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Physiology When blood is lost, the greatest immediate need is to stop blood loss.

The second greatest need is replacing the lost volume. This way remaining red blood cells can still oxygenate body tissue. Normal human blood has a significant excess oxygen transport capability, only used in cases of great physical exertion. Provided blood volume is maintained by volume expanders, a quiescent patient can safely tolerate very low haemoglobin levels, less than 1/3rd that of a healthy person. The body automatically detects the lower haemoglobin level, and compensatory mechanisms start up. The heart pumps more blood with each beat. Since the lost blood was replaced with a suitable fluid, the now diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is released to the tissues. These adaptations are so effective that if only half of the red blood cells remain, oxygen delivery may still be about 75 percent of normal. A patient at rest uses only 25 percent of the oxygen available in his blood. In extreme cases, patients have survived with a haemoglobin level of 2 g/dl, about 1/7th the norm, although levels this low are very dangerous. With enough blood loss, ultimately red blood cell levels drop too low for adequate tissue oxygenation, even if volume expanders maintain circulatory volume. In these situations, the only alternatives are blood transfusions, packed red blood cells, or oxygen therapeutics (if available). However in some circumstances, hyperbaric oxygen therapy can maintain adequate tissue oxygenation even if red blood cell levels are below normal life-sustaining levels. Types There are two main types of volume expanders; crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. Colloids Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by crystalloids due to hemodilution. [1] Therefore, they should theoretically preferentially increase the intravascular volume, whereas crystalloids also increases the interstitial volume and intracellular volume. However, there is still controversy to the actual difference in efficacy by this difference.[1] Another difference is that crystalloids generally are much cheaper than colloids.[1]

Hydroxyethyl starch
Main article: Hydroxyethyl starch Hydroxyethyl starch (HES/HAES, common trade names: Hespan, Voluven) is one of the most frequently used colloids. An intravenous solution of

hydroxyethyl starch is used to prevent shock following severe blood loss caused by trauma, surgery, or some other problem. It increases the blood volume, allowing red blood cells to continue to deliver oxygen to the body. Crystalloids The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Ringer's lactate or Ringer's acetate is another isotonic solution often used for large-volume fluid replacement. A solution of 5% dextrose in water, sometimes called D5W, is often used instead if the patient is at risk for having low blood sugar or high sodium. The choice of fluids may also depend on the chemical properties of the medications being given. Intravenous fluids must always be sterile.

Ringer's solution
Lactated Ringer's solution contains 28 mmol/L lactate, 4 mmol/L K+ and 1.5 mmol/L Ca2+. It is very similar - though not identical to - Hartmann's Solution, the ionic concentrations of which differ. Ringer's acetate consists of 28 mmol/L acetate, 4 mmol/L K+ and 1.5 mmol/L Ca2+.

Normal saline
Main article: Saline (medicine) Normal saline (NS) is the commonly-used term for a solution of 0.91% w/v of NaCl, about 300 mOsm/L.[2] Less commonly, this solution is referred to as physiological saline or isotonic saline, neither of which is technically accurate. NS is used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia. NS is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation, and has long been believed to be the safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of NS can cause metabolic acidosis.[3]

Glucose or dextrose
Intravenous sugar solutions, such as with glucose or dextrose have the advantage of providing some energy, and may thereby provide the entire or part of the energy component of parenteral nutrition. Types of glucose/dextrose include:

D5W (5% dextrose in water), which consists of 278 mmol/L dextrose D5NS (5% dextrose in normal saline), which, in addition, contains normal saline.

Comparison table
Composition of common crystalloid solutions

Solution Other Name [Na+](mmol/L)

[Cl-] (mmol/L)

[Glucose](mmol/L) [Glucose](mg/dl)

D5W

5% Dextrose

278

5000

2/3D & 1/3S

3.3% Dextrose / 51 0.3% saline

51

185

3333

Halfnormal saline

0.45% NaCl 77

77

Normal saline

0.9% NaCl

154

154

Ringer's lactate

Lactated Ringer

130

109

D5NS

5% Dextrose, Normal Saline

154

154

278

5000

Effect of adding one litre

Solution

Change in ECF Change in ICF

D5W

333 mL

667 mL

2/3D & 1/3S

556 mL

444 mL

Half-normal saline 667 mL

333 mL

Normal saline

1000 mL

0 mL

Ringer's lactate

900 mL

100 mL