Intravenous Fluids

Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Crystalloids and colloids have different general compositions, which affect distributions through the body’s fluid compartments and guide clinical use. Crystalloid solutions are typically used for patients who are hypovolemic, dehydrated, or have ongoing fluid losses. Colloidal solutions may be used in cases of low oncotic pressure. Providers should choose fluid types based on the clinical scenario and best available evidence. All recipients of IVFs should be closely monitored to determine the goal and status of the fluid therapy.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Overview

Fluid compartments of the body

  • Intracellular fluid (ICF):
    • All fluid enclosed in cells by plasma membranes
    • Approximately 60%–65% (⅔) of the total body water (TBW)
    • The fluid volume tends to be very stable because the amount of water in living cells is closely regulated.
  • Extracellular fluid (ECF):
    • Fluid outside the cells
    • 2 primary constituents:
      • Plasma (the fluid component of the blood): approximately 10% of TBW
      • Interstitial fluid (IF) surrounding all cells: approximately 25% of TBW
  • TBW = 60% of total body weight = ICF + ECF
Distribution of total body water

Distribution of total body water (TBW):
⅔ of the body’s water is intracellular fluid (ICF) and ⅓ is extracellular fluid (ECF). Of the ECF, ¾ is interstitial fluid and only ¼ is intravascular fluid.

Image by Lecturio.

Movement of water across the compartments

  • From plasma to IF: 
    • Occurs via Starling forces acting across the capillary membrane
    • Capillary pressure (Pc) pushes fluid out of the capillary.
    • Interstitial fluid pressure (Pif) pushes fluid into the capillary.
    • Plasma colloid osmotic (oncotic) pressure (πc) pulls fluid into capillary.
    • Interstitial fluid colloid osmotic pressure (πif) pulls fluid out of the capillary.
  • From ICF to ECF: 
    • Occurs via osmosis across the selectively permeable cell membrane Cell Membrane A cell membrane (also known as the plasma membrane or plasmalemma) is a biological membrane that separates the cell contents from the outside environment. A cell membrane is composed of a phospholipid bilayer and proteins that function to protect cellular DNA and mediate the exchange of ions and molecules. The Cell: Cell Membrane
    • Water flow: from less concentrated to more concentrated solution
Starling forces and equation in transcapillary exchange

Starling forces in transcapillary exchange:
Outward forces include hydrostatic pressure of blood in the capillary (Pc) and interstitial fluid colloid osmotic pressure (πif). Inward forces include hydrostatic pressure of the interstitial fluid (Pif) and plasma colloid osmotic pressure (πc) of the capillary.

Image by Lecturio.

Osmolarity, osmolality, and tonicity

  • Osmosis:
    • Spontaneous movement of water across a semipermeable membrane 
    • Water moves from a region of ↓ solute concentration → a region of ↑ solute concentration
    • Tends to equalize the solute concentrations on either side of the membrane
  • Osmotic pressure: Hydrostatic pressure is necessary to counteract the process of osmosis.
  • Osmolality and osmolarity:
    • Osmolar concentration of a solution
    • In medicine, osmolarity and osmolality can be used interchangeably:
      • Not necessarily the same as tonicity 
      • Normal range: 275–295 mOsm/kg
    • 80% of the total osmolarity of IF and plasma is due to Na and Cl ions. 
    • ½ of the total osmolarity of ICF is due to K ions; the remainder is due to other intracellular substances.
  • Osmotic gradient: the difference in the osmolarity of 2 solutions on either side of a semipermeable membrane
  • Tonicity:
    • The measurement of the effective osmotic gradient between 2 fluids separated by a semipermeable membrane
    • Only accounts for osmotically active solutes (cannot cross a semipermeable membrane)
    • Glucose is osmotically active, but the effect is temporary:
      • Glucose is quickly metabolized within the cell → removes the osmotic activity
      • The net result is the addition of solute-free water.
      • The temporary glucose osmoles are not factored into the solution’s net tonicity.
    • Examples of dyssynchrony between osmolarity/osmolality and tonicity:
      • 5% dextrose in water: iso-osmolar but hypotonic
      • 5% dextrose-0.9% NaCl: hyperosmolar but isotonic 
      • 5% dextrose-0.45% NaCl: hyperosmolar but hypotonic

Crystalloid Fluids

  • Most commonly used IVF in a hospital setting
  • Consist of aqueous electrolyte solutions
  • Do not readily cross plasma membranes, but do cross capillary membranes 
  • Remain only in the ECF and do not distribute into the ICF
  • Within the ECF, the distribution is ¼ into the intravascular volume and ¾ into the interstitial space.

