Infusion Therapy Complete

B|BRAUN
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Background
Information
on
Infusion Therapy
Dr. Rolf Franke

Otto Bergmann
B. Braun Melsungen AG
Hospital Care Division
Medical Science & Training
Date: 2001-08-21
Version: 08
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INTRODUCTION
INFUSION THERAPY AND B|BRAUN
While in the USA the development of Infusion therapy was characterised by names
like Donald Baxter or Foster McGaw, in Germany it was inseparably associated with
Dr. Bernd Braun and consequently with B. Braun Melsungen AG. In the field of
infusion solutions comprising trade-marks as Stereofundin or Plasco as well as
with the introduction of medical products such as Braunula, Intrafix and
Perfusor, B|BRAUN set milestones in the development of application techniques
that have nowadays become routine. Also with regard to economical aspects, the
development of infusion therapy is closely connected to the rise of the company to
one of the leading hospital suppliers in Europe since more than half of the total
turnover is achieved by sales out of the various product lines for infusion therapy.
HISTORICAL DEVELOPMENT
The discovery of the blood circulation by William HARVEY in 1628, reported in his
"Exercitatio anatomica de motu cordis es sanguinis in animalibus" served as the
physiological-anatomical basis for the clinical use of intravenous injection, infusion
and transfusion. The first practical injection trials in animals were, however, not
carried out by physicians, but rather by laymen. The cavalry captain, VAN
WAHRENDORF, injected wine into the veins of his hunting dogs and observed the
typical symptoms of drunkenness in them. Further trials are reported from England.
WREN carried out intravenous injections in animals in 1656, WREN, BOYLE and
CLARKE continued these experiments in the following years, using a small tube to
which an animal bladder was attached. The substances injected included among
others water, wine, milk, beer, opium solutions, meat bouillon, emetics. The
physicians Johann Sigismund ELSHOLTZ, Johann Daniel MAJOR and Michael
ETTMLLER introduced the technique of intravenous application of drugs for
therapeutic purposes in Germany.
In 1657 Robert BOYLE carried out the first blood transfusion followed by Jean DENIS
in 1667. While in the first case blood was transfused from one animal to another the
second one was the very first case where a sheeps blood was transfused to a
human being (fig. 1). Further descriptions were provided by LOWER and KING, 1667
and GAYANT, 1667/1668. In the 18th century intravenous injections were carried out
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in physiological and pharmacological trials as well as for therapeutic purposes,

however, without the final medical breakthrough being yet to come. Though some
very few cases of successful injection were reported, the side effects acted as a
significant deterrent.
All in all, the medical profession remained rather reticent during the first half of the
19th century. Though bloodletting, rectal syringes and cannulae had been known
since antiquity, the technique of intravenous injection had posed a major problem to
the physicians since the 17th century as can be gathered from the variety of methods
recommended. The most serious problem to cope with was how to inject fluid into the
vein of a patient through the bloodletting wound used for this purpose. The English
surgeon HUNTER is reported to have mentioned a sharpened hollow needle for the
first time in 1830. During the second half of the 19th century, the newly invented
technique gave the first major impetus to the method of intravenous injection for
therapeutic use.
In 1853 Karl PRAVAZ described a glass syringe with a hollow needle attached to it.
The piston was driven forward by means of a thread. He tried to thrombose the
aneurysm of a peripheral artery by injecting iron chloride. In 1858 WOOD published a
report on a graduated glass syringe to which a thin, hollow needle was attached. In
1869, LUER constructed a piston syringe made of glass with a cone for attaching the
needle.
In 1881 LANDERER finally succeeded in introducing the method of intravenous
injection to clinical practise by using the PRAVAZ syringe. He recommended a
technique that did not involve prior venae section to expose the vein, but to puncture
it through the intact skin following compression. The discovery of the blood groups by
Karl LANDSTEINER in 1901 also provided the basis for modern blood transfusion. In
1906 the record syringe, made of glass and metal, was introduced in Germany.
Administration of drugs by way of infusion, however, did not become a commonly
used technique until Albert FRNKEL introduced strophanthin in 1906 and Paul
EHRLICH introduced salvarsan in 1910. The therapeutic use of these two drugs
contributed to physicians becoming familiar with the method of intravenous injection.
While shortly after the second world war infusions were still carried out only in cases
of severe illness, often using self-made devices, they are nowadays one of the
indispensable therapeutic methods in modern clinical practice. Since 1960 single-use
articles meeting the highest technical standards and medical requirements have
replaced multiple-use products for reasons of hygiene and rationalisation. With these
new products, an i.v. infusion requires only little more effort than any other i.v.
injection.
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INFUSION THERAPY TODAY

Today infusion therapy is of considerable importance in intensive-care medicine,
serving as a method for the intake of water, electrolytes, blood and substrates. It is
also used for the intravascular administration of drugs as well as for diagnostics. The
parenteral administration of drugs is thus a routine form of application in clinical
therapy. In modern intensive care medicine, for example, the patient receives
parenteral nutrition as well as all drugs which are necessary for treatment by way of a
central line catheter.
All in all, infusion therapy plays a highly important role in modern medicine. In
particular, clinical anaesthesia, reanimation, intensive care therapy and emergency
medicine would not be possible without it.
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PURPOSE OF THE LECTURE NOTES

The lecture notes Background Information on INFUSION THERAPY are designed
for training internal B|BRAUN staff as a means of preparation prior to the seminar.
Two goals are important here: On the one hand, learning beforehand shall establish
a common level of knowledge among the participants so that during the seminar
attention can be focused on practical examples. On the other hand, when working
through the notes, individual gaps of knowledge can be found that will be eliminated
during the seminar.
The lecture notes could help healthcare professionals to prepare their own lectures or
students to understand the principles of infusion therapy.
STRUCTURE OF THE LECTURE NOTES

The present lecture notes are divided into two sections. The first part comprises
background information on biological structures and the function of the body. This
basic knowledge is indispensable for the understanding of infusion therapy. The
second part finally deals with the essential elements of infusion therapy serving as a
lead-in to the complex field of this therapy .
As these lecture notes should serve as a learning tool, they include some elements
which support the learning process.
! The training objectives stated at the beginning of each chapter give an overview
of the material that shall be worked through in this chapter.
! At the end of the chapters there are comprehension questions which help to
control ones own learning success
! In the annex of the script you will find a glossary giving the most important
technical terms. The terms explained in the glossary are underlined in the text.
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BIOLOGICAL BACKGROUND
INFORMATION
ON INFUSION THERAPY
This part contains basic information on biological structures and the processes of the
body. This basic knowledge is an indispensable prerequisite for comprehending the
complex field of infusion therapy. Each infusion means a surgical intervention into the
biological mechanisms. That is why comprehension of infusion therapy requires a
solid basic knowledge of biology.
Out of the complexity of existing structures in the human organism only those will be
explained that directly relate to the topic of infusion therapy. First of all the basic
building block of all life the cell is described. Beside the basic composition of the
cell the most important cell structures will be explained The following chapter
presents information about blood, describing the main tasks of blood, its single
components as well as the process of blood coagulation. In the following the
cardiovascular system is described including a short explanation of heart and vessels
as well as the existing pressure conditions. Further, the most important components
and processes of the water balance are described. The first section closes with a
chapter about the basic elements of the nutrition of the organism.
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Training Objectives:
" Knowledge of the general cell components
" Short description of the most important cell structures
THE CELL
The cell (lat. Cellula = small chamber) is considered to be the basic building block of
all life. The organism consists of a number of cells. They are the elementary
structural and biological units of the body and are the basis of its functions. Every cell
type is specialised for a particular job in the organism. It constantly exchanges
energy and substances with the surrounding milieu. It can nourish itself, grow,
reproduce and react to stimuli from its surroundings. Following a survey of the
general cell components, these lecture notes give details of the most important
structures of the cell.
1.1 General Cellular Structure

The basic parts of the cell are A) the cell body (cytoplasm or protoplasm) and B) the
cell nucleus. The cell membrane (plasma membrane) separates the cell from its
surroundings. The cytoplasm consists of a variety of highly organised bodies, called
organelles. Important organelles are, for example, the mitochondria.
PLEASE NOTE:
There are also cells without a nucleus, the erythrocytes (red

blood cells); only during the initial state do they have a
nucleus, and are called reticulocytes (see 2.2 The Blood)
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Fig. 1: The cell
1.2 Important Cellular Structures

