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Clinical science

Intravenous fluid therapy (Parenteral fluid therapy)

Summary
Parenteral fluid therapy usually involves the intravenous administration of crystalloid solutions, colloidal solutions,
and/or blood products. The choice of fluid, the amount of fluid to be infused, and the rate of infusion are determined by
the indication for fluid therapy. Fluid therapy with crystalloid solutions is used to resuscitate patients who are
hypovolemic, to correct free water deficits in the case of dehydrated patients, to replace ongoing fluid losses, and to
meet the fluid requirements of patients who cannot take fluids orally. The use of colloidal solutions is now
controversial. However, colloidal solutions (such as albumin solution) may be indicated either as a monotherapy or in
combination with crystalloid solutions in severe cases of low oncotic pressure, especially in children. In the case of
severe bleeding, the use of blood products must be considered. All patients on fluid therapy should be closely
monitored using a combination of clinical parameters and laboratory tests to determine the end-point of fluid therapy.

General indications for parenteral fluid therapy

Fluid resuscitation
Patients who are in hypovolemic shock require rapid fluid infusions in the form of fluid challenges to maintain
intravascular volume.

1. Rapid infusion of a 500–1000 mL bolus; of normal (isotonic) saline (NS) or lactated Ringer's solution (RL) within 15
minutes
2. Observe the patient for a clinical response
3. Repeat the fluid bolus infusion if the clinical response is inadequate.
An inadequate response to fluid resuscitation is characterized by:
Low urine output (< 0.5 mL/kg/hr; best indicator)
Increased heart rate
Low blood pressure
Low CVP (central venous pressure)
4. If the patient does not respond to multiple fluid challenges:
Consider the use of vasopressors and/or inotropes
Consider other causes of shock besides hypovolemia (e.g., cardiogenic shock, sepsis).

Replacement of free water deficit

Indicated to treat dehydration and/or hypernatremia
Free water deficit (in liters) = k × weight (kg) × (Current [Na+]/140 – 1)
Intravenous fluids that can be used to replace free water deficit
5% dextrose
Hypotonic saline (e.g., ½NS, ¼NS)

Replacement of ongoing fluid loss

Fluids are also indicated in the post-resuscitation phase when the patient is no longer hypovolemic but still has
ongoing abnormal fluid loss that cannot be compensated for by oral intake alone.
Some common conditions associated with an ongoing fluid loss are:
Burns
Polyuria (high output renal failure, diabetes insipidus)
Surgical drainage
 Significant ongoing gastrointestinal loss (vomiting, diarrhea)
The amount and rate of fluid infusion should ideally match the amount and rate of ongoing fluid loss.
The composition of fluid given should ideally match the composition of the bodily fluid lost.

Composition
Fluid from the surgical drain Ideal replacement fluid
Na+ K+ Cl- HCO3-
Gastric secretions 50 mmol/L 15 mmol/L 110 mmol/L – D5½NS + 20 mEq/L KCl
Pancreatic secretions 140 mmol/L 5 mmol/L 75 mmol/L 115 mmol/L RL ± sodium bicarbonate
Bile 140 mmol/L 5 mmol/L 100 mmol/L 35 mmol/L RL ± sodium bicarbonate
Ileum 140 mmol/L 5 mmol/L 100 mmol/L 30 mmol/L RL ± sodium bicarbonate

Maintenance fluid therapy

Maintenance fluids are indicated in patients who cannot or are not allowed to take fluids orally.
Normal daily maintenance dose
Adults: 30 mL/kg of water, 1 g/kg of glucose (to prevent starvation ketosis), 1–3 mEq/kg of Na+, 1–3 mEq/kg of
Cl-, and 0.5–1 mEq/kg of K+ per day
Children: Holliday-Segar formula (4,2,1 rule); : 4 mL/kg/hr for the first 10 kilograms + 2 mL/kg/hr for the next
10 kilograms + 1 mL/kg/hr for the remaining weight
Neonates: 150 mL/kg/day
Certain conditions may alter the amount of maintenance fluids required.
The use of hypotonic intravenous fluids in children and adolescents
↑ Maintenance fluids: fever , tachypnea
requiring maintenance therapy has historically been standard practice in
↓ Maintenance fluids: congestive cardiac failure,
pediatrics. low output
However, there renal failure
is a high incidence of hyponatremia and
The maintenance fluid requirement is higher associated neurologic
in children impairment in patients receiving hypotonic
than in adults!
maintenance fluid therapy. The American Academy of Pediatrics
recommends the use of isotonic solutions with appropriate levels of
Other indications potassium chloride and dextrose to decrease the risk of these complications.
This recommendation does not apply to patients with hepatic disease,
Correction of electrolyte imbalances (seecancer,
sodium
renal
imbalance,
impairment,
potassium
diabetes
imbalance)
insipidus, copious watery diarrhea,
As a solvent for IV drugs: e.g., 5% dextrose
severe
forburns,
noradrenaline
or cardiac
infusions
disease, or those who have undergone
neurosurgery.
References:[1][2][3][4][5][6]

