IV Fluid Therapy

1. IV Fluid Therapy Presented by: Ahmed A. Al Faqih Ibrahim T. Al Mutairi Supervisor : Dr. Ghiath Al Saied

2. Overview: Definitions Types of IV fluid Indications of IV fluids Calculations Procedures Monitoring Complications/Side effects

3. Definition: Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body.

4. Types: There are Three main types of IVF: Isotonic fluids. Hypotonic fluids. Hypertonic Fluids.

5. Isotonic fluids Have a total osmolality close to that of extra cellular fluids (ECF) and don't cause RBCs to shrink or swell. Isotonic have a tonicity equal to the body plasma. When administered to a normally hydrated patient, isotonic crystalloids do not cause a significant shift of water between the blood vessels and the cells. Thus, there is no (or minimal) osmosis occurring Helpful with patients who are hypotensive or hypovolemic.

6. Hypotonic Fluids Less osmolarity than serum. (meaning: in general less sodium ion concentration than serum) These fluids DILUTE serum thus decreasing osmolarity. Water moves from the vascular compartment into the interstitial fluid compartment ? interstitial fluid becomes diluted ?osmolarity descreases ? water is drawn into adjacent cells. Caution with use because sudden fluid shifts from the intravascular space to cells can cause cardiovascular collapse and increased ICP in certain patients. Examples: half normal saline, dextrose 2.5% (D2.5W)

7. Complications of excessive use of hypotonic solutions include: Intravascular fluid depletion. ��Decreased blood pressure. � Cellular edema.

8. Hypertonic Fluids These have a higher osmolarity than serum. These fluids pull fluid and sometimes electrolytes from the intracellular/interstitial compartments into the intravascular compartments. Useful for stabilizing blood pressure, increasing urine output, correcting hypotonic hyponatremia and decreasing edema. These can be dangerous in the setting of cell dehydration. Examples: 5% dextrose in 0.9% NaCl (D5NS), 3% NaCl, 10% dextrose in water (D10W)

9. There are two main groups of fluids: 1-Crystalloids 2-Colloids

10. Crystalloids Clear solutions �fluids- made up of water & electrolyte solutions; small molecules. These fluids are good for volume expansion. Both water & electrolytes will cross a semi-permeable membrane into the interstitial space and achieve equilibrium in 2-3 hours. Remember: 3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood.(Why?) This is because approximately 2/3rds of the solution will leave the vascular space in approx. 1 hour. In the management of hemorrhage, initial replacement should not exceed 3L before you start using blood components because of risk of edema, especially pulmonary edema. Example:

11. Advantages of crystalloids: 1-They are inexpensive. 2-Easy to store with long shelf life. 3-Readily available with a very low incidence of adverse reactions. 4-There are a variety of available formulations that are effective for use as replacement fluids or maintenance fluids. Disadvantage: 1-It takes approximately 2-3 x volume of a crystalloid to cause the same intravascular expansion as a single volume of colloid. 2-Causes peripheral edema. 3-Dilute plasma proteins.

12. 0.9% Normal Saline: Basically �Salt and Water� Principal fluid used for IV resuscitation and replacement of fluid & salt loss. -Contains: Na+ 154 mmol/l, K+ - Nil, Cl- 154 mmol/l;. . -Distribution: Stays almost entirely in the Extracellular space. Of 1 liter ? approx 700ml stays Extracellular fluid; 300 ml moves Intravascular fluid. So for 100 ml blood loss(???) ? need to give 300-400ml NS [only �-1/3 remains intravascular] Uses : Shock , Hyponatremia , Blood transfusions , Resuscitation Can lead to overload Use with caution in patients with heart failure or edem

13. 0.45% Normal saline: (�Half� Normal Saline = HYPOtonic saline) Use with caution! Can be used in severe hyperosmolar states E.g. severe dehydration. Leads to HYPOnatraemia if plasma sodium is normal. Uses : Water replacement or Gastric fluid loss from NG or vomiting May cause cardiovascular collapse or increased intracranial pressure

14. 1.8, 3.0, 7.0, 7.5 and 10% Saline: (HYPERtonic saline) -Reserved for plasma expansion with colloids or acute hyponatrema. -In practice it is rarely used. -Large volumes will cause HYPERnatraemia and IC dehydration.