In the following, the most important cell structures are explained; these can be seen
with the help of an electron microscope. Some of the cell structures are also shown in
fig. 1.
The cell body

The cell body is also called cytoplasm or protoplasm. It consists of protein, H2O,
salts and metabolites.
The cell membrane

The cell membrane consists of the three outer layers of the cell: The
semipermeable cell membrane protects the cytoplasm from damaging
influences; it functions as a filter.
Nucleus (or karyosome)

When not being in the state of division, it consists of a nuclear membrane, one
or more nucleoli, and an achromatic nuclear reticulum (does not take on dyes)
containing the chromatin and the karyolymph.
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The nuclear membrane

Forms a definite border between the nuclear substance and the surrounding
cytoplasm.
The nuclear reticulum

The interior of the nucleus contains nucleic acids (desoxyribonucleic acid DNA). DNA contains the chemical substances that characterise the
chromosomes (soma = body), the carriers of inherited characteristics
(genes).
Karyolymph (nuclear sap)

The gaps between the single parts of the nuclear reticulum are filled with a
clear basic mass, the karyolymph. It plays a role in the changes of the
nucleuss shape, the transport within the nucleus and between nucleus and
cytoplasm.
Nucleoli
They carry metabolic substances and reserve substances for protein
synthesis.
The cytological organelles

Cytological organelles are cytocentres that are usually located right near the
nucleus. The cytocentres are very important for the process of cell division
(mitosis).
The mitochondria
By means of certain enzymes (protein molecules that affect chemical
reactions, speeding them up without themselves being changed), the
mitochondria are responsible for correct oxidation processes in the cell. They
supply the cell with the energy required for metabolism. The mitochondria are
located where energy-consuming processes take place.
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Golgis apparatus (Dalton complex)

Golgis apparatus is also located near the nucleus. It consists of fat and
protein substances. It plays an important role in the secretion mechanism of
the cell.
1.3 Summary
The cell is considered to be the basic building block of all life.
The cell components are differentiated by the cytoplasm (cell body) and the nucleus
(cell nuclear). The cell is protected against its surroundings by means of the cell
membrane. However, it is in constant energy- and metabolic interaction with its
surroundings.
1.4 Comprehension Questions

! Why is a basic knowledge of biology an indispensable prerequisite for the
understanding of infusion therapy?
! What rough differentiation regarding the cell structure can be applied?
! What function does the cell membrane have?
! What function does the mitochondrion have?
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! Explanation of the functions of the blood
! Identification of the blood components, arrangement of
the components, description of the most important
characteristics (function, size, etc.)
! Knowledge of the blood clotting phases
THE BLOOD
The blood is an organ system; its cells float in fluid. All organs of the body form a
functional unit through the mediation of the blood. First of all blood is a means of
transportation. The following is a description of important functions of the blood and
its components. It should be borne in mind, that size and form of the blood
components play an important role in infusion therapy. The chapter closes with a
presentation of the blood clotting process.
2.1 Functions of the Blood

The balance in the interior milieu is called homeostasis. Every cell contributes to the
homeostasis and profits from it at the same time. The blood is of particular
importance for the homeostasis. The human being shows a highly sensitive reaction
to the slightest change of certain blood parameters such as pH-value, the
concentration of the blood-sugar-value or the temperature of the blood.
The blood has got the following important functions:
! Transport of substances, i.e. nutrients and oxygen are transported to the cells
and tissues of the body. Catabolites (such as carbonic acid, water, urine and
CO2 ) are transported to the excretory organs.
! Maintenance of a constant body temperature.
! Maintenance of a constant concentration of hydrogen ions (pH value of 7.42),
electrolyte ions and thus isotonicity.
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! Protective and defence functions against invading micro-organisms.

! Closure of a wound.
2.2
Blood Composition
Blood makes up about 7.6% of the whole bodyweight; that means there are
approximately 4-5 litres, with about 3.5 litres constantly in circulation.
The blood is composed of formed parts and the blood plasma. The volume proportion
between the red blood cells and the fluid blood components is called packed cell
volume or haematocrit. An overview of the different substances of the blood are
shown and explained in fig.2.
Blood 44 -- 55 litre
litre
Blood
Bloodplasma
plasma55%
55%
Blood
Formedcomponents
components45%
45%
Formed
Erythrocytes
Erythrocytes
Thrombocytes
Thrombocytes
Leukocytes
Leukocytes
4,5-5 million/mm3
4,5-5 million/mm3
200.000-300.000 mm3
200.000-300.000 mm3
4,5-5 million/mm3
4,5-5 million/mm3
Granulocytes
Granulocytes
60%
60%
Monocytes
Monocytes
4%
4%
Bloodserum
serum
Blood
Fibrinogen
Fibrinogen
Lymphocytes
Lymphocytes
36%
36%
Figure 2: Blood Composition
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2.2.1 STRUCTURED COMPONENTS

Erythrocytes, leukocytes and thrombocytes (platelets) are the formed components of
the blood.
Erythrocytes: (red cells)

! Number: 4.5 5 Mill/mm
! Appearance: Round, bi-concave discs ,2 m thick at the edges, 1 m thick in the
middle, and 7.5 m in diameter.
! Composition: Each erythrocyte consists of 63% water and 37% dry substance,
mainly haemoglobin (red blood pigment). Haemoglobin is a protein compound
containing iron (Fe2+) that transports oxygen and carbon dioxide.
! Function: Supply the body with oxygen.
! Characteristics: They are characterised by a high plasticity allowing them to
pass through even very small capillaries with a diameter of 5 m.
! Place of origin: In adults they are formed in the flat bones (shoulder blade,
breastbone, hip bone). During the maturation phase in the bone marrow they lose
their nucleus.
Leukocytes (also called white blood cells)

Leukocytes fend off the attempts of invasion by bacteria and viruses for a life time.
Their number is ca. 4,500-8,000/mm. There exist granulocytes and lymphocytes
(basic-type) as well as monocytes.
Granulocytes
! Number: They represent the largest share of the white blood count
(approx. 60%)
! Size: approx. 10 m in diameter
! Function: They are able to devour micro-organisms (e.g. bacteria). They
are therefore also called macrophages or phagocytes.
! Characteristics: They can also use amoeboid motion to leave the
bloodstream actively and penetrate tissues.
! Place
of
origin:
They
are
produced
in
the
red
bone
marrow
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Lymphocytes
! Number: In adults they make up 36% of all white blood cells.
! Size: approx. 7-9 m in diameter
! Function: They produce antibodies against foreign substances. They are
capable of recognising invading pathogens and are therefore also termed
memory cells.
! Characteristics: They are only capable of limited amoeboid movement and
cannot carry out phagocytosis.
! Place of origin: They are formed in the lymphoid organs (spleen and
lymph nodes).
Monocytes
! Number: They make up approx. 3-6 % of all white blood cells
! Size: They are the biggest blood cells (about 20 m in diameter)
! Function: They eliminate foreign substances mainly with chronic infections.
! Characteristics: They move out of the blood into the tissues and settle
down there, while gaining in size.
! Location of genesis: They are also produced in the red bone marrow.
Thrombocytes (platelets)
! Number: 150,000 300,000/mm
! Appearance: They are extremely small (1-3 m in diameter); They are
variable in form.
! Function: They form a clot (thrombus) by means of apposition when a
vessel is damaged.
! Characteristics: The thrombokinase, an important element in the blood
clotting process, is released upon thrombocytolysis (see chapter 2.3 Blood
Coagulation).
! Place of origin: They are also produced in the red bone marrow.
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2.2.2 BLOOD PLASMA

The blood plasma consists of fluid components (blood serum) and firm components
(for example fibrinogen)
! Composition: The plasma contains 90% water, 7-8% proteins, fats, lipoids,
enzymes, hormones, pigments, mineral substances and the entire amount of
nonprotein nitrogen.
! Function: The plasma water is the ideal means of transportation for all watersoluble substances.
! Function of the protein substances: The protein substances (albumin,
globulins) are active in defence functions, but also in the binding of water and
thus electrolytes (salts, sodium, potassium, calcium, chlorides). These complex
mechanisms also maintain the blood within a slightly alkaline range (pH = 7.42).
Important
2.3
The electrolyte concentration in blood corresponds approx.

