IV FLUIDS & BLOOD

TRANSFUSION
GROUP 1 ANAESHESIA-BMS 5.1(LIRA SITE)
 INTRODUCTION
• Water is life
• Life on earth started in water
• Water is also a dramatic paradox
• Too less or too much= incompatible with life
• So life is geared up around maintaining the equilibrium
• In fact the entire life of the living thing is spent maintaining
fluid balance & pH balance
 INTRODUCTION
• Quantitatively it’s the most important body constituent
• Males-60% of BW
• Females- 50% of BW (attributed to larger fat content)\
• Its found in each and every tissue of the body including
bones and cartilage
BODY COMPARTMENTS
 PERCENTAGE DISTRIBUTION OF
VARIOUS BCs
• Tissues-40% and Water-60%
 TOTAL BODY WATER
• Sum of intracellular water & extracellular water
• Latter consists of
• Interstitial or tissue fluid
• Intravenous fluid or plasma
• TBW is about 60% of the body weight
 DEFINITIONS
• Extracellular fluid
• It’s the water content found outside the body cells
• It constitutes 2 major compartments ie Intravascular & Interstitial
• It also contains trans-cellular fluids which are formed by active
transport processes. It includes; Fluids of the eye & secretory
glands eg saliva,GIT & sweat glands; In cavities & channels of the
brain&SC(CSF), Lymph, In body cavities lined with
serous(moisture-exuding), In muscular & other body tissues,
Ingested water & metabolic water(produced by body’s metabolic
pocesses)
 DEFINITIONS
• Intracellular fluid
• Fluid within the cell membranes of tissue cells, throught most
of the body
• Contains dissolved solutes that ares essential to electrolyte
balance and to healthy metabolism
• Aka intracellular water
• Constituting about 30-40% of the body weight
 RULE OF 1/3
• Out of the 3 compartments in TBW
• We can manipulate only the ECF compartment
• More specifically only intravascular compartment
• Quantity of ECF is 1/3rd of the TBW
• Quantity of the intravascular compartment is 1/3 rd of ECF
 INTRAVASCULAR VOLUME (BLOOD)
• Blood volume is the volume of blood(both RBCs and
plasma) in the circulatory system of any individual
• Effective circulating volume- the proportion of intravascular
volume (thus of ECF) that is effectively perfusing tissue cells
• It is in direct proportion to the
• ECF
• Solute dissolved in it(especially Na+ salts)
• Solutes hold water in the ECF
 SOLUTES
• A solute is a substance dissolved in another substance or
water
• Both in-organic as well as organic origin
• Solutes in the ECF; by and large of in-organic type eg Na+,
Cl-, HCO3-
• Solute in ICF; mixture of both eg K+, Organic phosphate
esters (ATP, creatine phosphate etc)
 OSMOLE
• Amount of a substance
 OSMOLALITY
• is a measure of the number of solute particles present in a
solution
• Its dependent of the size/weight of the particles
• Expressed as milliosmoles per kilogram of water (m Osm/kg)
• Osmolality of a solution is the number of osmoles of solute
per kilogram of solvent (m Osmol/kg)
 OSMOLARITY
• This is the number of osmoles of solute per liter of the solution (m
Osm/L)
 OSMOLALITY & OSMOLARITY
• Value measured in the lab is usually refered to as Osmolality
• Value calculated from the solute concentration is reported by the
laboratory as osmolarity
• The osmolar gap is the difference between these two values
 TONICITY
• It refers to effective osmolality
• Its equal to sum of concentration of solutes which have the capacity to
exert an osmotic force across the membrane
• Osmolality is a property of a particular solution and is independent of
any membrane
• Tonicity is a property of a particular solution in reference to a
particular membrane
 TONICITY
• It is strictly wrong to say this/that fluid is isotonic with plasma
• What should be said is that the particular fluid is isotonic with plasma
in reference to the cell membrane
• By convention this specification is not needed in practice as it is
understood that cell membrane is the reference membrane involved
 TONICITY VS OSMOLALITY

