The fluid therapy indication determines the fluid choice, the amount of liquid to be infused, and the infusion rate.
Parenteral preparations are sterile pharmaceuticals administered to the human body by injection.
The fluid therapy parenteral administration generally involves intravenous crystalloid solutions, colloidal solutions, or blood products.
Fluid therapy with crystalloid solutions is used to renew hypovolemic patients and correct the free water deficit in the case of dehydrated patients.
Replace ongoing fluid losses and meet fluid requirements for patients who cannot take fluids by mouth.
The use of colloidal solutions is now controversial.
However, colloidal solutions (such as albumin solution) may be indicated as monotherapy or in combination with crystalloid solutions in severe cases of low oncotic pressure, especially in children.
In the case of severe bleeding, the use of blood products should be considered.
All patients receiving fluid therapy should be closely monitored using a combination of clinical parameters and laboratory tests to determine the endpoint of fluid therapy.
When patients have problems eating or digesting food, it is sometimes necessary to provide nutrition with artificial foods specially formulated to provide the proper balance of fats, proteins, sugars, vitamins, and minerals.
These artificial preparations can be administered into the intestine to be absorbed in the usual way, known as enteral nutrition.
Alternatively, they can be delivered into the bloodstream through a drip to bypass the gut, known as parenteral nutrition.
If the patient’s intestine cannot be used to absorb nutrients, then the nutrition must be delivered into the patient’s bloodstream, bypassing the intestine.
Only liquid substances can be administered, the parenteral pharmaceutical preparation is liquid, or the solid substance can be diluted with a sterile liquid or solvent before being issued.
Solvents other than water should not interfere with the effectiveness and stability of the prepared solution.
However, substances can be added to increase the effectiveness of the preparation; the important thing is that the additives do not cause toxicity or adverse effects.
When parenteral solutions are to be stored in multi-dose containers, antimicrobial preservatives are added to these formulations to prevent and inhibit the growth of microorganisms in the container.
It is necessary to validate the effectiveness of such preservatives before the start of the parenteral production process.
If the active ingredient degrades and oxidizes, antioxidant substances are added to the parenteral preparation and packaged under a vacuum, moving with nitrogen or inert gas.
The containers where parenteral preparations are supplied and stored are varied: vials, bottle ampoules, and plastic bags.
Containers must be transparent to allow visual inspection of the parental liquid contained.
Glass has usually been the preferred material for packaging where parenteral products are stored.
Borosilicate glass is the most resistant to chemical attack. However, plastics are becoming more common, and several types are used daily.
The choice of material will depend on the composition of the parenteral product.
The standardization for the choice of materials is established by the pharmacopeias.
These institutions are the ones that establish quality standards for active ingredients, excipients, container material, and label and storage conditions.
When injectable samples must be taken from the containers, a particular type of closure is necessary to prevent the entry of any microorganism or bacteria.
The closure material should allow passage of a hypodermic needle with minimal difficulty and have the ability to reseal when the hand is withdrawn.
Devices called elastomers are widely used as closure material for bottles.
They are also used in primary parenteral packaging such as vial caps, plungers, tip caps for pre-fill syringes, plungers and seals for cartridges, and ports for plastic bags.
To ensure that high quality, consistent with an exemplary manufacturing process, is maintained for parenteral product packaging, each final container must be individually inspected for any contaminants.
Parenteral product labels must contain the name of the parental preparation, the amount of the active ingredient, storage conditions, and what diluent or solvent must be used to achieve the necessary concentration to administer the product.
The label should never cover the entire container to inspect the product quickly.
Types of parenteral preparation
Injections are prepared by dissolving the active ingredient and other substances in water for injections to form solutions.
The solution to be injected may show sediment that can be easily dispersed by shaking the container.
The suspension should be viewed as a homogeneous mixture to deliver the same concentration of the active ingredient each time the parent solution is taken from the container.
These parenteral preparations are composed of a sterile aqueous solution with water as the continuous phase.
These preparations become isotonic with the blood and must be free of bacterial or pyrogen endotoxins.
Injection powders are pure solid compounds that, when shaken, mix to form a clear solution that should be free of particles.
For injections, concentrated solutions to be administered via injection or intravenous infusion must be diluted with water.
Implants are solid, sterile devices implanted into the tissue, where the active ingredient will be released for a prolonged period.