to a 0.9% sodium chloride solution (normal saline).
The Blood Coagulation
The task of the numerous complex factors necessary for blood clotting is to ensure
that the clot is limited to the site of injury and does not have any life-endangering
effects.
The process of blood clotting is divided in 3 phases:
1st phase
Normally prothrombin is a constituent part of the blood. Its formation in the liver
involves vitamin K. Because of the destruction of the tissues and the decay of
the clotting blood platelets, the enzyme thrombokinase is activated. With the
participation of disintegrated thrombocytes, electrically charged calcium ions
and various coagulation factors (13 factors are differentiated at present),
prothrombin is converted into thrombin. The blood activator and tissue activator
are also involved.
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2nd phase
The thrombin produced in this way transforms the fibrinogen in the blood
plasma into fibrin. This forms a fibrilliform mesh enclosing blood cells. In fact
this is the reason for the blood clotting (the thrombus).
3rd phase
The fibres of the fibrin mesh and are contracted (retraction). The blood clot is
differentiated from the fluid pressed out (blood serum = plasma minus the
coagulation factors).The fibrous mesh solidifies and can then close a small
defect in the vascular wall.
The blood clotting process is followed by the fibrinolysis (lysis = dissolution). Normal
blood plasma also contains the precursor of the enzyme fibrolysin, which can
redissolve a clot. Normally, there is a balance between fibrin formation and
fibrinolysis.
2.4 Summary
The blood has a number of important functions: transport of oxygen, maintenance of

body temperature, maintenance of the hydrogen ion concentration as well as
protection and defence activities.
Blood consists of formed components and blood plasma, this proportion is called
packed cell volume. The formed components are erythrocytes (oxygen supply),
leukocyte (defence against foreign substances) and thrombocytes (thrombus
formation). Besides these different functions the named components differ with
regard to the following characteristics: Number, appearance, components and
genesis. Size and plasticity play an important roll in infusion therapy.
The blood plasma consists of firm and fluid components. The firm components are
first off all proteins. Beside defending activities, their function is the binding of waterand electrolytes. It is also important that the concentration of sodium ions and
chloride ions in the blood is approx. equivalent to a 0.9% sodium chloride solution.
The process of blood coagulation is divided into three interconnected phases,
followed by the fibrinolysis.
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! What functions does the blood have?
! What does homeostasis mean?
! What pH-value does the blood have?
! What are the components that blood consists of? What share do the single
components have?
! Name the three most important groups of blood cells and give the approximate
size of each.
! Was does the term packed cell volume describe?
! Which solution does the electrolyte concentration of blood approx. correspond to?
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Learning objectives:
!
Description of the cardiovascular system

components including the functions
! Knowing of the pressure rate in the veins, arteries
and capillaries.
THE CARDIOVASCULAR
SYSTEM
The cardiovascular system describes the course taken by the blood from the heart
through the arteries, capillaries, and veins back to the heart. The different parts of the
cardiovascular system are characterised by very different pressures. These
pressures are very important for infusion therapy since they require different technical
devices to bring fluid into the vessel concerned.
Veins
Arteries
Arterioles
Venules
Capillaries
Fig. 3: The cardiovascular system
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3.1 The heart

The heart is the beginning as well as the end of the bloods circulation. It is a hollow
muscular organ having a suctive and compressive function. In a human being the
heart has four chambers: right atrium, left atrium, right ventricle and left ventricle.
3.2 The vessels

The Veins
The veins are vessels transporting blood back to the heart. They are thin walled
and have only low elasticity. The venous valves serve as a reflux stop. Small
venous valves are integrated In the big trunk veins. Venules are fine branches
of the veins.
The largest vein of the body is the vena cava. The central venous pressure
(CVP) is measured here, which is an indicator for the volume contained within
the cardiovascular system. It indicates hidden bleedings or wrong infusion rates.
As an exception, the pressure is measured in cm water column instead of
mm Hg. Normally it is about 2-10 cm water column. In the trunk veins the
pressure is approx. 10 mm Hg. The pressure in the venules is about 15 mm Hg.
The Arteries
They are the vessels with the thickest wall in the vascular system and serve to
transport the blood away from the heart. Pressures are 120-160 mm Hg.
Arterioles are finer branches of the arteries. The pressure is about 33 mm Hg.
The Capillaries
Capillaries are small blood vessels connecting the arteries and veins. They
come out of small arterioles and lead to the smallest venules. Their diameter is
approx. 5 m.
The capillaries are surrounded by tissue fluid (lymph). Their walls are flimsy and
permeable. There is a permanent gas and oxygen exchange between the
blood, the capillaries and the lymph. The pressure in them is approx. 15-30 mm
Hg. The filtration pressure here exceeds 10 mm Hg.
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3.3 Summary
The cardiovascular system is the way of the blood through the arteries, capillaries
and veins back to the heart. The heart is the beginning as well as the end of the
blood circulation. The thick-walled arteries lead the blood away from the heart; the
blood returns through the thin-walled veins. The capillaries connect the arteries and
the veins.
The different parts of the cardiovascular system are characterised by very different
pressures. Those pressures are very important for infusion therapy.

! What pressures predominate in the different cardiovascular vessels? What role do
these rates play in infusion therapy?
! What is the central venous pressure (CVP)?
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" Naming of the places in the body where water is found.
Percentage of water found there.
" Listing of the most important cations and anions
" Description of osmosis and knowledge of technical terms
" Knowledge of the regulation mechanism of the acid-base
balance.
" Naming of the water intake and output mechanisms and
their portions.
" Description of the gastrointestinal fluid balance
WATER AND
ELECTROLYTE BALANCE
The water and electrolyte balance plays a central role in infusion therapy. First the
most important areas of the organism where water is located are explained followed
by the most important salts in the body. Furthermore, an explanation about the basic
regulation mechanisms is given. These mechanisms help to maintain the water and
electrolyte balance. The chapter closes with explanations about the water balance in
human beings including the process of fluid intake and loss.
4.1 Water (H2O)

Water makes up approx. 60 % of the total weight of an adult human body. The
cellular and tissue structure divides the organism into various segments containing
water or aqueous solutions. We distinguish between intracellular and extracellular
areas. Here again the extracellular area is divided into interstitial and intravascular
parts. Table 1 gives the percentage share of body fluids in the different areas.
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Intracellular Space (ICS)

All metabolic processes in the somatic cells occur within an aqueous milieu.
Extracellular space (ECS)

Outside the cells, water serves as a means of transport to and from the cells
and as a solvent for the somatic colloids. The extracellular space is further
divided into the:
Interstitial part
All cells are separated by fine spaces. These extracellular spaces are called
interstitial. They warrant that all body cells are rinsed by the same fluid, which
contains the necessary salts and nutrients for the supply of the cells.
Intravascular part
The intravascular part is the plasma water.
Table 1: Distribution of body fluid and fluid percentage of body weight for men,
women, and children
Men
Women
Children
Total body fluid
60 %
50 %
75 %
Intracellular space (ICS)
40 %
30 %
48 %
Extracellular space (ECS)
20 %
20 %
27 %
Interstitial part
15 %
16 %
22 %
intravascular part
5%
4%
5%
Important
The fluid spaces are separated from one another both

functionally and anatomically.
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4.2 Salts
Human body fluids contain various salts, which dissociate in the aqueous solution
into charged particles (ions). The dominant salt contained in the extracellular fluid is
dissolved sodium chloride. (approx. 9 gr. per litre). We distinguish between positively
charged ions (cations) and negatively charged ions (anions), which are listed in
table 2. Besides these, there are other dissolved substances such as glucose, urea,
creatinine.
Table 2: Cations and Anions
Positively charged ions

Cations (+)
Negatively charged ions

Anions (-)
Sodium, Na+
Bicarbonate, HCO3-
Potassium, K+
Chloride, Cl-
Calcium, Ca2+
Phosphate, HPO4--
Magnesium, Mg2+
Proteins
Hydrogen, H+
Organic acids
The electrolytic mixture and concentration differs among the fluid spaces. The
organism is always working to maintain constant levels of water and electrolyte
distribution. Various mechanisms for the operation to maintain this homeostasis
(balance) are described in the following.
4.3 Osmosis
Osmosis is the passage of a component in one phase through a membrane into
another phase. Semipermeable membranes are only passable for certain
components, while other components cannot pass.
The cell walls are semipermeable membranes, i.e. structures that allow water
molecules to pass through, but not dissolved particles.. When, for instance, the
extracellular electrolyte concentration rises, water diffuses out of the cell, raising the
intracellular concentration level and diluting the extracellular fluid.
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In fig. 4 the process of osmosis is explained: Water diffuses freely through the
semipermeable membrane (M), while the main direction of flow is from the less
dense (less concentrated) solution (B) into the denser (more concentrated) solution
(A) - see arrow.
Figure 4: Diagramme of osmosis. The concentration of the solute in the fluid is shown
by the black dots, which indicate the dissolved particles.
4.3.1 OSMOTIC PRESSURE

