FLUIDS AND ELECTROLYTES

In a nutshell

Body fluid compartments

Tonicity
The different types of IV fluids
Indications for IV fluids
Assessment of fluid status
Electrolyte imbalance
Handling of IV fluids
IV solution containers
Some terminologies: Osmosis, Osmolarity, Colloids Vs. crystalloids
Fluid distribution
Body fluid compartments

Fluid is 60% Body weight (BW)in adult male , 50 % in adult female

& 80% in child
Intracellular 40% BW and extracellular 20%BW.
Extracellular is divided in to Intravascular ( plasma ) 5% BW and
Interstitial compartments ( between cells ) 15% of BW
In a 70 kg man
Fluid balance

Fluid intake should be in balance with the fluid loss.

Fluid intake -fluid from food and drink (around 2.2 L/day)+fluid
formed by metabolism (0.3 L/ day)
Fluid loss-in urine (1.5 L/day), feces (0.1 L/day) +Insensible loss
(evaporation during breathing (lungs) and by the process of
sweating (skin)
Negative balance Output > intake
Positive balance Intake > output
Tonicity

Solution Mixture of 2 or more substances

Solvent Liquid that dissolves the substance resulting in solution
Solute-Substance dissolved in the solvent
In saline , sodium chloride is solute and water is solvent
Osmolarity is the concentration of all the solute particles in a
solution ( sum of all the particles in the solution)
Osmosis

If solutions with different osmolalities are separated by semi-permeable (a

membrane that does not allow the larger solute particles to cross to the other
side), water will move from the area of lower osmolarity to the area of higher
osmolarity, to equalize the osmolarity in both the compartments.
Osmotic pressure

The amount of physical pressure required to oppose this flow of

water across the membrane is called osmotic pressure.
The larger the difference in concentrations (osmolarity) between
the two solutions, the higher is the osmotic pressure.
Osmolarity of the extracellular fluid (ECF) is approximately equal
to that of the intracellular fluid ( ICF) due to Osmosis
Calculated plasma Osmolarity = (2 x Sodium) + Glucose + Urea (all
in mmol/L) .Plasma osmolarity can also be measured directly in
laboratory
Osmolarity

Normal osmolarity of plasma is 285-295 milli-osmoles per

kilogram.
A lower serum osmolarity - fluid overload;
A higher serum osmolarity - dehydration and hemo-concentration.
Eg Hyperglycemic hyperosmolar state.
Significance of understanding osmolarity?

The effect of an I.V. solution on fluid compartments depends on

the solutions osmolarity compared with the serum osmolarity.
3 types of IV solutions
o Isotonic osmolarity same as body fluids and stays in the
intravascular compartment expanding it without drawing fluid in
to vessels .One indication hypotension due to hypovolemia .eg
Lactated Ringer 273mosm/L , Normal saline 308 mosm/L
Significance of understanding osmolarity?

o Hypertonic solutions: Osmolarity higher than serum osmolarity.

When infused, serum osmolarity initially increases causing fluid to
be pulled from the interstitial and intracellular compartments into
the blood vessels by osmosis. Indication- postoperatively as shift of
fluid into the blood vessels reduces edema and stabilizes the blood
pressure. Eg.3% Saline (1026 mOsm/L), 10% dextrose in water (505
mOsm/L), dextrose 5% in half-normal saline (405 mOsm/L),
dextrose 5% in normal saline (560 mOsm/L).
Significance of understanding osmolarity?

o Hypotonic solutions: Osmolarity lower than the serum osmolarity.