They are stored in sterile containers individually.
They are aqueous solutions with varying concentrations of electrolytes and are the most commonly used fluids in a hospital setting.
Crystalloids increase intravascular volume. The extent to which they do so depends on the effect on the liquid compartments.
A colloid is a high molecular weight substance that mostly remains confined to the intravascular compartment and generates oncotic pressure.
Colloidal solutions are divided into:
- Natural colloids: albumin, fresh frozen plasma.
- Artificial colloids: gelatins, dextrans, hydroxyethyl starch.
Transfusion of blood products is indicated in the case of massive blood loss.
General indications for parenteral fluid therapy
Patients in hypovolemic shock require rapid fluid infusions in the form of fluid problems to maintain intravascular volume.
Replacement of the free water deficit
This replacement is indicated to treat dehydration and hypernatremia.
Fluid leak replacement in progress
Fluids are also indicated in the post-resuscitation phase when the patient is no longer hypovolemic but still has an ongoing abnormal fluid loss that cannot be compensated for by oral intake alone.
Some common conditions associated with an ongoing fluid leak are:
- For burns.
- Polyuria due to high-performance renal failure, diabetes insipidus.
- By surgical drainage.
- Constant significant gastrointestinal leakage in case of vomiting and diarrhea.
Maintenance fluid therapy
Maintenance fluids are indicated in patients who cannot take fluids by mouth.
- Correction of electrolyte imbalances.
- As a solvent for intravenous drugs.
Parenteral nutrition is, by definition, intravenous.
There are two types of parental nutrition:
Partial parenteral nutrition
This type of nutrition provides a part of the nutritional requirements needed daily and complements oral intake.
Many hospitalized patients receive dextrose or amino acid solutions using this method.
Total parenteral nutrition
This type of nutrition provides all the nutritional requirements that are needed daily.
Total parenteral nutrition must be performed through a central venous catheter since complete parenteral nutrition solutions are concentrated and cause peripheral vein thrombosis.
Total parenteral nutrition may be the viable option for those patients whose gastrointestinal tract is not functional or who suffer from disorders that require complete intestinal rest, such as in the following conditions:
- In ulcerative colitis .
- When intestinal obstruction of the intestine (ileus) cannot function.
- Pediatric gastrointestinal disorders such as congenital gastrointestinal abnormalities and prolonged diarrhea regardless of cause.
- Short bowel syndrome due to surgery. A large part of the intestine has been removed, and the patient cannot absorb enough food.
- Bowel perforations where feeding will result in worsening infections.
- Where parts of the intestine are diseased and cannot absorb properly (functional short intestine).
Parenteral nutrition is slowly pumped into the bloodstream through a drip.
Because it can be very irritating to blood vessels, it is usually given into a large vein near the heart through a central venous line in the upper arm, chest, or neck.
The use of parenteral nutrition can sometimes result in serious problems, such as blood infections or a disorder in biochemistry.
Therefore, patients need intensive monitoring.
If the problem with bowel function is permanent or persists for a long time, some patients may be taught how to administer their parenteral nutrition at home (home parenteral nutrition).
Many commonly used solutions can have electrolytes added according to the patient’s needs.
The solutions to be administered vary according to other disorders present and the age of the patient, as expressed below:
- For kidney failure not treated with dialysis or liver failure: the parental fluid must have a reduced protein content and a high percentage of essential amino acids.
- For heart or kidney failure, the parental fluid administration should be in a limited volume.
- For respiratory failure: the parent fluid should be a lipid emulsion that provides the majority of non-protein calories to minimize carbon dioxide production from carbohydrate metabolism
- For neonates: the lowest dextrose concentrations (approximately 17 to 18%).
Because the central venous catheter must remain in place for a long time, the strict sterile technique must be used during insertion and maintenance.
Complications are related to the central venous access line.
- Hyperglycemia or hypoglycemia.
- Liver dysfunction
- Hepatomegalia dolorosa.
- Serum electrolyte and mineral abnormalities
- The volume overload.
- Metabolic bone disease (osteoporosis or osteomalacia).
- Adverse reactions to lipid emulsions include dyspnea, allergic skin reactions, nausea, headache, back pain, sweating, and dizziness.
- Gallbladder complications such as cholelithiasis, gallbladder sludge, and cholecystitis.