This pressure is determined by the total number of ions and molecular components
contained in a solution. It is measured in milliosmoles (mOsm). The total osmotic
concentration of the plasma (fluid part of blood) is approx. 280 mOsm/l.
Solutions which have the same osmolarity as plasma are called isoosmotic; Solutions
with a higher osmolarity are hyperosmotic and those with lower osmolarity are called
hypoosmotic.
Table 3: Osmotic pressure in plasma:
300 mOsm/l = isoosmotic

More than 300 mOsm/l = hyperosmotic
Less than 300 mOsm/l = hypoosmotic
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4.3.2 COLLOID-OSMOTIC OR ONCOTIC PRESSURE

A further mechanism for the distribution of fluids in areas, is the colloid-osmotic (or
oncotic) pressure. This means the ability of dissolved protein particles to bind water.
The intravascular space is particularly rich in proteins due to the blood plasma
content, so that water is maintained. About 90% water lost into the interstitial space
at the arterial end of the capillaries is taken back at the venous end.due to this effect
(the other 10% flow through the lymphatic system back into the vena cava). If the
blood plasma protein level drops too low an accumulation of fluid inside the interstitial
space (oedema) will be the consequence.
4.4 pH-Regulation
(Regulation of the acid-base balance)
Definition: pH = unit of measure for the concentration of hydrogen ions in aqueous
solutions; these ions determine the acid/base content of the solution.
! Acidic solutions have a pH below 7.0 (and down to not more than 0) and have an
excess of hydrogen ions.
! Basic solutions have a pH above 7.0 (to a maximum of 14). These solutions are
capable of absorbing hydrogen ions.
The pH of blood corresponds to the hydrogen concentration (H+ - ion concentration)
in the plasma and indicates the acid-base content As given in fig. 6, the normal pHin the human arterial blood is 7.40. Also shown is the normal physiological range
(7.35 7.45) as well as the values for acidosis and alkalosis (see glossary).
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Acidosis
Alkalosis
Figure 6: Acid-Base Balance
Normally, the kidney and lungs are responsible for excreting an excess of acid and
basic substances. In case one or both of these two organs fail or if the organism
suffers from an excess of acid or base or loses large amounts of either, a deviation
from the normal value occurs, i.e. a pH shift. The balanced state must be reinstated
as soon as possible: The body activates its buffer systems.
These systems are capable of giving off or binding H+ ions as required. This buffer
capacity is, however, exhausted after a certain period of time. Buffer substances are
proteins, bicarbonate, phosphate, and haemoglobin. The most important buffer
substance is the bicarbonate HCO3-, which is released during breathing.
Normally both mechanisms, buffering and excretion of H+ - ions, lead to a constant
pH. If they are no longer capable of doing so, the acid-base balance is disturbed and
a pH-shift occurs. If this is due to a pulmorary failure (related to the breathing
apparatus), we speak of a respiratory acidosis or alkalosis; otherwise these are
described as metabolic conditions.
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4.5 Hormonal Regulation

The interaction of various hormones enables the body to maintain a constant balance
of water and electrolytes as long as losses are replaced. If the capacity of the body's
regulatory mechanisms is strained, the fluid and electrolyte balance is disturbed.
4.6 The Water Balance in a Healthy Person

As already said, water makes up approx. 60 % of the total weight of an adult human.
This water content is kept constant in an extremely exact manner. Water intake and
output are possible in different ways. Fig. 7 gives a survey of the average water
intake and output of an adult.
Intake
Output
100 ml
Food
Drinks
700 ml
1000
bis
1500
ml
1000
bis
1500
ml
400 ml
stool
urine
Lungs
+
Oxydation waterr
(resulting from oxidation of
calorific substrates)
Total
300 ml
2000 - 2500 ml
500 ml
Skin
Unnoticed output o
water
(perspiratio
insensibilis)
2000 - 2500 ml
Figure 7: The average adult water intake and output.
4.6.1 INTAKE OF FLUID

Normally, the fluid cycle in a healthy adult involves 2-3 l per day. Intake does not only
include drinks, but also water in solid food (pre-formed water) as well as water
resulting from oxidation (oxidation water). Most of the intake, however, is accounted
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for by the daily amount drunk - approx. 1 1/2 l. Intake is the sum of the following three
volumes (see table 4). The water contained in solid food has considerable influence
on the body's drinking requirements.
Table 4: Drinking water, pre-formed water, oxidation water in comparison
Drinking water
Pre-formed water
Oxidation water
Drinking water is quickly absorbed into the plasma compartment. If no solid food
intake takes place, this process requires less than 1 hour. A direct consequence is an
increase in blood volume and blood pressure, leading to the opening of inactivated
capillary segments and venous vessels in the liver and spleen. Following this, water
enters the interstitial space and finally, since the increased interstitial water volume
lowers the osmotic pressure in this space, it enters the cells.
The behaviour of the kidneys during this adaptation period depends on the fluid
status prior to fluid intake. Given a prior haemoconcentration (thick blood) situation
due to lack of fluids, the kidneys do not begin to excrete until all three compartments
(plasma, cells, interstitial space) have reached their normal volume levels. Excessive
fluid intake is of course excreted immediately by the kidneys.
4.6.2 REMOVAL OF FLUID

Fluid excretion is regulated mainly by the kidneys. The other excretion pathways are
not as much in evidence, but are nonetheless of vital importance. Whereas water is
excreted in liquid form together with stool and urine, water vapour is removed from
the body through the lungs. Water is also given off through the skin, usually in the
form of vapour. Water loss through the skin can also take the visible form of
perspiration when the body overheats. "Perspiratio insensibilis" is the term used for
the unnoticed loss of fluid via skin and lungs. It amounts to approx. 1 l per day.
This level is raised by a further 500 ml per degree of fever.
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4.6.3 SHIFTS IN GASTROINTESTINAL FLUID BALANCE

A special fluid balance exists between the blood plasma and the digestive tract
secretions, which are formed of plasma as well. The total amount of fluids separated
out in the intestinal tract may reach 8,200 ml in 24 hours. Fig. 8 explains the loss of
fluid types and their constituent amount.
This large amount of fluid is reabsorbed through the mucosa of the large and small
intestines into the bloodstream. This explains the fact that prolonged periods of
vomiting or diarrhoea can lead to death within hours unless the lost fluid is replaced.
This can be avoided by a massive infusion intake.
Saliva (1500 ml)
Gall (500 ml)

Gastric juice (2500 ml)
Pancreatic juice (700 ml)
Small intestine secretion (3000 ml)
Figure 8: Fluid types (with constituent amount) that are lost because of vomiting and
diarrhoea.
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4.7
Summary
The human water and electrolyte balance plays a central role in infusion therapy. The
cellular and tissue structures divide the organism into various segments containing
water or aqueous solutions. We distinguish between intracellular and extracellular
areas. Here again the extracellular area is divided into interstitial and intravascular
parts.
The fluid parts are functionally and anatomically separated. The electrolytic mixture
and concentration differ among the fluid spaces. The organism is always working to
maintain constant levels of water and electrolyte distribution. Various mechanisms
operate to maintain this homeostasis (balance): The osmosis (passing of water
through water permeable membranes that wont let dissolved substances pass),
mechanisms of the pH-regulation (excretion and activation of the buffer systems) and
hormonal regulation.
The share of water in the human weight is very high (approx. 60%). The water intake
is based on the intake of drinking water, pre-formed water and oxidation water. The
fluid output takes place through urine, stool and unnoticed water output through the
lungs and skin (perspiratio insensibilis). The water balance is kept constant in an
extremely exact manner. A special situation of fluid constancy exists between the
blood plasma and the secretions of the alimentary tract. Diarrhoea and prolonged
periods of vomiting can lead to death within hours unless the lost fluid is replaced by
infusion therapy.
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! Name the different areas in the body in which water or aqueous solutions are
present.
! What are the percentage amounts of body fluids in the different areas?
! Name the most important cations and anions in the human body fluids.
! Shortly explain the most important mechanisms which can be used for the
maintenance of homeostasis.
! How high is the osmotic pressure of the blood plasma? How do you call the
pressure increase or decrease?
! What is the normal pH-value in a human artery? What is an acidosis or an
alkalosis?
! What happens with the buffer systems during a pH-shift?
! Name the most important buffer substances in case of a pH-shift.
! Explain the average water intake and output of an adult!
! What is the ratio between drinking water, pre-formed water and oxidation water?
! Describe the possible consequences of fluid constancy between blood plasma
and the secretions of the alimentary tract.
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" Knowledge of the most important function of nutrients
" Description of both, mechanism and function of
gluconeogenesis
" Knowledge of the difference between essential and
conditionally essential nutrients
" Knowledge of the standard energy requirement as well
as of energy required in case of illness
" Explanation of the terms enteral nutrition and
parenteral nutrition
NUTRITION OF THE BODY

