Fluid in clinical practice part 3

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 Fluid in clinical practice

Fluid :: part 3


IV Fluid is like a drug. It's improper use may even endanger life. So careful choice of fluid is needed in every patient. And choice of fluid is based on Clinical condition. No single fluid can be used in every situation. One can say normal saline is normal, it can be used everywhere. But actually it's a misnomer, there is nothing normal with it. Choice of fluid depends on underlying pathology. 


A fluid can be hyper, hypo, isotonic in different situation. Such as 5% DA is isotonic in vitro, but hypotonic in vivo. Normal saline is isotonic ( 286mosm/L) in normal condition, but hypotonic in hyperglycemic hyperosmolar state( here blood osmolality >>310mosm/L, that is far more than normal saline tonicity). And every fluid has its own ionic components. So it should be considered about the underlying ionic imbalance when prescribing a fluid. And also a fluid has a specific pH . It must be considered . Such as in a disease there is loss of gastric fluid which is acidic. So in this case choice of fluid should be acidic fluid. I have to just replace acid in case of acid loss.And here is also a problem that an acidic fluid in vitro can be alkaline in vivo. so fluid components and metabolism also be kept in mind.


Before prescribing fluid for infusion, keep in mind

1. Fluid for resuscitation, routine maintenance, replacement, redistribution or reassessment

2. Underlying cause

3. type of fluid

4. Rate and volume of fluid

5.Assess the patient’s likely fluid and electrolyte needs from their •history, •clinical examination, •clinical monitoring and •laboratory investigations: 

••History should include any previous limited intake, the quantity and composition of abnormal losses, and any comorbidities.

••Clinical examination should include an assessment of the patient's fluid status, including: pulse, blood pressure, capillary refill and jugular venous pressure, presence of pulmonary or peripheral oedema, presence of postural hypotension.

••Clinical monitoring should include current status and trends in: NEWS( National early warming score, calculate from website), fluid balance charts, weight.

••Laboratory investigations should include current status and trends in: full blood count, urea, creatinine and electrolytes.


0.9% NaCl has osmolarity 308mosm/L, how is it isotonic. Actually ions act differently in a solution, so there is different interaction. That needs a correction factor, called osmotic coefficient, for normal saline it is 0.93. so actual osmolarity is( 308× 0.9)= 286 mosm/L


Source: NICE guidance, 

Guyton and Hall textbook of medical physiology,13Ed


By Dr. Manilal Biswas

SSMC (2012-13)

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