15. Lactated Ringers Isotonic (osm = 304) Lower Na than plasma � 130 mEq Uses : Dehydration , Burns , Lower GI fluid loss , Acute blood loss , Hypovolemia Contains potassium, don�t use with renal failure patients Don�t use with liver disease, can�t metabolize lactate

16. 5% Dextrose: (D5W)�Sugar and Water� -Primarily used to maintain water balance in patients who are not able to take anything by mouth; Commonly used post-operatively in conjuction with salt retaining fluids ie saline; Often prescribed as 2L D5W: 1L N.Saline [�Physiological replacement� of water and Na+ losses] -Provides some calories [ approximately 10% of daily requirements] -Regarded as �electrolyte free� � contains NO Sodium, Potassium, Chloride or Calcium -Distribution: <10% Intravascular; > 66% intracellular -When infused, is rapidly redistributed into the intracellular space; Less than 10% stays in the intravascular space therefore it is of limited use in fluid resuscitation. -For every 100ml blood loss � need 1000ml dextrose replacement [10% retained in intravascular space. -Common cause of iatrogenic hyponatraemia in surgical patient. - Uses : Fluid loss Dehydration Hypernatremia Use cautiously in renal and cardiac patients � Can cause fluid overload

17. Dextrose saline: �salt and sugar� -Similar indications to 5% dextrose; Provides Na+ 30mmol/l and Cl- 30mmol/l . -Primarily used to replace water losses post-operatively. -Limited indications outside of post-operative replacement. - Advantage � doesn�t commonly cause water or salt overload.

18. Colloids -Colloids are large molecular weight solutions (nominally MW > 30,000 daltons). -These solutes are macormolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments. -Because of their high osmolarities, these are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries. -These work well in reducing edema because they draw fluid from the interstitial and intracellular compartments into the vascular compartments. -Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids.

19. Colloids -Albumin solutions are available for use as colloids for volume expansion in the setting of CHF . -There are other solutions containing artificial colloids available. Types: -Synthetic: Dextran, Hetastarch -Dextran: Polysaccharide used for volume expansion Associated with anticoagulation. Use for vascular surgery � prevent thrombosis. - If Infusions exceeding 20 ml/kg/d can interfere with blood typing, renal failure, prolong BT. -Non-synthetic: Human serum albumin (5%, 25%). -5% Albumin: will remain in the intravascular space. It is the most efficient way to treat shock. -this effect is not permanent in patients who are hypoalbuminemic.

20. Colloids Advantages of Colloids: 1-? plasma volume. 2- Less peripheral edema. 3-Smaller volumes for resuscitation. 4-Intravascular half-life 3-6 hrs . Disadvantages of Colloids: 1-Much higher cost than crystalloid solutions. 2-Small but significant incidence of adverse reactions. 3-Because of gelatinous properties, these can cause platelet. dysfunction and interfere with fibrinolysis and coagulation factors thus possibly causing coagulopathy in large volumes. 4-These fluids can cause dramatic fluid shifts which can be dangerous if they are not administered in a controlled setting.

21. Indications: Establish or maintain a fluid & electrolyte balance. Administer continuous or intermittent medication. Administer bolus medication. Administer fluid to keep vein open. Administer blood or blood components. Administer intravenous anesthetics. Maintain or correct a patient's nutritional state. Administer diagnostic reagents. Monitor hemodynamic functions.

22. How to use it ? -H2O is the most abundant constituent in the body, approx 50% of body weight in women and 60% in men. -Total body water is distributed into two major compartments: 55-75% ICF and 25-45% ECF (which is intravascular and extravascular in a ration of 1:3) -Water balance is maintained by plasma osmolality (solute or particle concentration of a fluid) and the normal range is 275 to 290 mOsm/kg and is VERY sensitive. -To maintain a steady state, water intake must equal water excretion. -Obligate water losses: urine, stool (minor component), & evaporation of from skin & respiratory tract .

23. There are 4 types of patients: When considering appropriate IV fluids keep in mind that in general, there are 4 types of patients when it comes to administering IV fluids: 1-Hypovolemic Patient: Pneumonia, Sepsis, Hemorrhage, Gastroenteritis. 2-Hypervolemic Patient: CHF, renal failure, cirrohsis. 3-NPO Patient, surgical patient, euvolemic: Awaiting surgery, unsafe swallow. 4-Eating/drinking normally.