In all phases of life the human body is in need of a constant supply of nutrition, in
order to ensure growth or to maintain the normal bodily functions.
This chapter will provide information about the nutrients the human body needs as
well as about the functions of the single nutrients. The consequences arising from a
deficit of certain nutrients will be shown. You will get to know some mechanisms the
body is able to activate in order to compensate these deficits for at least a short
period of time. In this context the differentiation between essential and conditionally
essential nutrients is of relevance. Furthermore you will get information about the
energy required by the human body including the basal metabolic rate as well as the
energy required in case of illness. The chapter closes explaining the different
methods of feeding that might be applied in case of illness. It is to be distinguished
between enteral and parenteral nutrition.
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5.1 Nutrient Groups

Nutrients may be divided into two major groups i. e. calorific and non-calorific
nutrients. The division of these two major groups of nutrition is based upon the fact
that non-calorific nutrients do not provide the body with the necessary substances for
energy production which, among other tasks (as described below), is ensured by high
calorie nutrients.
Non-calorific nutrients are water, electrolytes, vitamins and trace elements.
! Water is the biological solvent in which all biochemical processes take place.
! Electrolytes (sodium, potassium, calcium, magnesium, chloride, phosphate and
bicarbonate) ensure the correct division of the fluid spaces and maintenance of
the correct conditions that are necessary to perform important tasks such as the
transmission of stimuli as well as muscle movements. Apart from that electrolytes
contribute to the formation of bones and teeth.
! Vitamines (A, D, E, K, B1, B2, B6, B12, C, biotin, folic acid, nicotinic acid and
pantothenic acid) as well as trace elements (iron, copper, zinc, manganese,
selenium, molybdenum, chromium, iodine and fluorine) are mainly important as
parts of enzymes. Enzymes are substances the human body needs to perform
certain biochemical processes that would not go without them.
Calorific nutrients are proteins, carbohydrates and lipids:

! Proteins are substances consisting of up to 20 different building blocks, the socalled amino acids. They are the only substances of the body containing a
considerable quantity of the element nitrogen, i. e. 16 % of their dry weight. The
body produces its own proteins out of amino acids in order to ensure a variety of
different functions. In terms of quantity the development of muscles is of prior
importance since they provide the ability to perform physical work. Proteins that
are solved in fluid spaces as well as in blood are in second place as regards
quantity since they ensure defence reactions against infections, the binding and
transport of water-insoluble substances as well as blood coagulation in case of
injuries, just to name a few.
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Important
Proteins are the functional mass of the body. All bodily

functions are based upon specialised and body-produced
proteins. They are chemically characterised by their 16 %
share of the element nitrogen.
Protein metabolism and synthesis are a constant process in the human body.
Amino acids that are produced as a result of protein metabolism are largely
reused for protein synthesis. Some, however, get lost during the oxidation
process, i. e. amino acids are transformed into the carbohydrate glucose (socalled gluconeogenesis) serving as energy source for oxidation processes. So,
proteins do also contain calories, in fact 4 kcal/g. The process of
gluconeogenesis serves to ensure that those cells and organs that cannot make
use of an alternative energy source (see section carbohydrates) are sufficiently
supplied with glucose. Gluconeogenesis is increased in case of infections or
injuries (see chapter 5.4).
Those amino acids lost in the process of gluconeogenesis must be supplied to
the body in the form of food protein which is found in high concentrations in meat,
fish and eggs.
Important
Gluconeogenesis is the production of glucose serving to

ensure the supply of brain and red blood cells with this energy
source.
! By carbohydrates we understand a group of substances consisting of different

building blocks, all of them having in common the chemical formula Cn(H2O)n. In
terms of quantity glucose is the most important building block. The main purpose
of carbohydrates is to supply energy (4 kcal/g). In food they are mainly found as
starch in cereal products or potatoes. Further important carbohydrates are cane
sugar (saccharose) and milk sugar (lactose). Cells are only able to oxidise
glucose. Other building blocks of carbohydrates such as for example fruit sugar
(fructose) are therefore at first transformed into glucose.
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Glucose is the only energy source all body cells make use of for energy
production. For the brain and the red blood cells it is the only energy source. In
view to their central importance the body must ensure a continuous supply with
glucose. Therefore, after intake of carbohydrates as part of the food a certain
share of glucose is stored in the liver as glycogen. This glycogen means a
reserve of 200 g of glucose. In case of a lack of external administration a
constant energy supply of the brain and red blood cells is ensured for a period of
18 hours. The only additional source of glucose the human body has is the
protein (see above).
Important
Glucose is the only energy source for the brain and blood
cells. In case of a lack of external administration the human
body makes use of two mechanisms in order to keep these
tissues supplied with energy: The conversion of glycogen into
glucose and the conversion of amino acids into glucose
(gluconeogenesis).
! Among the lipids triglycerides mainly serve as energy source. Triglycerides

consist of glycerol and fatty acids, the latter being of importance for the synthesis
of membranes. Triglycerides also serve as the major medium for energy storage
in the body. Triglycerides mainly occur in oils and fats as well as in the fatty tissue
of meat. Oxidation of 1 g of triglycerides produces an average of 9 kcal.
Table 5 gives a survey on the calorific values of calorific nutrients
Table 5: Average calorific value of important nutrients per gram
1 g Carbohydrate
4 kcal
17 KJ
1 g Protein
4 kcal
17 KJ
1 g Fat
9 kcal
40 KJ
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5.2 Essential and Conditionally Essential Nutrients

Since the body has to sustain a natural loss of all nutrients, these losses need to be
compensated. In view to this fact the following questions arise:
1. To which extent may nutrients be interchanged against one another?
2. When does the reduced intake of a single nutrient lead to a deficit?
3. What consequences does the deficit of a nutrient have?
Since the answers to these questions are rather complex and extensive only basic
information will be given.
Ad 1) Substitution of nutrients:
In most cases nutrients cannot be substituted against one another. This is the case,
for example, in all non-calorific nutrients, in 8 out of the 20 amino acids as well as in
the nitrogen contained in proteins, where the body is either not able to produce these
substances itself or the quantity produced is so small that the natural losses cannot
be compensated. These nutrients are called essential.
While the absolute need of calories must be covered by administration, carbohydrate
calories may to a large extend be substituted by lipid calories and vice versa. The
triglycerides of certain lipids, however, do contain two essential fatty acids, the
linoleic acid and the -linolenic acid. Their functions in the membranes cannot be
replaced by any other nutrient.
Important
The majority of nutrients is essential which means, the body

needs the substance for functioning. However, it is not in a
position to produce the substance at all or the quantity
produced is only insufficient.
Ad 2) Development of deficits:
Essential nutrients need to be supplied by the intake of food in order to avoid the
development of deficits. The development of deficits depends on the degree of
nutrient demand. So in normal life a severe deficit in water develops after a period of
a few days already while a protein deficit is the result of a several weeks lasting lack
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of supply. In case of illness, a nutrient deficit can develop much more quickly. So, a
severe diarrhoea, for example, might lead to a serious water deficit within a few
hours time and the considerably increased gluconeogenesis going along with
infections makes severe protein deficits occur after a few days already.
Ad 3) Consequences resulting from deficits
If a deficit of certain nutrients occurs, their tasks are ensured to a limited degree only
and finally are no longer fulfilled at all. This leads to the development of diseases that
may be treated by supplying the respective nutrient. An increase in deficit goes along
with a progression of the disease, increased disturbance of the bodily functions and
finally death from nutrient deficit.
Important
Nutrient deficits lead to severe illness that might result in

deficit-related death
Apart from essential nutrients there is the group of so-called conditionally essential
nutrients. In concrete terms, as regards their function these nutrients may not be
substituted by other nutrients. The healthy adult, however, does not really need to
supply them by way of food intake, since the body is able to produce them itself. In
elder or ill patients the demand of conditionally essential nutrients may be increased
or the endogenous production reduced which leads to a nutrient deficit. 12 out of 20
amino acids, for example, are not essential for the healthy adult while none of the 12
amino acids functions may be compensated by another amino acid. Thus, a deficit of
such an amino acid will lead to the same consequences as it is the case for essential
nutrients (see above). Infants are a typical example, since almost all 20 amino acids
are essential.
Important
Any nutrient getting into a deficit becomes essential, if its

function cannot be ensured by a substitute nutrient
For most of the nutrients there exist valuable recommendations for an adequate and
well-balanced food intake in healthy people, e. g. recommendations issued by the
Deutsche Gesellschaft fr Ernhrung.
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5.3 Human Energy Requirements