TONICITY OSMOLALITY
• Refers to what the cell does in a • Refers to the relative
certain environment concentration of two solutions
• If envt is hypertonic, cell will • Hyperosmotic means
shrink due to water leaving the concentration of solutes outside
cell the cell is greater than
• If envt is hypotonic, water enters concentration inside the cell
the cell making it expand and
possibly burst
 TONICITY VS OSMOLALITY EFFECT
• The effect is the same
• If a hyperosmolar/hypertonic solution was administered to a patient,
this would tend to cause water to move out of the cell
 ELECTROLYTES
• An electrolyte is a substance that ionizes when dissolved in suitable
ionizing solvent such as water
• This includes most soluble salts, acids & bases
• Cations- Na+, K+, Ca++, Mg++
• Anions- Cl-, HPO4-, SO4-
 MAIN ELECTROLYTES PER
COMPARTMENT
ELECTROLYTE(mEq/L) ECF; CATIONS ECF; ANIONS ICF; CATIONS ICF; ANIONS

sodium 135-145 8-10

potassium 3.5-5.5 148-152
calcium 7-10 0.001
magnesium 1.5-4 40
chloride 95-105 1-2
bicarbonate 20-24 4-7
Phosphate & sulphate 5-9 145-155
 PLASMA OSMOLALITY
• Is the number of solutes dissolved in plasma
• Normal range is 275-290 m Osmols/kg of plasma
• Plasma osmolality= 2x S.Na+ S.Glucose/18 + BUN/2.8
• Conversion factor for BUN=B.Urea(mg/dL)/2.14
• Plasma Osm=2x S.Na + S.Glucose/18 + B.Urea x 2.8/2.14
 BODY WATER REGULATION
• Increase in osmolality stimulates osmo-receptors in anterolateral
hypothalamic nuclei leading to;
• Thirst
• Stimulation of the neurohypophysis
• ADH & AVP
• Decreased excretion through kidneys by increasing re-absorption
 INSENSIBLE WATER LOSS
• Skin= 400-450ml/day
• RS= 400-500ml/day
• GIT(Stool)= 100-200ml/day
• Sweat is not insensible water loss
• Total minimal loss around 1L/day
INTRAVENOUS FLUIDS
CLASSIFICATION
 RELATIVE TONICITY
• Isotonic; RL, 1N NaCl, D5W(becomes hypotonic inside the body)
• Hypertonic; 5DNS, 5D in RL, 5D in ½ N NaCl, 3% NaCl
• Hypotonic; ½ N NaCl
• 20% albumin has osmotic effect 5 times its volume ie 100ml will
increase plasma volume by 400-500ml, given at a rate of 1-2ml/min
correcting fluid deficit is absolutely imperative

• 5% will increase plasma volume by 100ml (0.5-1ml/min)