24. Determining Appropriate IVF Step 1: Assess volume status What is the volume status of my patient? Do they have ongoing losses? Can my patient take PO safely? Are the NPO for a reason? Step 2: Determine Access Peripheral IV Central line

25. Step 3: Select Type of Fluid:

26. Step 4: Determine Rate -If you are trying to fluid resuscitate that patient, you might be giving fluids �wide open� or 500 cc/hr. -The hypovolemic pt may need multiple 1L bolus to reestablish intravascular volume. -For others use the method :

27. Hypovolemia: -True volume depletion (hypovolemia): usually refers to a state of combined salt and water loss exceeding intake which leads to ECF volume contraction. ECF volume contraction is manifested as a decreased plasma volume and hypotension. Signs of intravascular volume contraction include decreased jugular venous pressure, postural hypotension, and postural tachycardia. Larger and more acute fluid losses lead to hypovolemic shock and manifest as hypotension, tachycardia, peripheral vasoconstriction, & hypoperfusion.

28. Treatment of Hypovolemia: The goals of treatment is to restore normovolemia with fluid similar in composition to that lost and replace ongoing losses. Mild volume losses can be corrected via oral rout. More severe hypovolemia requires IV therapy. Isotonic or Normal Saline (0.9%NaCl) is the choice in normonatremic and mildly hyponatremic patients and should be administered initially in patients with hypotension or shock.

29. Severe hyponatremia may require Hypertonic Saline (3.0% NaCl) In Hypernatremic patient, there is a proportionately greater deficit of water than sodium, therefore to correct this patient you will use a Hypotonic solution like � NS (0.45% NaCl) or D5W. Patients with significant hemorrhage, anemia, or intravascular volume depletion may require blood transfusions or colloids (albumin/dextran). Hypokalemia can be simultaneously corrected by adding appropriate amounts of KCl to replacement solutions.

30. -Hypervolemic Patient: -Avoid additional IVF -Maintain access IV access with Hep-Lock ( A small tube connected to a catheter in a vein in the arm for easy access. It is an alternative in some cases to using an IV. Its called heplock because of the order of medicating using it which is saline, medication, saline then heparin) -NPO Patient now euvolemic: -Administer maintenance fluids. Goal is to maintain input of fluids to keep up with ongoing losses and normal fluid needs -For average adult NPO for more than 6-12 hours, consider D51/2NS at 75-100cc/hr -Constantly reassess, at least 2x day or with any change -Don�t give fluids blindly ie: if the patient is pre-procedure but has history of CHF, be CAREFUL! -The reason for giving dextrose (D5) is to prevent catabolism -Normal PO Intake: -No need for fluids if they are taking PO without problems! -Avoid IVF

31. Procedure: IV Devices -butterfly Catheter: -Deliver small amounts of medicine. -Infants. -Over the Needle catheter: -Peripheral IV catheter. -Medication administration. -Blood transfusion.

32. Vein Selection: Veins of the Hand: 1. Digital Dorsal veins2. Dorsal Metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic vein Veins of the Forearm: 1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. Median antebrachial vein

33. Types of IV Lines Peripheral: Infusion site for a peripheral is an area such as arm or hand, or rarely the leg.

34. Central: A catheter is used to access a large vein such as the subclavian or the jugular. This catheter is threaded through the vein into the right atrium.

35. Risks of intravenous therapy: Infection: Any break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter Phlebitis: Phlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Infiltration: Infiltration occurs when an IV fluid accidentally enters the surronding tissue rather than the vein. It is characterized by coolness and pallor to the skin as well as local edema. Fluid overload: This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete.

36. Electrolyte imbalance: Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of sodium, potassium, magnesium, and other electrolytes. Embolism: A blood clot or other solid mass, as well as an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel Extravasation: Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue

37. Resources: Harrison's principles of internal medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypovolemia Harrison's manual of medicine, 16th ed. New York (NY): The McGraw-Hill Companies, Inc.; c2004-2005. Hypo/Hypernatremia Steve Martin�s Intravenous Therapy http://www.touchbriefings.com/pdf/14/ACF7977.PDF Brown�s Department of Family Medicine Adult IVF Handout http://www.geocities.com/brownfamilymed/ Queen Mary�s School of Medicine & Dentistry Prescribing Skills http://www.smd.qmul.ac.uk/prescribeskills/ http://www.accd.edu/sac/nursing/math/ivprob.html http://en.wikipedia.org/wiki/Intravenous_therapy

38. Any questions?