The human energy requirements mainly depend on age, sex, height and weight as
well as of the degree of physical activity.
Apart from the need resulting from physical activity there is a minimum of energy a
person needs during the state of rest, the so-called basal metabolic rate. Depending
on the persons constitution it amounts to 1110 1800 kcal/day for an adult ,
however, it may vary in very small or very tall persons. There are different
possibilities to determine the basal metabolic rate, such as tables giving standard
basal metabolic rates depending on age, sex and height. Apart from that the
empirical formulas acc. to Harris and Benedict have proven their usefulness:
BMR male
= 66 + (13.5 x BW) + (5 x H) (6.8 x A)
BMR female
= 655 + (9.6 x BW) + (1.8 x H) 4.7 x A)
Fig. 8: Formula to determine the basal metabolic rate acc. to Harris & Benedict
BMR = basal metabolic rate, BW = body weight in kg, H = height in cm, A = age
The basal metabolic rate is ensured by the bodys utilisation of calorie-containing
nutrients. Proteins, carbohydrates and lipids contribute their respective share in this
process depending on the amount of intake respectively. In Europe the usual
nutrition consists of 10 20 % proteins, 40 60 % carbohydrates and 20 40 %
lipids, the total always amounting to 100 %, of course.
The relative share of calorie-containing nutrients in energy production corresponds to
their amount of intake. However, excessive intake of lipids leads to a storage of lipids
in the adipose tissue. Furthermore, excess quantities of carbohydrates resulting from
excessive intake are also transformed into lipids which is finally stored in the adipose
tissue.
In healthy subjects a calorie demand exceeding the basal metabolic rate is mainly
due to an increase in physical activity.
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Important
Energy requirements are defined as the amount of energy

the body needs depending on the situation. It is made out
by the basic metabolic rate and possible additional
requirements resulting from physical work.
5.4 Energy Requirements in Case of Disease

A disease may cause a substantial increase of energy demand at rest. This is a
disease-induced increase of basal metabolic rate.
In clinical practise the energy requirement of an adult is simply determined as
25 kcal/kg body weight per day. In case of acute infections and inflammation or
severe injuries this value may increase to about 30 kcal/kg body weight per day. In
very rare cases such as severe burns it may be even increased to 35 40 kcal/kg
body weight per day.
Situations as described are characterised by a strongly increased consumption of
proteins. It may amount to four times the standard value and is due to a strong
increase of the gluconeogenesis. Since proteins represent the bodys functional
mass a severe, even life-threatening protein deficiency may develop.
Important
Infections, inflammations and injuries go along with an

increase in energy demand. The bodys proper
functioning is critically at risk because of the protein
catabolism which is due to the considerably increased
gluconeogenesis.
5.5 Enteral and Parenteral Nutrition

In clinical practise there may be situations where normal food intake by eating and
drinking is not possible. In case the intestine may be used as access, patients may
receive special diets by way of feeding tubes. This is called enteral nutrition
(enteros: greek for intestine). If enteral nutrition is not possible feeding is done via the
veins, the method being called parenteral nutrition (passing the intestine). Both,
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enteral and parenteral nutrition serve to supply the body with a sufficient quantity of
nutrients in order to maintain the bodys function. However, particular with regard to
maximum protein supply deficits can often not be completely compensated.
Important
If diseases make normal food intake impossible feeding

has to be done via tubes (enteral nutrition) or via the
veins (parenteral nutrition) since otherwise lifethreatening nutrient deficits may develop. In this respect a
protein deficit represents a particular risk.
Nutrient supply in enteral nutrition is mainly standardised by using tube feedings. As

regards composition and quantity of the respective single components these tube
feedings meet international dietetic demands.
Nutrient supply in enteral nutrition is done in accordance with a special diet regimen
consisting of suitable individual components such as
! Amino acid solutions
! Glucose solutions
! Lipid emulsions
! Electrolyte concentrates
! Vitamins and trace element preparations
Sooner or later all nutrients develop into a deficit if they are not adequately supplied.
Since such a deficit entails severe consequences, it must be ensured that in
parenteral nutrition all nutrients are supplied in sufficient large quantities.
As regards nutrient supply in different clinical situations scientific literature provides a
number of useful recommendations (e. g. Safe Practices for Parenteral Nutrition
Formulations, JPEN 22 (1998) 49 66).
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5.6 Summary
Nutrients may be divided into two large groups: Among the non-calorific nutrients are
water, electrolytes, vitamins and trace elements while proteins, carbohydrates and
lipids belong to the group of calorific nutrients. The single nutrients contribute their
individual shares to maintain the bodys function.
The majority of nutrients is essential, i. e. the body is in absolute need of them,
however, it cannot produce them itself (either at all or in sufficiently large quantities).
Talking of conditionally essential nutrients, we mean those nutrients, which the
human body is actually able to produce in sufficient quantities. However certain
circumstances may cause these nutrients to develop into a deficit.
The basal metabolic rate of humans depends on age, sex, body height and
weight. In addition, energy demand is influenced by the degree of physical activity.
The relative share of energy-containing nutrients in the bodys energy production
corresponds to the amount of them being supplied.
Illness may lead to a (significant) increase of energy demand. In case of severe
injuries, such as burns, the metabolism of proteins is significantly increased due the
process of gluconeogenesis which may result in a life-threatening protein deficiency.
Enteral nutrition (by way of tubes into the intestine) as well as parenteral nutrition (by
way of catheters into the veins) are supplied in order to ensure sufficient intake of all
nutrients and thus maintenance of the bodys function.
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! Name the four non-calorific nutrient classes and explain their function for the
body!
! Explain the great importance of glucose!
! What function do triglycerides have?
! How many kcal of energy are respectively produced during metabolisation of
glucose, proteins and fat?
! Explain the process of gluconeogenesis, its purpose as well as the resulting
consequences in parenteral nutrition of severely injured patients!
! Explain the difference between essential and conditionally essential nutrients!
! What is to be understood by enteral and parenteral nutrition?
! On which factors does the human energy demand depend?
! What is the simplified formula to be applied for determining the energy demand in
enteral and parenteral nutrition?
! What consequences do acute infections and inflammations or severe injuries
have with regard to energy consumption?
! What individual components does a regimen for parenteral nutrition consist of?
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II
FUNDAMENTAL ELEMENTS
OF INFUSION THERAPY
The second section of these lecture notes will provide information about the
fundamental elements of infusion therapy. Let us look at the standard definition of
infusion:
Definition
Infusion (lat. Infundere, infusus):

The introduction of liquids into the body in a process that
circumvents the gastro-intestinal tract. Usually the liquid
is introduced into a vein (intravenous), less often an
artery, the subcutaneous adipose tissue (earlier
customary as a subcutaneous saline infusion)
Infusion thus means the introduction of liquid into the body venously, arterially or
subcutaneously. The medical indication determines which substances must be
administered to the body. Infusion therapy deals with the question: How can I bring
this substance/solution (optimally) into the body?
To answer this question, knowledge of various factors is required which are dealt with
in the section Infusion Therapy of these lecture notes.
To begin with, various infusion containers will be presented which have different
advantages and disadvantages depending on their respective characteristics. The
chapter dealing with infusion solutions then gives an overview of the treatment fields
in which infusion therapy is used and in the process indicates the most important
solutions for the different application fields. A chapter on infusion technology follows
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which systematically presents the different application possibilities. In the final

chapter, you receive information concerning the dosage of the infusion quantities and
learn about the function of the various kinds of infusion equipment which have a
considerable influence on the exactitude of the dosage.
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" Gain an overview of the various infusion containers
" Ability to cite the most important advantages and
disadvantages of the various infusion containers as well
as their areas of application
THE INFUSION
CONTAINERS
In the following chapter, the advantages and disadvantages of different infusion
containers are explained and the special features of the containers are identified.
Infusion containers may be distinguished on the basis of characteristics such as their
area of application, transparency, sturdiness, weight, sterility, user-friendliness,
environmental impact, etc.
6.1 The Glass Bottle

