...اورﮨﻢ ﻧﮯ ﮨﺮ ﺟﺎﻧﺪار ﭼﻴﺰ ﮐﻮ ﭘﺎﻧﯽ ﺳﮯ ﺑﻨﺎﻳﺎ ﮐﻴﺎ ﭘﻬﺮ ﺑﻬﯽ ﻳﻘﻴﻦ ﻧﮩﻴﮟ ﮐﺮﺗﮯ اور اﷲ ﻧﮯ ﮨﺮ ﭼﻠﻨﮯ ﭘﻬﺮﻧﮯ واﻟﮯ (ﺟﺎﻧﺪار) ﮐﯽ ﭘﻴﺪاﺋﺶ (ﮐﯽ ﮐﻴﻤﻴﺎﺋﯽ اﺑﺘﺪاء) ﭘﺎﻧﯽ ﺳﮯ ﻓﺮﻣﺎﺋﯽ … DISCLAIMER This educational material has been developed as a service of Otsuka Pakistan Limited. It contains detailed information that has been compiled with professional diligence. Although Otsuka Pakistan strives to provide the latest scientific information related to its products and general medical conditions, the information may be limited and should not be taken as being comprehensive. Otsuka Pakistan does not warrant the accuracy, effectiveness or completeness of any information in this educational material. The information related to various medical conditions and their management is not meant to be a substitute for the advice of a healthcare professional. Advice from a professional healthcare provider must always be sought. Otsuka Pakistan makes no representations or warranties of any kind whether express or implied. In no event shall Otsuka Pakistan be held liable for damages or injury of any kind, direct or indirect, consequential or incidental, from access or the impossibility of access or with the use of this educational material. You assume total responsibility and risks for your use of this material. Index Preface…………….………………………………………………………………………….……………. 1 1. Intravenous Fluid Administration – A Short History………………….….….……. 2 2. Introduction to Body Fluids……………………………………………………….…..……….. 4 3. Osmosis……………………………………………………………………………………………………. 9 4. Water Balance………………………………………………………………………………..……….. 15 5. Sodium…………………………………………………………………………………………………….. 20 6. Potassium……………………………………………………………………………………….……….. 28 7. Calcium…………………………………………………………………………………………..……….. 39 8. Magnesium……………………………………………………………………………………………….. 43 9. Phosphorus………………………………………………………………....................……….. 47 10. Acid Base Balance…………………………………………………………………………………... 50 11. Acid Base Disorders……………………………………………………………………….……….. 55 12. Fluid Therapy in Special Situations……………………………………………….……….. 61 Diarrhea and Dehydration………………………………………………………….. 61 Vomiting…………………………………………………………………………….……….. 67 Heat Illness………………………………………………………………………….……….. 68 Fluid Therapy in Calcium Disorders…………………………………….………. 69 Fluid Therapy in Surgical Patients……………………………………………….. 69 Fluid Therapy in Burns………………………………………….............……….. 73 References/Suggested Reading…………………………………………………….……….. 76 13. Plabottle………………………………………………………………….....................……….. 77 14. Product Identification……………………………………………………………………………... 79 15. Large Volume Parenterals……………………………………………….............……….. 83 Pladex-5……………………………………………………………………………….………. 83 Pladex-10…………………………………………………………………………….……….. 86 25% Dextrose Injection B.P……………………………………...........………. 89 Plasaline.....................................................................………. 92 Pladexsal.....................................................................……… 95 Pladexsal ½................................................................………. 98 Pladexsal 1/3...............................................................……… 101 Pladexsal 1/5...............................................................……… 104 Nisf Normal Saline........................................................……… 107 Ringer’s Solution for Injection........................................……… 110 Ringolact............................................................................ 113 Ringolact-D........................................................................ 117 Plabolyte-M........................................................................ 121 Plabolyte-40....................................................................... 125 Osmotol............................................................................. 129 Peri Solution....................................................................... 133 16. Small Volume Parenterals............................................................... 137 0.9% Sodium Chloride Infusion B.P........................................ 137 Potassium Chloride Injection……………………………………………………….. 140 25% Dextrose Injection B.P……………………………………................... 143 Meylon 84………………………………………………………........................... 146 Water for Injections B.P………………………………………………………………. 150 Table of Otsuka IV Solution Characteristics……………………………………………. 