Normal saline (0.9% NaCl)

  • Osmolarity approximates normal plasma (275–295 mmol/L):
    • 0.9% = 9 g NaCl in 1,000 g H2O (equals 1 L of H2O)
    • 154 mmol/L Na + 154 mmol/L Cl = 308 mmol/L in total 
  • Isotonic-to-normal plasma

Ringer’s lactate (RL)

  • Osmolarity approximates normal plasma
  • Isotonic-to-normal plasma
  • Contains:
    • 130 mmol/L Na
    • 109 mmol/L Cl
    • 4 mmol/L K
    • 3 mmol/L Ca2
    • 28 mmol/L lactate
  • Distributes throughout fluid compartments like normal saline

Plasma-Lyte© (PL)

  • Osmolarity approximates normal plasma
  • Isotonic-to-normal plasma
  • Contains:
    • 140 mmol/L Na
    • 98 mmol/L Cl
    • 5 mmol/L K
    • 3 mmol/L Mg
    • 23 mmol/L gluconate 
    • 27 mmol/L acetate
  • Distributes throughout fluid compartments like normal saline

Half-normal saline (0.45% NaCl)

  • Osmolarity is approximately ½ of normal plasma:
    • 0.45% = 4.5 g NaCl in 1,000 g H2O
    • 77 mmol/L Na + 77 mmol/L Cl = 154 mmol/L in total
  • Hypotonic to plasma
  • Example: 1 L 0.45% NaCl:
    • Equal to 500 mL solute-free water + 500 mL 0.9% NaCl
    • 500 mL 0.9% NaCl remains only in the ECF:
      • 125 mL (¼) into intravascular volume 
      • 375 mL (¾) into interstitial space
    • 500 mL solute-free water distributes throughout the TBW (ICF + ECF):
      • 333 mL (⅔) into the ICF
      • 167 mL (⅓) into the ECF (42 mL into intravascular space + 125 mL into interstitial space)
    • Combined: only 167 mL into the intravascular space

Quarter-normal saline (0.225% NaCl)

  • Osmolarity is approximately ¼ of normal plasma:
    • 0.225% = 2.25 g NaCl in 1,000 g H2
    • 38.5 mmol/L Na + 38.5 mmol/L Cl = 77 mmol/L in total 
  • Hypotonic to plasma
  • Example: 1 L 0.225% NaCl infused:
    • Equal to 750 mL solute-free water + 250 mL 0.9% NaCl
    • 250 mL 0.9% NaCl remains only in the ECF:
      • 62.5 mL (¼) into intravascular volume
      • 187.5 mL (¾) into interstitial space
    • 750 mL solute-free water distributes throughout the TBW (ICF + ECF):
      • 500 mL (⅔) into the ICF
      • 250 mL (⅓) into the ECF (62.5 mL into intravascular volume + 187.5 mL into interstitial space)
    • Combined: only 125 mL into the intravascular space

5% dextrose in water

  • Osmolarity approximates normal plasma: 50 g dextrose in 1 L H20 = 252 mmol/L
  • Hypotonic to plasma 
  • Dextrose is necessary to prevent hemolysis:
    • Extremely hypotonic fluids (pure water) cannot be given safely by IV.
    • If pure water is given by IV, water will shift very quickly into cells → hemolysis
    • Dextrose adds enough solutes to slow down water shifts → prevents hemolysis
    • Dextrose is only osmotically active for a short time after infusion (the effect dissipates because dextrose is rapidly metabolized).
    • Net effect is the addition of solute-free water.
  • Example: 1 L 5% dextrose in water infused:
    • Equals 1 L solute-free water
    • Distributes throughout the TBW (ICF + ECF):
      • 667 mL (⅔) in ICF
      • 333 mL (⅓) in ECF (83 mL into intravascular volume + 250 mL into interstitial space)
    • Only 83 mL of every 1 L of 5% dextrose in water contributes to the intravascular volume.