In earlier times, glass bottles were the standard container; today they are increasingly
being superseded by plastic containers or bags. On the basis of their advantages,
however, glass bottles are still the container of choice for special solutions and
applications.
The glass bottle features various advantages. It is:
# transparent - this criterion is particularly important for the detection of
particles (there are also coloured bottles for light-sensitive contents).
# gas-proof and chemically inert - i.e. it does not react chemically with the
contents and is thus suitable for all types of infusion solutions.
# always the same size and therefore it is easy to calculate quantities,
because the graduation does not shift as the bottle empties.
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The advantages of the glass bottle are, however, countered by various

disadvantages. The glass bottle:
$ is breakable.
$ has a considerable weight.
$ must be vented - this requires monitoring at the end of the infusion to
prevent a possible air embolism.
$ cannot support a pressure infusion using a pressure cuff.
$ has a piercing site which is not per se sterile and must therefore be
disinfected.
$ entails the risk of considerable particle contamination.
Note:
In the hospital, reuse of glass bottles is only possible

when they contain the same solution and when a certain
type of glass is used. Recycling can only be done via the
usual public possibilities (glass disposal).
6.2 Infusion bags

In Germany, infusion bags are not frequently used. In other countries, however, they
are widely used and in some areas they are the predominant infusion container. To
avoid perforations, a special bag piercing spike is necessary.
Low weight, low costs and a range of application advantages have made bags
popular particularly with standard solutions. Infusion bags feature the following
advantages:
# They are user-friendly, i.e. it is not possible for the infusion system and in
particular the drop chamber to run empty because the bag collapses and at
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the end of the infusion there is an automatic stop of the fluid column thus
making it a closed system which in turn makes an air embolism impossible.
# The infusion sets functions without venting.
# It is easy to mix the contents when admixtures are made.
# They are flexible (important for pressure infusions).
# They are transparent (important for detecting possible precipitations).
# They are easy to use for a pressure infusion.
6.2.1 BAGS MADE OF PVC

Bags also have considerable disadvantages, if made from PVC for example:
$ High particle contamination.
$ High content of plasticisers.
$ A high gas permeability - therefore not suitable for all solutions (danger of
oxidation). As storage time and temperature increase there is substantial
water evaporation.
$ There are environmental problems regarding the disposal of PVC.
Incineration, for example, produced hydrochloric acids.
$ Extreme absorption of many drugs.
6.2.2 ECOBAG C.E. AND ECOBAG I.V.

BAGS FROM B|BRAUN
The Ecobag consists of a composite film made of polyethylene (PE) and
polypropylene (PP). It has got three significant advantages:
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# It has a low particle contamination.

# The disposal of the Ecobag bags is environmentally harmless; waste
volume is small and in contrast to PVC-bags no hydrochloric acid and dioxins
are produced during incineration.
# The material does not adsorb drugs.
6.2.3 THE MIXING BAG (NUTRIMIX FROM B|BRAUN)

The mixing bag is used for preparing mixed infusions during total parenteral nutrition
(TPN). It has got the following advantages:
# Adjustment to the patient is possible: Nutrition solutions for a whole days
requirements (2 -3 l) can be prepared in this bag for the special needs of the
patient.
# Reduced work: The construction of large infusion regimens (administration
via numerous different containers) is not necessary.
# No incompatibility: The danger of an incompatibility during infusion does
not exist.
# Low particle contamination: Particle contamination in contrast to large
infusion regimens is kept to a minimum.
# Transparency: The bag body is fully transparent.
# Low level of contaminants: The entire bag is free from PVC and
plasticisers.
Note:
If lipid solutions are added, then the mixed solution

cannot be administered via an 0.2 m filter. A special
1.2 m lipid filter must be used.
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Nutriflex, Nutriflex Lipid from
B|BRAUN
These products are pre-filled (ready to use) mixing bags for parenteral nutrition
(PVC-free).
6.3 Plastic Bottles: Polyethylene Bottles

Particularly in Germany, plastic bottles are very widely used because they represent
a good combination of the advantages of the traditional glass bottle and the plastic
bag. The application fields are similar to those of plastic bags:
6.3.1 PLASCO
The Plasco is no longer produced by B|BRAUN. Because this product is still sold
by other companies, its advantages and disadvantages are presented here to assess
its fields of application.
Plasco has got the following advantages:
# Low particle contamination in contrast to glass bottles and PVC bags.
# Lower water evaporation in contrast to PVC bags.
# Low weight: Plasco is only half the weight of a glass bottle.
# Unbreakable.
# Environmentally harmless: Plasco does not contain any plasticisers and
is recyclable. Even when incinerated the only by-products are CO2 and H20.
The Plasco also has the following disadvantages:

$ Venting of the system is necessary for complete emptying (the bottle
collapses slowly).
$ Clouding: Plastic bottles have a slight clouding effect as a result of the
material.
$ Exact fluid balancing is not possible without venting and with a collapsed
bottle.
$ Larger amount of air in the container.
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6.3.2 ECOFLAC PLUS from B|BRAUN

The Ecoflac Plus has got the following advantages:
# Unbreakable.
# No venting necessary.
# Good handling, stable.
# Polyethylene is suitable for nearly all solutions.
# Low particle contamination.
# Space for the admixture of additional drugs.
# Low waste quantities, low weight.
# Recyclable.
A disadvantage is the low accuracy of the scale, making fluid balance difficult.
6.3.3 MINI-PLASCO
The B|BRAUN company has launched the Mini-Plasco as an alternative to injection
ampoules. In the sizes 5, 10 and 20 ml, they serve as a replacement for glass
ampoules and have got the following advantages:
# Free-standing.
# Even open containers that fall over do not run out
# Opening without filing, that means without splinters and the danger of
injury.
# Simple, problem-free disposal (see Plasco bottle)
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Note:
Glass bottles, plastic bottles, Ecobag as well as mixing

bags (NUTRIMIX) are all being used with normal infusion
sets (sharp, pointed and long piercing spikes). For the
use of other infusion bags and for blood transfusion bags
only the special bag infusion sets should be used
because of the danger of perforation (For information
about
infusion
sets,
see
Chapter 9).
6.4 Summary
Glass bottles, infusion bags and plastic bottles are available as infusion
containers. Infusion containers differ in regard to characteristics such as
transparency, robustness, weight, sterility, user-friendliness, environmental
characteristics, etc. Because of their different advantages and disadvantages, the
different infusion containers are suitable for different areas of application.
Glass bottles, plastic bottles, Ecobag ,mixing bags (NUTRIMIX) and ready-to-use
systems such as Nutriflex and NuTRIflex Lipid are used with normal infusion sets
(sharp, pointed and long piercing spikes). For the use of other infusion bags and for
blood transfusion bags only the special bag infusion sets should be used because of
the danger of perforation.