Types of parenteral fluids

Crystalloid solutions
Aqueous solutions with varying concentrations of electrolytes
The most commonly used fluids in a hospital setting
Crystalloids increase intravascular volume. The extent to which they do this depends on the effect on fluid
compartments.

Type of
Crystalloid Effect on fluid
crystalloid Specific Indications Risks
solution compartments
solution

↓ Intracellular
volume Osmotic
Hypertonic 3% NaCl Acute severe hyponatremia
↑ Extracellular myelinolysis
volume

Replacing free water deficit

↑ Intracellular Maintenance fluid therapy: no
½ normal Cerebral edema
volume longer recommended for patients 28
Hypotonic saline (0.45% Pulmonary
↑ Extracellular days to 18 years of age in
NaCl) edema
volume postoperative and medical acute
care settings
 Type of
Crystalloid Effect on fluid
crystalloid Specific Indications Risks
solution compartments
solution

No change in
Normal saline intracellular volume Fluid resuscitation Hyperchloremic
(0.9% NaCl) ↑ Extracellular Maintenance fluid therapy acidosis
volume

Lactic acidosis
↑ Extracellular
in patients with
Ringer's volume
liver failure
lactate Minimally elevated
Fluid resuscitation Clumping of red
solution (RL intracellular volume
Maintenance fluid therapy cells if RL is co-
or Hartmann Mild buffer action
administered
solution) that counters
Isotonic with blood
acidosis
products

The sodium-free
water becomes
evenly distributed
5% dextrose among both fluid Replacing free water deficit Hyperglycemia
(D5W) compartments Maintenance fluid therapy in diabetic
↑ Intracellular Total parenteral nutrition patients
volume
↑ Extracellular
volume

Patients 28 days to 18 years of age requiring maintenance intravenous fluid therapy should receive isotonic solutions
(which have a sodium concentration similar to plasma) with appropriate levels of potassium chloride and dextrose to
reduce the risk of hyponatremia!

Colloidal solutions
A colloid is a high molecular weight substance; that mostly remains confined to the intravascular compartment;
and thus generates oncotic pressure
Examples:
Natural colloids: albumin, fresh frozen plasma (FFP)
Artificial colloids: gelatins, dextrans, hydroxyethyl starch (HES)
Effects
Colloids have a greater effect on intravascular volume than crystalloids
Decreased blood coagulability
Anti-inflammatory effect
Administration: : Their use is controversial, but they may be indicated in combination with crystalloids (for more
information, see the table in extra information below).
Adverse effects
Volume overload
May interfere with blood grouping and cross matching
Impairment of platelet aggregation ("coating") after infusion with a large volume of HES
Pruritus with prolonged use
Anaphylactoid reactions
Nephrotoxicity (especially in the case of pre-existing renal damage)

Although colloids are much more effective than crystalloids as intravascular volume expanders, they are more
expensive and are also associated with more side effects than crystalloids without being demonstrably superior. Their
use is, therefore, controversial!