Combined solutions

  • Osmolarity is > normal plasma, tonicity is not.
  • Example: 5% dextrose-0.9% NaCl = 252 mmol (5% dextrose in water) + 308 mmol (0.9% NaCl) = 560 mmol/L
  • Tonicity is not affected because the solutes from the dextrose are metabolized quickly.

Bicarbonate (HCO3) solutions

  • Crystalloid solutions compounded by the hospital pharmacy (include varying amounts of HCO3 and are generally not produced commercially)
  • HCO3 ↑ the pH of the solution to physiological or supraphysiological levels
  • The osmolarity and tonicity of the resulting solutions can be adjusted depending on the combination of the starting fluid (usually 5% dextrose in water or 0.45% NaCl) and the amount of added HCO3.
  • Example: isotonic HCO3:
    • 3 ampules NaHCO3 in 1 L 5% dextrose in water
    • 3 ampules NaHCO3 = 150 mmol Na + 150 mmol HCO3 = 300 mmol/L

3% hypertonic saline (3% NaCl)

  • Osmolarity and tonicity are significantly ↑ than normal plasma:
    • 3% NaCl = 30 g NaCl + 1,000 g H2O
    • 513 mmol Na + 513 mmol Cl = 1026 mmol/L in total
  • Example: 1 L 3% NaCl infused:
    • Solute load is equivalent to 3.33 L of 0.9% NaCl (3%/0.9%).
    • Hypertonicity results in the mobilization of approximately 2.33 L of solute-free water from the ICF to the ECF (through osmotic shifts) and 1 L of fluid infused into the ECF as 3% NaCl:
      • ¼ into intravascular volume = 832.5 mL
      • ¾ into interstitial space = 2,500 mL

Overview of composition of common crystalloid solutions

Table: Composition of common crystalloid solutions
Fluid Na mEq/L Cl mEq/L K mEq/L Ca2 mEq/L Glucose g/L Buffer mEq/L Osmolarity mOsm/L Tonicity
Normal plasma 140 100 4 2.4 0.85 HCO3 24 290 N/A
0.9% saline 154 154 0 0 0 0 308 Isotonic
0.45% saline 77 77 0 0 0 0 154 Hypotonic
Ringer’s lactate 130 109 4 3 0 Lactate 28 273 Isotonic
5% dextrose in water 0 0 0 0 50 0 252 Hypotonic

Colloid Fluids

  • Colloid solutions include large proteins or cells.
  • Do not readily cross capillary membranes
  • Remain in the ECF and do not distribute into the ICF (similar to crystalloids)
  • Unlike crystalloids, colloids do not distribute throughout the ECF:
    • Remain within the intravascular space
    • Do not distribute into the interstitial space 
  • Blood products are also examples of colloid solutions.

Albumin

  • A naturally occurring colloid and the most abundant protein in plasma
  • Responsible for 80% of plasma oncotic pressure
  • ↑ Plasma oncotic pressure → osmotic shift of fluid from the interstitial space into the intravascular volume
  • Duration of volume expansion effect is 12–24 hours.
  • Albumin is the only commonly used colloid in clinical practice:
    • Primarily used for specific indications rather than volume expansion
    • More expensive than crystalloids and without commensurate benefit

Synthetic colloids

  • Hydroxyethyl starches, dextrans, and gelatins
  • Developed for use as volume expanders due to the hypothetical benefit of remaining within the intravascular volume 
  • Not commonly used in practice:
    • Colloid solutions are not clinically superior to crystalloid solutions for volume expansion (despite remaining exclusively in the intravascular space).
    • Expensive
    • Hydroxyethyl starches have been associated with acute kidney injury Acute Kidney Injury Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury.
    • Unlike albumin, synthetic colloids do not have any other specific indications for use.