154 Preface The administration of fluids and electrolytes is an integral part of patient care. Knowledge regarding physiology of intravenous fluids is essential for their appropriate routine use and during emergency situations. Although intravenous solutions are very frequently prescribed and the electrolyte panel is one of the most frequently ordered investigations in the emergency department, very little importance is given to fluid and electrolytes in the undergraduate curriculum. Inappropriate use of intravenous fluids can be a cause of increased morbidity and mortality. This includes not only the amount of the fluid but also the type of the solution. In choosing the suitable type of intravenous fluid, it is important to know the components of the commonly available solutions. No one solution can fit all – the modern approach to intravenous solutions has enabled an increased understanding of clinical application of the various solutions in line with the clinical condition of the patient. The Basics of Fluids and Electrolytes is an endeavor from Otsuka Pakistan for Continuing Medical Education and is been presented in a user-friendly format for better understanding. However, it is not a substitute for standard textbooks and journals and reference should be made to them whenever required. 1 Intravenous Fluid Administration --- A Short History The first ever known intravenous infusion was administered in 1492 in an attempt to save the life of a dying pope through administering blood by a vein-to-vein anastomosis. Dr. James Blundell carried out the first successful transfusion in 1818 in a patient during childbirth. However, the first use of intravenous fluids can be traced back to 1830’s during the cholera epidemic. In 1832 during the epidemic, William O’ Shaughnessy highlighted the importance of restoring saline levels for managing cholera. This idea was picked up by Thomas Latta who then put it into practice. Ringer’s Solution was developed by Sidney Ringer as an isotonic solution of sodium, potassium and calcium chloride in 1883. The routine use of saline infusions during major surgery was initiated by Rudolph Mata in 1924. Alexis Hartmann introduced Lactated Ringer’s Solution in 1932. He described the buffering action of intercellular fluid in maintaining the composition of blood and emphasized the replacement of lost electrolytes and water to completely overcome the effects of dehydration. He described the methods for the preparation of sodium lactate solution, Lactated Ringer’s Solution, Dextrose solution and Sodium Bicarbonate Solution. In the Journal of American Medical Association Hartmann wrote in 1934: “Lactete-Ringer’s solution may be given by any of the parenteral routes. It has almost entirely replaced the use of physiologic solution of sodium chloride or Ringer’s solutions in the St. Louis Children’s Hospital for routine treatment of dehydration with or without the knowledge of coexisting chemical changes”. The integration of body fluid physiology and clinical practice was made possible by the pioneering work of James Gamble and Dan Darrow. Gamble was the first to describe the nature and composition of extracellular fluid. He described the ECF as closely resembling to the sea water. Darrow showed how the body fluids react to deficiencies of potassium and increased or decreased amounts of sodium. He was the 2 first to add potassium to parenteral fluid therapy and emphasized on the replacement of estimated deficits rather than rapidly restoring ECF. It was many years later that this deficit parenteral replacement gave way to oral rehydration therapy (ORT). The principles governing the administration of fluids in the perioperative period have been the subject of much debate. Pringle and his colleagues were the first to observe a reduction in urine volume after surgery. However, Francis Moore recommended restricted fluid regimens in the perioperative period. By contrast, Tom Shires and colleagues ascribed the loss of extracellular fluid in surgery to internal redistribution and advocated additional fluid infusions for replacement of these losses. Fluid management in surgical patients since then, have evolved from the initial, salt-rich solutions being replaced by dextrose-based solutions, to the current critical care regimens. Recent volume kinetic studies of infused fluids have helped in further understanding of fluid mechanics in surgical patients. 3 Introduction to Body Fluids Intravenous therapy is almost routine now. Almost every patient in the hospital will have some sort of intravenous (IV) access. However intravenous therapy should not be routine. In many disease processes the wrong IV solution could do harm to the patient. There should be a working knowledge of all types of IV fluids, with the understanding that exceptions exist for all the rules. BODY FLUIDS The body fluids provide a medium in which all the chemical reactions of the cells take place. It also provides a medium of transport for different substances. These fluids are constantly losing and replacing their constituents and their composition remains remarkably constant at all times. The body mass can broadly be divided into body fat and fat free