Increase in Duration
Colloidal Chemical
Available forms intravascular of volume Specific indications
solution structure
volume expansion
 Increase in Duration
Colloidal Chemical
Available forms intravascular of volume Specific indications
solution structure
volume expansion

Acute
management of
+ 80% of the severe burns
5% albumin (iso-
administered Hypoalbuminemic
oncotic)
volume states (following
Naturally
paracentesis, liver
occurring
cirrhosis)
colloid in
Spontaneous
plasma 16–24
Albumin bacterial
(accounts for hours
peritonitis
80% of plasma
Acute lung injury
oncotic + 200–400% Diuretic resistant
pressure) 25% albumin of the nephrotic
(hyperoncotic) administered syndrome
volume In plasmapheresis
as an exchange
fluid

To improve micro-
circulatory flow in
microsurgical re-
Highly 6% solution (dextran- + 100–150%
implantations
branched 40) of the 6–12
Dextrans Priming
polysaccharide 10% solution (dextran- administered hours
extracorporeal
molecules 70) volume
circulation during
cardio-pulmonary
bypass

Acute
management of
Succinylated gelatins hemorrhagic
(e.g., gelofusine, hypovolemia
plasmagel) Priming
+ 70–80% of
Synthesized by Urea cross-linked extracorporeal
the <6
Gelatin the hydrolysis gelatins (e.g., circulation during
administered hours
of collagen cardio-pulmonary
polygeline/Haemaccel®) volume
bypass
Oxypolygelatins (e.g.,
Volume pre-
gelifundol)
loading before
regional
anesthesia

1st generation: hespan

2nd generation:
Derived from hextend, hetastarch, + 100% of Acute
amylopectin (a pentastarch
Hydroxyethyl the 8–12 management of
starch (HES)
highly 3rd generation: administered hours hemorrhagic
branched tetrastarch (side effects volume hypovolemia
starch) are less pronounced in
comparison to other
colloids)

Blood products
The transfusion of packed RBC concentrate is indicated in the case of massive blood loss (see blood transfusion).
References:[7][6][8]

Route of parenteral fluid therapy

IV access: : The intravenous route is most commonly used for administering fluids and/or medication
Intraosseous (IO) access
In “difficult/collapsed” peripheral veins, IO (intraosseous) access is preferred to central venous access for
resuscitation.
Central venous access
Central venous catheters are longer and hence permit a slower flow rate than peripheral venous catheters;
with the same lumen diameter. However, a much higher flow rate can be achieved with special large bore
central venous catheters (e.g., high-flow Hickman catheters, Shaldon catheters)
Indications
Fluid resuscitation in a patient with “difficult/collapsed” peripheral veins (when IO access in not
feasible)
Hemodynamic monitoring: measurement of central venous pressure, pulmonary artery catheterization
Administration of veno-irritant substances: vasopressors, chemotherapeutic drugs, prolonged
parenteral nutrition
Measures to reduce risk of infection during placement, e.g. central-line associated blood stream infection
(CLABSI)
Use a cap, mask, long-sleeved sterile gown, sterile gloves, and a sterile full body drape.
Prepare skin with chlorhexidine and alcohol before inserting the catheter.
Systemic anticoagulation and antibiosis may be considered in oncology patients who require long-term
central venous access.
Technique of insertion: is based on the Seldinger technique, which involves the use of a guide wire to gain
access to blood vessels.
1. A special, wide-bored needle (trocar) is inserted into either the jugular , subclavian, or the femoral vein
with/without ultrasonographic guidance.
2. Following needle insertion, a guide wire is passed through a needle into the selected vein
3. The needle is removed while maintaining the guide wire in position and the central venous catheter is
passed over the guide wire
4. Once the central venous catheter is in place, the guide wire is slowly removed
5. Proper positioning of the central venous catheter (in the case of jugular or subclavian approaches)
The tip of the catheter is correctly positioned in the superior vena cava with the help of ECG leads
by observing the changes occurring in the P wave
A chest x-ray must be taken after the placement of a central venous line

The flow rate is subject to Poiseuille's law: The flow rate is 16 times slower if a lumen's diameter is halved, but flow rate
doubles if the catheter's length is halved!

References:[9]

Titration parameters for IV fluid therapy

The indication for fluid therapy determines the amount of fluid administered and the rate of fluid therapy (see
“General indications for fluid therapy” above).
Hemodynamic measures: pulse, blood pressure, capillary refill time, jugular venous pressure (or central venous
pressure)
Monitor for complications of IV fluid therapy, which include:
Signs of fluid overload; : pedal edema; , fine crackles on pulmonary auscultation
Electrolyte imbalances: (see sodium imbalance and potassium imbalance)
Fluid balance charts: These charts should record the fluid intake (total amount of fluid administered) and fluid
output (urine output, output from surgical drains, and, if applicable, the volume of loose stools or vomit)
References:[10]

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