HANDBOOK ON IV FLUID
THERAPY
Dr. SURESH KANNA
Dr. MATHISHA EBBY PERIN.R
DEPARTMENT OF GENERAL MEDICINE
SREE BALAJI MEDICAL COLLEGE,
CHROMEPET, CHENNAI-600044.
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coagulation of the cells leading to release of vasoactive substances subsequently
altering the haemodynamics of the body fluid leading to hypovolemia
Fluid resuscitation:
The commonly used regimen in these types of cases is called `parkland
regime’ where the volume of fluid to be given is calculated as 4 ml percentage
in proportion to the percentage of burn and body weight and is given over a
period for twenty four hours. The percentage of fluid to the given is divided into
8 hours and the rest of the fluids is given over the reminder of 16 hours
`Muir and burclay’ regime refers for usage of colloids for resuscitation
over a period of twelve to twenty four hours and is divided into rations. Each
ration is calculated based on the percentage of burns multiplied by the weight of
the patient divided by [Link] regimens include the Galveston, modified
brooke and evans [Link] used fluid includes ringer lactate which is
the most commonly preferred however for the first 24 hours crystalloids are
preferred since they have the ability to permeate through the wall of the
capillaries. After 24 hours upto the period of 2 days colloids are preferred to
help to prevent loss of plasma and albumin is preferred in these types of cases.
Normal saline can also be used in these cases and is calculated by multiplying
0.5 millimoles and the weight of patient and calculated percentage of burns over
body surface. The preferred rate of fluid resuscitation for these cases tend to be
in the range of 4 to 4.5ml/kg/hr. To assess the patients recovery and proper fluid
correction urine output must be between 20 to 40 ml/hr.
CONGESTIVE HEART FAILURE
Congestive heart failure as discussed above occurs due to hyponatremia
due to preceding retention of water and sodium extravascularly. An interesting
course of treatment is that fluid resuscitation in these patients can be easily
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established only through oral ingestion of fluids rather than parenteral or
intravenous route. Sodium restriction and potassium deficit correction is part of
the treatment. Treatment for reduced sodium levels is done trough usage of
ionotropes rather than addition of sodium rich fluids or addition of salt to
prevent complications.
ACUTE RENAL FAILURE
Acute renal failure is one of the dreaded complications of inefficient fluid
resuscitation so the general guidelines for management include restricting fluid
intake which is calculated as the sum of the total urine output of the day and
addition of 500ml. Addition of salt in diet is reduced to less than 3 grams per
day. Patients with no azotaemic complications can be started on 500 to 1 liter
normal saline intravenously over a period of a couple of hours and addition of
loop diuretics like furosemide is warranted in cases to increase urine output .In
cases of acute renal failure associated with highly reduced urine output
5%dextrose or 10% dextrose can be used.
HEPATIC FAILURE
The common condition pertaining to hepatic failure is ascitis commonly
occurring after cirrhosis and in other conditions like fatty liver, alcoholic
hepatitis and non alcoholic steato hepatitis. Fluid resuscitation is highly
regulated in cases of ascitis and procedures such as paracentesis are done in a
slow regularized rate so as to prevent electrolyte and fluid imbalance. Favorable
fluids in these cases include 10% and 20% dextrose and dextrose normal saline.
Ringer lactate resuscitation may induce alkalosis due to break down of its
contents as bicarbonates in the liver and also impairs the lactate cycle. Isolyte G
solution can also be given in certain conditions and have a higher chance of
induction of hepatic encephalopathy. Common clinical features of
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encephalopathy include astrexis(flapping tremors),lethargy ,daytime fatigue and
coma in refractory case.
FLUID THERAPY IN VOMITING
Fluid loss due to vomiting tends to lead to loss of H+ Rich ions from the
body and leads to a state of HCO3 excess causing metabolic alkalosis. The
treatment consists of correction of the following induced alkalosis.
Hypokalemia sets in due to loss of sodium from the vomitus which changes the
aldosterone production leading to increased sodium reuptake. Treatment of the
following include usage of isotonic saline which helps to establish fluid balance
by increasing the level of extra cellular fluid and through decreasing amount of
bicarbonate uptake,it also helps to correct the reduced chloride levels. Except
potassium level correction isotonic saline helps to correct all other electrolyte
deficits. Isolyte G is the preferred fluid for correction of vomitus induced
metabolic alkalosis and preferably helps to correct potassium deficit too as
compared to isotonic saline.
HEAD TRAUMA
It is an emergency procedure which warrants upkeep of hemostasis and
normotensive state of patient during crisis .Since ages use of mannitol has been
advocated in cases of increased intracranial tension since mannitol has the
ability to absorb water through the blood brain barrier thereby reducing edema.
Other indicated intravenous therapies include use of normal saline, however use
of dextrose produces anaerobic breakdown of glucose leading to production of
lactate which causes brain damage. Albumin and starch derivatives have very
little influence over correcting cerebral edema.
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CONCLUSION:
Treatment of each of the above mentioned cases require an individual
based resuscitation rather a generalized approach directly out of a fluid manual,
a single fluid such as a colloid or a crystalloid fails to cover and cure all aspects
of hypovolemia. Crystalloid fluids are favored in cases of specifically
resuscitation of fluid volume and thereby interstitial fluid levels and also
remains cost effective whereas colloidal fluids help to increase the tissue
oxygen perfusion rate and thereby the cardiac output. Considering all the
aspects of property of fluids and the condition, specific requirement of the
patient treatment fluid therapy to be started and maintained at an optimal rate.
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