Fluid shifts out of the blood vessels and into the cells and
interstitial spaces. Hydrates cells while reducing fluid in the
circulatory system. Eg.hypernatremia, true dehydration (without
loss of electrolytes) and in Sickle Cell Disease-RBC get hydrated
reducing sickling process.Eg 0.45 % Normal Saline (154 mOsm/L)
and 5% Dextrose in water (252 mOsm/L)
IV Fluids - Colloids and Crystalloids

Colloids contain protein or substances with high molecular weight

that remain in intravascular space for a long time exerting osmotic
pressure ,drawing in fluid from intracellular and interstitial
spaces. eg. blood products PRBC, Plasma; Plasma substitutes like
dextran and albumin. Colloids superior in acute blood loss as they
remain in intravascular compartment.Whole blood and PRBC can
also carry o2.Negative side expensive , difficult to store , cross
matching .
IV Fluids - Colloids and Crystalloids

Crystalloids have much smaller particles than colloid. Therefore

capable of passing through a semi-permeable membrane as used in
dialysis.Eg. Normal saline, Lactated Ringers and Dextrose 5% in
water (D5W). They do not have a high osmotic pressure , cheap,
store well and they are good fluid replacers (as opposed to
blood replacers).
Assessment of fluid deficit
Assessment of fluid excess
Electrolytes
Sodium correction

Rapid correction of Hyponatremia can result in damage to certain

structures in the brain (especially the Pons) -Central pontine
myelinolysis acute paralysis, difficulty swallowing, difficulty
speaking, and other neurological symptoms. This can sometimes
be irreversible or fatal.
Rapid correction of Hypernatremia may lead to cerebral odema,
potentially resulting in seizures, permanent brain damage, or
death.
So sodium correction should be carefully monitored .
Electrolytes
Electrolytes
Electrolytes
Electrolytes
Electrolytes
pH

Describe the degree of acidity of a solution. Range of the pH scale is

from 0 to 14. Solutions with a pH less than 7 are acidic and those of
values more than 7 are alkaline.
Plasma is slightly alkaline at pH of 7.4. I.V. solution too acidic or
alkaline difficult to tolerate. Solution pH alters effect and the
stability of drugs eg. Antibiotics may be unstable in solutions with pH
more than 8.0 or less than 4.0.
In case of phlebitis, an alkaline solution is preferred as it renders the
I.V. solution less painful on administration.
Classification of fluids based on indication

Hydrating solutions: Usually isotonic, supply water e.g., NaCl 0.9 % (Normal
saline), Dextrose 5%, Dextrose 5% + 0.18% NaCl
Replacement solutions: They replace the loss of fluids & electrolytes (but not
severe electrolyte imbalance) e.g., Ringers solution, Lactated Ringers solution.
Therapeutic solutions:
To correct acidosis Sodium bicarbonate (NaHCO3) 4.2% & NaHCO3 8.4%
To correct alkalosis Ammonium chloride
To supply energy Dextrose 10%, 20%, 25% & 50%, Fat emulsion injection 10% & 20%
To promote anabolism Amino acid injection, Protein hydrolysate injection.
Inspection procedures on the I.V. fluids
before administering

Check the fluid for discoloration, cloudiness, foreign particles

Squeeze the plastic bag to check for leakage
Hold the glass bottles of fluids against the light & rotate to look for cracks
Check I.V. sets for discoloration or defects
Follow policies and procedures of infection control as related to
technique, insertion, flushing, adjusting the flow rate, changing of I.V.
containers, I.V. administration sets and cannulas.
Return defective solution or equipment to stores, with a note
IV fluid Containers

Glass: high quality glass treated to resist chemical changes, hung by a plastic
hanger or drip cage, packed under vacuum and sealed by rubber closure
.Requires air inlet to facilitate flow of the solution into the drip tube & set
Semi-rigid polyethylene and flexible containers Do not require an air inlet as
atmospheric pressure pressing on the containers force the fluid to flow.
Sometimes semi-rigid containers need the facility of an air inlet, but it is not
recommended by infection control
Flexible (Viaflex) PVC with 2 ports, one port for inserting the I.V. set spike and
the second port for the addition of solutions and drugs into the bag. This
container is used extensively in mixing T.P.N. solutions. It does not require an
inlet.
I.V. fluids, their contents (mmol), tonicities
& pH:
IV solutions and their Characters
IV solutions and their Characters
IV solutions and their Characters
Nursing considerations
Nursing considerations
Nursing considerations
Thank you