 CRYSTALLOIDS
• Are the first line choice for fluid resuscitation in; hypovolemia,
hemorrhage, sepsis and dehydration
• Situations where crystalloids are useful;
• As solution for IV medication n delivery
• To deliver maintenance fluid in pts. with ltd or no enteral nutrition
• Blood pressure mgt
• To increase diuresis to avoid nephrotoxic drug/toxin-mediated end
organ damage
 VARIOUS CRYSTALLOIDS
• Normal saline (0.9% NaCl solution)
• Lactated Ringers/ Hartman’s solution (lactate buffered solution)
• Acetate buffered solution
• Acetate and lactate buffered solution
• 0.45 % NaCl (hypotonic solution)
• 3% NaCl (hypertonic solution)
• 5% dextrose in water
• 10% dextrose in water
 HOW DO THEY ACT
• Most commercially available crystalloids are isotonic to human
plasma
• They approximate concentrations of various solutes found in plasma-
they don’t exert an osmotic force in vivo
• They function to expand intravascular volume
• Without disturbing ion concentration or
• Causing significant fluid shifts between intracellular, intravascular &
interstitial compartments
 HOW DO THEY ACT
• Hypertonic solutions (not to be routinely administered)
• Like 3% saline solns contain higher concentration of solutes than
those found in human serum/plasma
• As a result of this discrepancy in concentration;
• These fluids are osmotically active & will thus cause fluid shifts
• Their primary indication is for emergency replacement of serum
solutes such as in hyponatremia with neurological symptoms
 HOW DO THEY ACT
• Buffered solutions
• Contain molecules that metabolize in vivo to HC03-
• They were designed to sustain a normal physiologic plasma pH
• 3 commonly used are lactate, acetate and gluconate
• Lactate and gluconate are hepatically metabolized to bicarbonate
• Acetate is predominantly metabolized peripherally by skeletal muscle
 HOW TO ADMINISTER
• FLUID RESUSCITATION
• In an acute setting, rapid infusion of crystalloid maybe indicated;
• To be administered via large bore peripheral line (18G or larger)
• Through a central venous cannula (blood/products also can be)
• It may require a pressure apparatus to the bag of fluid to achieve
higher infusion rate
 HOW TO ADMINISTER
• MAINTENANCE FLUIDS
• In 1957 Holliday and Segar determined that the fluid requirements of
patients was related to their caloric requirements
• Since this time their initial formula has been modified to provide
clinicians with guidelines for the administration of maintenance
crystalloid fluids
• The mass based formula uses the 4-2-1 rule ie
• 0-10kg (+4mL/kg/hr); 10-20kg(+2mL/kg/hr) & >20kg(+1mL/kg/hr)
• E.g. 70kg pt; 20kg(40+20mL/hr)+ 50kg(50mL/hr)= 100-110mL/hr
 ADVERSE EFFECTS
• Volume expansion with crystalloids may cause latrogenic fluid overload
• The risk becomes particularly elevated in pts. with
• Impaired kidney function(AKI, CKD etc.)
• These pts. should therefore receive treatment with judicious use of IV
fluids
• Pts. with CHF are at increased risk as fluid overload can cause life
threatening pulmonary edema and the worsening of DHF & SHF leading
to end organ damage or even death
• Its imperative to monitor these pts. carefully & admin the minimum
required volume to maintain homeostasis
 ADVERSE EFFECTS
• NORMAL SALINE (0.9% saline)
• Has higher concentration of Cl- (154mmol/L) than is found in human serum
(98-106mmol/L)
• With admin of large volume of NS hyperchloraemia
• Increase in Cl- concentration>substantial plasma ion difference>more free
water in intravascular space>increase in H+ to maintain electrochemical
neutrality>excess renal bicarbonate excretion>MA
• Dilution of serum HC03- through non buffered crystalloids(eg NS) may
contribute to acidosis
• Additionally higher volumes of NS may cause hyperchloraemia-induced renal
afferent constriction which can cause decrease in GFR
 ADVERSE EFFECTS
• Acetate buffered crystalloid solutions controversial
• Studies performed on dogs have shown that even small volumes of
acetate containing crystalloids can significantly increase serum acetate
concentration to 10-40 times the physiologic level
• Acetate may potentiate hemodynamic instability by decreasing both
myocardial contractility & BP
• Unlike acetate buffered solutions, lactated crystalloids can induce
hyperglycemia therefore their administration maybe of concern to
diabetic pts.
 CRYSTALLOID
CONTRAINIDCATIONS
• PTS with fluid overload(avoid)
• Special care is required when administering them to pts. with CHF or
those with significant renal impairment (eg CKD-V dialysis dependent
pts.)
• Hypertonic saline in all clinical settings except pts with severe
hyponatremia with neuro symptoms
• Rapid correction of hyponatremia may cause central pontine
myelinolysis
• Hypotonic solutions should not be given to pts with/at high risk of
developing cerebral edema
 CRYSTALLOID
CONTRAINDICATIONS
• Crystalloids containing K+(RL etc) are relatively contraindicated in
hyperkalemia pts due to risk of developing ventricular arrhythmias
• Avoid crystalloids containing dextrose in pts with hyperglycemia
• RL contains Ca+, calcium can induce coagulation of blood products in
the IV tubing & so inhibit their effective delivery thus blood products
should utilize a separate IV set up
 MONITORING
• Pts should undergo assessment for S/S of dehydration & fluid
overload
• Urine output; target is 0.5-0.6mL/kg/hr which indicates adequate hyd
• Urine output maybe useful to assess volume status in pts with renal
impairment
• Assess for new/worsening crackles (pulmonary edema due to
overload)
• Any new/worsening peripheral edema in extremities
 COLLOIDS
• DEXTRANS
• Branched polymers of glucose molecule
• Act as anti thrombotic by decreasing RBC aggregation
• Total dose not more than 20ml/kg in 24hrs
• Hyperglycemic effect
• No longer used these days
 COLLOIDS
• STARCHES
• Excellent volume expanders
• All the volume remains in intravascular compartment
• Effect lasts 4-6hrs
• Interfere with platelet aggregation
• Increase the volume by nearly 100% to 150% depending on their %
concentration
• Made from corn starch(least antigenic)
• Up to 35-50ml/kg 24hrs can be given
THE END
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