IV isotonic solutions: Why is one chosen over the other?

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    I understand the way the solutions work (iso, hypo, hyper), but I can't understand why one isotonic is chosen over another. I am not in Peds, but adult med/surg. I have a client with a recent Lap. Appendectomy. He was started on LR 125ml x 8hrs, then LR 100ml/hr. Meds are post-op, Labs only show slightly low Lymph% and 111 Glucose Random. All other CBC's & electrolytes are WNL. Urine specific gravity is 1.025, UpH 5.5. These labs are all from pre-op with no updated labs since.
    Why isn't he given 0.9NS, D5W etc? This is the part that really has me stumped. I understand that dextrose will metabolize quickly, leaving free water. This means that once inside the body, it is hypotonic--pulling fluid from the intravascular into the cells. Does the glucose random of 111 have anything to do with NOT giving D5W? (Dextrose metabolizes leaving glucose, therefore it would increase his glucose, therefore not a good choice?)
    But why even have him on it at all? Could it be to KVO (don't know why though, surgery is done), or to maintain body fluid balance since he was in surgery and is on a clear liquid diet? I'm just soooooo confused!
    Thanks!
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  4. 0
    I don't know if this is a lightbulb moment or not. Is the client on continuous IV to help stimulate peristalsis since he just had abd surgery? Still don't know the answer to the rest of the above post though.
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    Our ER doc always liked LR for all abd stuff - he gave me a reason once, but it was way high tech and way confusing and WAY above my litte brain - I just always remembered, LR for abd stuff.......

    Sorry I have no further.....
  6. 0
    Quote from Woogy
    I understand the way the solutions work (iso, hypo, hyper), but I can't understand why one isotonic is chosen over another. I am not in Peds, but adult med/surg. I have a client with a recent Lap. Appendectomy. He was started on LR 125ml x 8hrs, then LR 100ml/hr. Meds are post-op, Labs only show slightly low Lymph% and 111 Glucose Random. All other CBC's & electrolytes are WNL. Urine specific gravity is 1.025, UpH 5.5. These labs are all from pre-op with no updated labs since.
    Why isn't he given 0.9NS, D5W etc? This is the part that really has me stumped. I understand that dextrose will metabolize quickly, leaving free water. This means that once inside the body, it is hypotonic--pulling fluid from the intravascular into the cells. Does the glucose random of 111 have anything to do with NOT giving D5W? (Dextrose metabolizes leaving glucose, therefore it would increase his glucose, therefore not a good choice?)
    But why even have him on it at all? Could it be to KVO (don't know why though, surgery is done), or to maintain body fluid balance since he was in surgery and is on a clear liquid diet? I'm just soooooo confused!
    Thanks!
    Your patient just had abdominal surgery. Once peristalsis returns and he is on a clear liquid diet, it is imperative to maintain an appropriate fluid/electrolyte balance to facilitate healing. Fluids are ordered to supplement the diet and ensure the pt is getting the appropriate levels. D5W only contains glucose, NS only contains Sodium Chloride, LR Solution contains Soduim, Chloride, Lactate, Potassium, and Calcium. A rate of 125, then 100, would be excessive if the intent was KVO. I'm sure it also has to do with F&E levels pre-op and post-op, as well as what part of the intestinal tract will be affected (certain electrolytes are more readily absorbed at various points within the GI tract and poor absorption following surgery could lead to deficiency). Deficiency of Potassium and Calcium could prove fatal. Hope that helps.
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    woogy. . .this is the only website i've ever found that has a table that lists the various iv solutions and why they are used:
    http://www.nursewise.com/courses/iv_hour.htm - this web site is not longer active--sorry!

    generally, iv fluids after surgery are given to replace fluids lost during surgery. i was told a long time ago that a patient looses considerable fluids to the atmosphere through their open incision while they are on the surgical table. also, when the intestines are touched in the or, peristalsis shuts down and the bowels begin to fill with fluid. the fluid that fills the intestines when the bowels are shut down is rich in electrolytes, but more importantly, it is lost fluid (third-spacing), so this contributes to the patient's fluid loss and needs to be replaced. don't know why the appy was done, but the patient may have had some problems with third spacing of fluid and peristalsis already going on in the bowel before he even got in to surgery. the reason lr is so preferred is because it contains a mixture of electrolytes that is at about the same concentration as what is found in plasma so is accepted well by the circulatory system and stays within the circulatory system. it expands extracellular fluid volume, something the post surgical patient needs.

