTITIAL TRANSCELLULAR

6. TYPES OF IV FLUIDS:
CRYSTALLOIDS
COLLOIDS

7. CRSTALLOIDS COLLOIDS

8. CRYSTALLOIDS:
 Isotonic, Hypotonic and Hypertonic

9. ISOTONIC
• Osmolality
of 250-375
mOsm/L
• No shifting
of fluid
• Only
serves to
increase
the ECF
HYPOTONIC
• Osmolarity of
>250 mOsm/L
• Shifting of fluid
from
intravascular to
both intracellular
and interstitial
spaces
• Hydrate the cells
causing them to
swell.
HYPERTONIC
• Osmolarity of 375
mOsm/L or
higher
• Water moves out
of the
intracellular
space increasing
ECF( volume
expanders)
• Dehydrate the
cells causing
shrinkage.

10. ISOTONIC
• 0.9% Nacl
• Lactated
Ringer
• Ringers’
Solution
• 5% Dextrose in
water
HYPOTONIC
• 0.45% Nacl
• 0.33% Nacl
• 0.2 % Nacl
• 2.5% Dextrose
water
HYPERTONIC
• 3% Nacl
• 5% Nacl
• 3%Nacl or 5%
Nacl +D/W
• >5% D/W
example,D10W

11. ISOTONIC SOLUTIONS
INDICATIONS:
•Isotonic solutions contain electrolytes such
as Nacl,KCL,Cacl and sodium lactate.
•Indicated in the treatment of vascular
dehydration, replaces sodium and chloride.
•5%D/W is isotonic when infused but
becomes hypotonic when dextrose has been
metabolized.
•Use cautiously in patients who are fluid-
overloaded or who would be compromised if
vasscular volume would increase such as
renal and cardiac patients.

12. ISOTONIC FLUIDS AND THEIR USES:
•Shock
•Resuscitation
•Fluid challenges
•Blood transfusions
•Metabolic alkalosis
•Hyponatremia
•DKA
•Use with caution in
patients with heart
failure,edema,or
hypernatremia.
•Can lead to fluid
overload.
•Dehydration
•Burns
•GI tract fluid loss
•Acute blood loss
•Hypovolemia
•Contains potassium, can
cause hyperkalemia in
renal patients.
Patients with liver disease
cannot metabolize
lactate.
Lactate is converted into
bicarb by liver.
•Fluid loss and
dehydration
•Hypernatremia
•Solution becomes
hypotonic when
dextrose is metabolized
•Do not use for
resuscitation
•Use cautiously in renal
and cardiac patients
0.9% Nacl Lactated Ringers’ D5W

13. HYPOTONIC SOLUTIONS
INDICATIONS (<250mOsm/L)
•Treatment of hypertonic dehydration.
•Gastric fluid loss
•Cellular dehydration from excessive diuresis
•Slow rehydration
SPECIAL CONSIDERATIONS:
•Do not give to patients at risk for ICP
•Not for rapid rehydration
•Electrolyte disturbances can occur
0.45% Nacl ½ normal saline

14. HYPERTONIC SOLUTIONS
INDICATIONS
USES:
•Heat related
disorders
•Fresh water
drowning
•Peritonitis
SPECIAL
CONSIDERATIONS:
•Avoid in impaired
cardiac or renal
function.
•Draw blood before
administering to
diabetics
USES:
•Hypovolemic shock
•Hemorrhagic shock
•Certain cases of
acidosis
SPECIAL
CONSIDERATIONS:
•Avoid in patients
with cardiac or renal
dysfunction.
•Monitor for
circulatory overload.
USES:
•Heat exhaustion
•Diabetic disorders
•TKO solution in
patients with renal or
cardiac dysfunction
SPECIAL
CONSIDERATIONS:
•NOT for rapid fluid
replacement
5%Dextrose in 0.9% Nacl
( D5NS)
5%Dextrose in
Lactated Ringers’
( D5LR)
5% Dextrose in
0.45% Nacl
(D51/2NS)

16. ACTIONS OF COLLOIDS: (Plasma
Expanders)
These contain large insoluble particles such as “gelatin”.
 Used if crystalloids do not improve blood volume.
BLOOD can be categorized as a colloid. Act like
HYPERTONIC solutions causing shifting of fluid out of
the cell increasing ECF.
 Long lasting effect than crystalloid hence should be
infused slowly and watch out for circulatory overload.
USES:
 Emergency treatment of shock,circulatory collapse
,hypotonic dehydration.

17. CAUTION :
Inappropriate IV therapy is a significant cause of pt mortality
and morbidity and may result from either too much or too
little volume.
TOO MUCH!
•Fluid overload has no precise definition but complications
usually arise in the context of preexisting cardiorespiratory
disease and severe acute illness.
TOO LITTLE!
•Insufficient fluid administration is readily identified by signs
and symptoms of inadequate circulation and decreased organ
perfusion .
INFUSION OF WRONG TYPE OF FLUID!!!
This results in derangement of serum sodium
concentration,which if severe,leads to changes in cell volume
and function and may result in serious neurological injury.
HYPERKALAEMIA
HYPOKALAEMIA
PERIPHERAL
EDEMA
HYPONATREMIA
PULMONARY
EDEMA
HYPERNATREMIA
HYPOVOLAEMIA

18. HOW TO AVOID LETHAL
CONSEQUENCES ???
2STRATEGIES:-
Fixed fluid replacement regimens:
Fixed fluid regimens should be considered guides to safe volume replacement,
with the actual amount to be given determined by clinical response, including
serial observations of heart rate blood pressure and urine
output.However,extremes of age,pre-existing disease severity of acute illness
and major surgery MUST be taken into account.
Recent studies support the safety of more restrictive perioperative fluid
regimens in uncomplicated elective surgery
Algorithmic approaches:
Recent evidence also suggests that volume replacement targetting a specific
circulatory parameter may improve patient outcome
These targets involve invasive monitoring of cardiac chamber filling
pressures (CVP and Pulmonary artery wedge pressure)and cardiac output.
THESE REGIMENS ARE RESTRICTED TO CRITICALLY ILL PATIENTS IN
ICU

19. PROTOCOL:

20. TAKE HOME MESSAGE !
•Measure serum sodium concentration daily in all patients
receiving maintenance fluids.
•Use a staggered regimen for fluid administration giving
isotonic fluids during the period of high ADH secretion (24-96
hrs)and introduce hypotonic fluids only later or if
Hypernatremia develops.
•Completely avoid all hypotonic fluids in patients whose serum
sodium concentration is low or falling rapidly (by>8mmol/L
per day)
•Acute decrease in serum sodium below 125mmol/L with
neurological symptoms should be considered a medical
emergency and should include prompt control of serum
sodium concentration.
•Rapid correction of chronic or asymptomatic hyponatremia is
not indicated.

21.  Acute increase in serum sodium above 150 mmol/L
should be assessed for a cause and corrected
 Diabetes insipidus is important to recognize as it can
cause large rapid losses of free water with a rapid rise
in serum Na concentration
 In either hypo or hypernatremia,the rate of correction
should be proportional to the rate of onset of
hypernatremia taking into account the presence and
severity of neurological symptoms.
 Overly rapid correction may result in cerebral
oedema,seizures or death…!

22. REFERENCES:
 Andrew K Hilton and et al,MJA(Medical journal of Australia) Avoiding
common problems associated with IV therapy.
 Ann Crawford PhD,RN,Helene Harris MSN,RN (Lippincot Nursing
Center)IV fluids-what nurses need to know.
 Algorithims for IV fluid therapy in adults,(NICE clinical guidelines Dec
2013)