Comparison of crystalloids and colloids

Table: Comparison of crystalloids and colloids
Crystalloids Colloids
Advantages Cheap Longer half-life
Accessible A smaller volume is required to expand intravascular volume.
Disadvantages Shorter half-life Expensive
A larger volume is required to expand intravascular volume. Risk of allergic reaction

Indications

Intravascular volume expansion

  • Isotonic crystalloid fluids:
    • Preferred IVF for volume expansion
    • RL and PL are considered “balanced” solutions: 
      • Approximate the pH and electrolyte composition of normal plasma more closely than 0.9% NaCl
      • Avoid hyperchloremic metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis associated with 0.9% NaCl 
      • Normal saline or RL are preferred to PL due to cost.
  • Colloid fluids:
    • Not a 1st-line therapy for volume expansion
    • Sometimes used in a hypervolemic state with ↓ effective arterial blood volume
  • Blood products: only used for volume expansion in specific circumstances:
    • Packed RBCs: acute bleeding or severe anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Platelets Platelets Platelets are small cell fragments involved in hemostasis. Thrombopoiesis takes place primarily in the bone marrow through a series of cell differentiation and is influenced by several cytokines. Platelets are formed after fragmentation of the megakaryocyte cytoplasm. Platelets: bleeding related to ↓ platelet count or platelet dysfunction
    • Fresh frozen plasma: bleeding related to coagulation factor deficiency

Maintenance fluid

  • Maintenance fluids are indicated for individuals able to take nutrition by mouth.
  • Most commonly a crystalloid fluid with or without added dextrose, bicarbonate, and/or potassium
  • Goal: approximate the content of lost fluid and replace the fluid at a rate similar to the loss
  • Normal daily maintenance dose:
    • Adults: 1,500 mL + 20 mL/kg for every kg above 20 kg
    • Neonates: 150 mL/kg
  • Conditions altering the amount of maintenance fluids:
    • ↑ Maintenance fluids: fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and tachypnea
    • ↓ Maintenance fluids: congestive cardiac failure and low-output renal failure

Specific sodium disorders

  • Hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia:
    • Hypotonic fluids (usually 5% dextrose in water or 0.45% NaCl) are given to replace the free water deficit.
    • The rate of fluid should be adjusted to target a gradual ↓ in chronic hypernatremia.
    • Overly rapid correction of hypernatremia can cause cerebral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema.
  • Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia:
    • Isotonic fluids (usually 0.9% NaCl) may be given for mild-to-moderate cases.
    • Hypertonic fluids (usually 3% NaCl) are indicated for severe cases, especially with neurologic symptoms. 
    • Overly rapid correction of hyponatremia can result in osmotic demyelination syndrome.

Cerebral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema

  • Hypertonic fluids (usually hypertonic saline) may be used to induce hypernatremia.
  • The result is the movement of water out of cells → ↓ intracranial pressure

Bicarbonate (HCO3) solutions

HCO3 may be indicated for:

  • Severe acidemia (pH < 7.2)
  • Urinary alkalinization (e.g., tricyclic antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications poisoning or certain chemotherapies)
  • Methanol or ethylene glycol poisoning

Nutrition

  • For individuals allowed nil per os
  • Partial parenteral nutrition (PPN):
    • Protein only
    • Can be given via peripheral or central line
    • For individuals allowed nil per os for a short duration of time (2–3 days).
  • Total parenteral nutrition (TPN):
    • Complete nutrition: carbohydrates Carbohydrates Carbohydrates are one of the 3 macronutrients, along with fats and proteins, serving as a source of energy to the body. These biomolecules store energy in the form of glycogen and starch, and play a role in defining the cellular structure (e.g., cellulose). Basics of Carbohydrates, proteins, and fats
    • Given via central line
    • For individuals allowed nil per os for a long duration of time.
    • ↑ Risk of infection due to bacteremia or fungemia

Albumin

Albumin is used for specific purposes:

  • Volume expansion in hypervolemic states with ↓ effective arterial blood volume (i.e., hypoalbuminemia cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis)
  • Treatment of hepatorenal syndrome Hepatorenal Syndrome Hepatorenal syndrome (HRS) is a potentially reversible cause of acute kidney injury that develops secondary to liver disease. The main cause of HRS is hypovolemia, often as a result of forced diuresis or drainage of ascites. This leads to renal vasoconstriction resulting in hypoperfusion of the kidneys. Hepatorenal Syndrome
  • Treatment of acute kidney injury Acute Kidney Injury Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury related to spontaneous bacterial peritonitis
  • Prevention of acute kidney injury Acute Kidney Injury Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury related to large volume paracentesis
  • Treatment of refractory edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema (added to loop diuretics Loop diuretics Loop diuretics are a group of diuretic medications primarily used to treat fluid overload in edematous conditions such as heart failure and cirrhosis. Loop diuretics also treat hypertension, but not as a 1st-line agent. Loop Diuretics)
  • Exchange fluid for plasmapheresis
  • Management of severe burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns

Adverse Effects

Frequently reassess goals of IVF therapy and tailor management to avoid adverse effects:

Volume overload

  • Risk factors:
    • Large volumes of administered fluid
    • Underlying cardiac issues
    • Hepatic impairment
    • Renal dysfunction
  • Clinical presentation:
    • Weight gain
    • Pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Body cavity effusions:
      • Ascites
      • Pleural effusions
    • Respiratory distress
    • Worsening supplemental oxygen requirement
  • Diagnosis:
    • Serial body weights
    • Chest X-ray
    • Serum BNP level
  • Management:
    • Discontinue or ↓ IVF.
    • Loop diuretics
    • Dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis (if severe or unresponsive to diuretics)

Metabolic abnormalities

Acid-base abnormalities:

  • Hyperchloremic metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis:
    • Nonanion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis caused by infusion of large amounts of chloride-rich fluids (e.g., normal saline)
    • May cause worse clinical outcomes (conflicting studies)
    • Diagnosed by: 
      • ↑ Serum Cl
      • ↓ Serum HCO3
      • ↓ Serum pH
      • Normal serum anion gap
    • Management includes: 
      • ↓ Chloride-rich IVF 
      • Switching to balanced crystalloid solutions (e.g., PL or RL)
  • Metabolic alkalosis Metabolic alkalosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic alkalosis also occurs when there is an increased loss of acid, either renally or through the upper GI tract (e.g., vomiting), increased intake of HCO3-, or a reduced ability to secrete HCO3- when needed. Metabolic Alkalosis:
    • Serum HCO3 and serum pH should be frequently monitored when administering any IVF containing HCO3.
    • Management: 
      • Discontinue or ↓ HCO3 solutions.
      • Give 0.9% NaCl to ↓ the pH (induces a slightly hyperchloremic metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis).
  • High anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis:
    • May occur if RL or PL is given in the setting of hepatic insufficiency
    • Adequate liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver function: needed to metabolize the lactate, gluconate, and/or acetate into HCO3
    • Management: Discontinue RL or PL.

Hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia can result from:

  • Large volumes of 0.9% NaCl 
  • Relatively small volumes of 3% NaCl

Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia:

  • Can occur from administration of any hypotonic fluid, depending on: 
    • Volume given 
    • Individual’s initial TBW
  • Commonly occurs with hypotonic fluids administered for long periods of time

Hyperkalemia Hyperkalemia Hyperkalemia is defined as a serum potassium (K+) concentration >5.2 mEq/L. Homeostatic mechanisms maintain the serum K+ concentration between 3.5 and 5.2 mEq/L, despite marked variation in dietary intake. Hyperkalemia can be due to a variety of causes, which include transcellular shifts, tissue breakdown, inadequate renal excretion, and drugs. Hyperkalemia:

  • RL and PL contain added K
  • May occur if large volumes of RL or PL are given in the setting of renal dysfunction
  • May occur if large volumes of packed red blood cells are given

Hyperglycemia:

  • May occur with dextrose-containing solutions 
  • The rate of IVF overwhelms the body’s capacity to metabolize the IVF’s dextrose load.
  • More likely to occur in diabetic individuals, but can also occur in nondiabetic individuals

References

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  2. Antequera Martín, A. M., et al. (2019). Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. The Cochrane Database of Systematic Reviews. 7, CD012247. https://pubmed.ncbi.nlm.nih.gov/31334842/
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