    isotonic saline has more sodium in it and would be used if there were a need for sodium. however, with isotonic saline solutions, the fluid does not remain in circulation and, unlike lr, rapidly leaves the circulation and goes into the interstitial spaces. that is not desirable after surgery.
    Last edit by Daytonite on Oct 22, '07
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    Wow! You guys are awesome! Although now I'm confused at why isotonic saline solutions don't stay in the circ system ( i know they don't stay "only" in the circ, but are you saying they reduce the circ volume?). I though they were to balance the fluid in the body. Geesh, I need to get some sleep. I'm sure I'll :smackingf in the morning.
    Thanks again!
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    woogy. . .think about this. why does any fluid move about in the body? it goes where osmotic pressure pulls it. going back to the basic principle of osmosis, fluids are going to go wherever they feel pulled to. they are always going to go to places where the mixture of fluids and electrolytes will be in equal concentrations. lr is what is called a balanced solution that very closely resembles plasma. once lr enters the veins, and assuming the patient is not suffering from any electrolyte balances, think of it as having found it's equal, in a manner of speaking. (ok. i can live with this!) it's going to be happy to hang out there keeping it's fluid content, thus increasing circulating fluid volume which is it's desired effect.

    a solution such a normal saline, on the other hand, while it may be isotonic, finds itself in an environment of ever so subtle unequal electrolyte concentration. so, by diffusion, it's water content is lost to the interstitial spaces very rapidly. (i'm outta here!) now, this is ok if that is what is desired, but in the case of a post-op gi patient, the physician specifically wants to boost the circulating volume. so, isotonic saline just doesn't quite fit the bill.

    regarding fluid loss in surgical patients, i just found this very interesting passage in fluid & electrolyte balance: nursing considerations, fourth edition by norma m. metheny, page 49, fluid volume imbalances: "varying degrees of third-spacing occur in surgical procedures and are related to tissue manipulation and injury. the amount of fluid lost from the extracellular space varies with the extent and nature of the surgical undertaking. minor operative procedures (such as appendectomy) are associated with considerably less fluid sequestration than are major operative procedures (such as extensive retroperitoneal dissection). for example, a simple laparotomy with a total small bowel exploration can result in 700 ml of ecf distributional loss, whereas an extensive colon resection can cause as much as 2 to 3 liters of ecf to sequester into the peritoneal cavity in 2 to 4 hours. after abdominal surgery, particularly pelvic surgery, fluid accumulates in the peritoneum, bowel wall, and other traumatized tissues, formation of a third-space after nonthermal traumatic injury occurs immediately and is maximal by 5 to 6 hours. in the surgical patient, it is difficult to assess fluid loss due to sequestration into the interstitial compartment. such unrecognized deficits of ecf during the early postoperative period are manifested primarily as circulatory instability."

    if your patient had some inflammation process already going on prior to the appendectomy there would have been some tissue trama already with some fluid sequestration, no doubt. it would be hard to know the extent. with fluid already confined to tissues in this area in unknown amounts, the physician definitely would not want to contribute to that by giving an iv solution of isotonic saline since the saline is going to go where? the interstitial space.

    clear as mud, now? :behindpc:
    Last edit by Daytonite on Sep 13, '06
    pooshx2 likes this.
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    To simplify, when our patients come to us from OR or have had a considerable loss of blood (with all of its fluid components) from trauma, LR is hands down the fluid of the day. NS is good for volume replacement but will not address the other lost electrolytes the way LR will. D5W, with its high glucose, is not appropriate for head bleeds and diabetics.
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    Thank you to everyone stuffing info into the little bit of space I have left in my brain! You guys are all a great support for me!

    Thank you, thank you, thank you!!!!!


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