IV FLUIDSIV FLUIDS

E Stanton RN MSN/ED, CEN, E Stanton RN MSN/ED, CEN, CCRN, CFRNCCRN, CFRN

There are three main There are three main types of fluidstypes of fluids

ISOTONICISOTONIC

HYPOTONICHYPOTONIC

HYPERTONICHYPERTONIC

Isotonic fluids Isotonic fluids  Close to the same osmolarity as serum. They stay Close to the same osmolarity as serum. They stay

inside the intravascular compartment, thus inside the intravascular compartment, thus expandingexpanding it. Can be helpful in it. Can be helpful in hypotensive or hypotensive or hypovolemic patients.hypovolemic patients. Can be harmful. There is a Can be harmful. There is a risk of fluid overloading, especially in patients with risk of fluid overloading, especially in patients with CHF and hypertension. Isotonic fluids contain an CHF and hypertension. Isotonic fluids contain an approximately equal number of molecules (blue approximately equal number of molecules (blue dots) SEE NEXT SLIDE as serum so the fluid stays dots) SEE NEXT SLIDE as serum so the fluid stays within the intravascular space. Remember that fluid within the intravascular space. Remember that fluid flows from an area of lower concentration of flows from an area of lower concentration of molecules to an area of high concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into balance). In this example, there is no fluid flow into or out of the intravascular space.or out of the intravascular space.

Examples: Lactated Examples: Lactated Ringer's (LR), 0.9 NSRinger's (LR), 0.9 NS

Hypotonic fluids  Hypotonic fluids 

Have less osmolarity than serum (i.e., it has less sodium ion Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells.  Can be decreases which draws water into the adjacent cells.  Can be helpful when cells are dehydrated such as a dialysis patient helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can be dangerous to use and interstitial compartments. Can be dangerous to use because of the sudden fluid shift from the intravascular space because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients increased intracranial pressure (ICP) in some patients

D5NS.45 (5% dextrose in 1/2 normal D5NS.45 (5% dextrose in 1/2 normal saline).saline).

Hypotonic fluids contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows).This decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it), which then causes fluid to move into the cellSsNote that the green arrows represent fluid movement, not molecule movement.

Hypertonic fluids Hypertonic fluids 

Have a higher osmolarity than serum. Have a higher osmolarity than serum. Pulls fluid and electrolytes from the Pulls fluid and electrolytes from the intracellular and interstitial compartments intracellular and interstitial compartments into the intravascular compartment. Can into the intravascular compartment. Can help stabilize blood pressure, increase help stabilize blood pressure, increase urine output, and reduce edema.  Rarely urine output, and reduce edema.  Rarely used in the prehospital setting. Care used in the prehospital setting. Care must be taken with their use. Dangerous must be taken with their use. Dangerous in the setting of cell dehydration.in the setting of cell dehydration.

Table of Commonly Used IV Solutions(MOST COMMON HIGHLIGHTED IN YELLOW)

Name of Solution

Type of Solution

Ingredients in

1-Liter

Uses Complications

0.45% Sodium ChlorideShorthan

d Notation:

½NS

HypotonicpH 5.6

77 mEq Sodium77 mEq Chloride

hypotonic hydration; replace sodium and chloride; hyperosmolar diabetes

if too much is mixed with blood cells during transfusions, the cells will pull water into them and rupture

0.9% Sodium ChlorideShorthand Notation:NS

IsotonicpH 5.7

154 mEq Sodium154 mEq Chloride

isotonic hydration; replace sodium and chloride; alkalosis; blood transfusions (will not hemolyze blood cells)

VOLUME OVERLOAD

5% Dextrose in WaterShorthand Notation:D5W

IsotonicpH 5.0

5 grams dextrose(170 calories/liter)

isotonic hydration; provides some calories

water intoxication and dilution of body's electrolytes with long, continuous infusionsRARELY USED

10% Dextrose in Water Shorthand Notation:D10W

HypertonicpH 4.3

10 grams dextrose(340 calories/liter)

may be infused peripherally;hypertonic hydration; provides some calories

5% Dextrose in 1/4 Strength (or 0.25%) SalineShorthand Notation:D5¼NS

HypertonicpH 4.4

5 grams Dextrose34 mEq Sodium34 mEq Chloride

fluid replacement; replacement of sodium, chloride and some caloriesRARELY USED

vein irritation because of acidic pH, causes agglomeration (clustering) if used with blood transfusions; hyperglycemia with rapid infusion leading to osmotic diuresis

5% Dextrose in 0.45 Sodium ChlorideShorthand Notation:D5½NS

Hypertonic

pH 4.4

5 grams Dextrose77 mEq Sodium77 mEq Chloride

hypertonic fluid replacement; replace sodium, chloride, and some calories

5% Dextrose in Normal SalineShorthand Notation:D5NS

Hypertonic

pH 4.4

5 grams Dextrose154 mEq Sodium154 mEq Chloride

hypertonic fluid replacement; replace sodium, chloride and some calories

Ringer’s Injection, U.S.P.

IsotonicpH 5.8

147 mEq Sodium4 mEq Potassium4 mEq Calcium155 mEq Chloride

electrolyte replacement; hydration; often used to replace extracellular fluid losses

rapid administration leads to excessive introduction of electrolytes and leads to fluid overload and congestive conditions; provides no calories and is not an adequate maintenance solution if abnormal fluid losses are present

Lactated Ringer’s

Shorthand Notation:

LR

IsotonicpH 6.6

130 mEq Sodium4 mEq Potassium3 mEq Calcium109 mEq Chloride28 mEq Sodium Lactate (provides 9 calories/liter)

isotonic hydration; replace electrolytes and extra-cellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis)TRAUMA FLUID- USED IN OPERATING ROOM ALWAYS

not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is present

5% Dextrose in Lactated

Ringer’s Injection

Shorthand Notation:

D5LR

Hypertonic

pH 4.9

5 grams Dextrose(170 calories/liter)130 mEq Sodium4 mEq Potassium3 mEq Calcium109 mEq Chloride28 mEq Sodium Lactate (provides 9 calories/liter)

hypertonic hydration; provides some calories; replace electrolytes and extra-cellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion

Examples: 9.0% NS, blood Examples: 9.0% NS, blood products, and albumin.products, and albumin.

**Hypertonic fluids

Contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.