! In what ways are the various infusion containers different from each other?
! List some of the important advantages and disadvantages of glass bottles,
infusion bags and plastic bottles.
! What is to be observed when adding lipid solutions using in mixing bags?
! Which kinds of infusion sets are to be used with the different infusion containers?
! Why does venting of infusion containers play an important role?
! What effect does the choice of the container have on the choice of the infusion
set?
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Knowledge of the different fluid spaces in the body and
their respective interactions.
Comprehension of the decisive influence of the sodium
concentration on the distribution of the infusion solutions
to the fluid spaces
Knowledge of the most important infusion solutions and
their areas of application
Knowledge of the standard infusion filters
THE INFUSION SOLUTIONS

All substances which are supplied externally that shall have an effect inside the body
(i. e. not on the bodys surfaces) need to enter the blood circulation. Distribution from
there to other fluid spaces or absorption by body cells mainly depends on the
purpose the substance has got for the body. So, for example, oxygen enters blood
circulation via the membranes of the lung tissue and is distributed from there into the
body cells. Nutrients enter the blood circulation via the membranes of the intestine
and in most cases they are distributed from there into the cells. There are, however,
a few exceptions, such as the electrolyte ions sodium and chloride that are hardly
absorbed by the cells and therefore remain in the fluid outside the cells, the so-called
extracellular space.
Drugs that shall have an effect inside the body also need to enter the blood
circulation first. They enter the blood circulation via the membranes of the lung, the
intestine or possibly the mucous membrane. The way drugs enter the blood
circulation are not the same for all drugs.
Generally speaking, for intake of nutrients as well as of drugs, entrance into the blood
circulation takes place via the intestine. There are situations, however, where the
intestine does not function (e. g. after major surgery of the intestine) or may not be
used (e. g. preparation for surgery of the gastro-intestinal tract). Finally, there are
substances such as insulin, for example, where the blood circulation is generally not
entered via the intestine. In those cases the substance needs to be dissolved in
water or a fat emulsion and is supplied by injection into then skin (subcutaneously),
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into the muscles (intramuscularly) or into the veins (intravenously). All methods of
administration circumvent the intestine and are therefore termed parenteral
(Greek: for by-passing the intestine).
With regard to preparation it is to be distinguished between solutions/emulsions for
injection and solutions/emulsions for infusion. The amount to be administered is the
decisive criteria for classification
! Solutions/emulsions for injection:
100 ml
! Solutions/emulsions for infusion
100 ml
The criteria of distinction for 100 ml containers is the configuration of the piercing
spike of an infusion set which does not fit for an injection container (see chapter 9.1).
Usually injection is done by help of an injection needle or a syringe into the muscular
tissue, sometimes injection is done into the skin or into a vein. The duration of
application is relatively short (between a few seconds and several minutes).
In infusions administration is always done via a vein. Apart from acute situations an
infusion lasts for a period of hours. Certain cases may require patients to be infused
for days and even weeks. Containers that have run empty will then be replaced by
new ones. Thus, the purpose of an infusion is to supply substances and fluids in
large quantities and usually for a longer period of time.
This chapter deals with the most important types of infusion solutions/emulsions
including their areas of application. It provides the physiological principles (physical
and chemical processes) necessary to comprehend the composition of infusion
solutions.
Important
Infusion solutions are large-quantity preparations of

substances which are dissolved in water or lipid
emulsions being supplied via the veins.
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7.1
Fundamental Physiology of the Fluid Spaces
7.1.1 THE FLUID SPACES

Inside the body the cells are separated by membranes. The fluid space inside these
cells is called intracellular space. This space is characterised by an electrolyte
profile being rich in potassium, magnesium and phosphate while sodium, calcium
and chloride are hardly present.
All cells are surrounded by a fluid, the fluid space being called interstitial space. The
circulatory system is a further fluid space, called intravascular space partly being in
contact with the interstitial space via membranes. With regard to their electrolyte
profile the interstitial and the intravascular space are almost identical (see tab. 6).
Compared with the intravascular space the fluids in these two spaces are relatively
rich in sodium, calcium and chloride while the content of potassium, magnesium and
phosphate is relatively low. The total of interstitial and intravascular space is termed
Table 6: Concentration of selected electrolytes in different fluid spaces
Intracellular space
Extracellular space
Intersitial space
Sodium
Potassium
Calcium
Magnesium
Chloride
Phosphate
Important
Intravascular space
10 mmol/l
143 mmol/l
141 mmol/l
155 mmol/l
4 mmol/l
4 mmol/l
< 0.001 mmol/l
1.3 mmol/l
2.5 mmol/l
15 mmol/l
0.7 mmol/l
1 mmol/l
8 mmol/l
115 mmol/l
103 mmol/l
65 mmol/l
1 mmol/l
1 mmol/l
Sodium is the predominant cation in the extracellular fluid
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7.1.2
EXCHANGE PROCESSES BETWEEN THE FLUID

SPACES
There is a constant process of exchange between the above fluid spaces. This
entails surmounting of barriers since the degree of the membranes permeability is
not the same for all substances. Processes of exchange have to take place through
the membranes and there exists a large number of different possibilities.
The easiest method of exchange is the substances passing the pores of the
membrane without being hindered. The pores diameter is much larger than the
diameter of the substances they shall let pass. The pores of the membranes
surrounding the intravascular and the interstitial space are so large, that substances
such as electrolytes, amino acids and glucose may easily pass while large molecules
(so-called macro-molecules) such as plasma proteins hardly pass. Since plasma
proteins retain water, exchange of the above products may take place between the
interstitial and the intravascular space without the level of fluid in the intravascular
space being reduced.
Sometimes exchange processes take place via special channels that allow
transportation of only certain substances or even one substance only. A special
mechanism is able to recognise the substance(s) in question and ensures transport
through the membrane by activating energy. This kind of transport is responsible to
ensure, for example, that sodium that has entered the intracellular space be pumped
out. This entails passive flow of water at a quantity that the sodium concentration in
the extracellular space remains normal. In view to distribution of an infusion solution
to the intra and the extracellular space the sodium concentration is therefore the
decisive parameter. In case a solution has got a sodium concentration that
corresponds to the one in the extracellular space the fluid that has been administered
cannot reach the intracellular space and is therefore distributed into the intravascular
and the interstitial space according to their relative sizes.
Solutions, that shall make water available to the cells as well (intracellular) need to
have a sodium concentration that is considerably lower than the one of the
Important
The sodium concentration of an infusion solution is the

decisive factor with regard to distribution of the fluid
between the intra- and the extracellular space.
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Solutions that shall remain in the intravascular space (see below plasma volume
substitutes) need to have the same sodium concentration as it is the case in plasma
as well as a macro-molecular substance, that ensures that the fluid is kept in the
intravascular space.
Important
7.2
If an infusion solution shall remain in the intravascular

space its sodium concentration needs to be the same as
in plasma. Further more, a macro-molecular substance
must be contained.
Administration of Water, Sodium and Chloride
7.2.1 CRYSTALLOID SOLUTIONS

Surgery may entail severe losses of extracellular fluid (interstitial fluid and blood).
The loss of interstitial fluid may be compensated by solutions that have a similar
concentration of sodium and chloride as extracellular fluids. Blood losses may also
be compensated by these solutions provided the quantity of the loss is not too critical.
Solutions used for this purpose in clinical work are called crystalloid solutions.
Along with the right concentration of sodium and chloride their concentration of
potassium and calcium is the same as in extracellular fluids. Since extracellular fluid
does also contain bicarbonate which produces quite some problems when preparing
an infusion solution, admixture of this substance is dispensed with in any case.
Instead, some crystalloid solutions do contain acetate and lactate, which the body
may easily transform into bicarbonate.
Crystalloid solutions are rapidly excreted by the kidney and appear virtually
unchanged. Furthermore these solutions are suitable to be used for dissolution and
parenteral administration of drugs. Upon supply these solutions are rapidly
eliminated. They have therefore proven to be the solutions of choice for
administration of drugs. Table 7 summaries typical crystalloid solutions.
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Tab. 7: Some typical examples of full electrolyte solutions

Electrolyte concentration in mmol/l
Solution
Sodium
Potassium
Calcium
Chloride
Lactate
Ringers solution
147
2.3
155.5
Lactated Ringers
131
2.0
112
28
Normal
solution
154
154
saline
Important
The electrolyte profile of crystalloid solutions is very

similar to the one of plasma. They act as substitutes for
losses of extracellular fluid caused by surgical
interventions or trauma and as carrier solution for drugs.
7.2.2
HALF-STRENGTH ELECTROLYTE SOLUTIONS
An infusion solution that contains half the sodium concentration contained in plasma
is termed half-strength electrolyte solution. A part of the solution administered acts
to supply the cells with water. These solutions serve to ensure the patient to be
moderately supplied with the most important nutrients such as water and sodium in
case an oral intake is not possible or allowed for a short period of time (some few
days). A certain amount of potassium is frequently added to these solutions.
The electrolyte profile is exactly half the one being typical for full electrolyte solutions
and is therefore termed half-strength (half-strength Ringers solution, half-strenmgth
lactated Ringers solution and half-strength normal saline solution).
Important
Half-strength electrolyte solutions primarily serve to supply

the body with water and sodium. They may act as simple
basic solution if the necessary amount of potassium is
being added.
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7.2.3
REHYDRATION SOLUTIONS
Solutions that do only contain a quarter of the sodium concentration compared to full
electrolyte solutions are termed quarter electrolyte solutions or rehydration
solutions since they make a large amount of water available to the cells. These
solutions do neither contain potassium or calcium nor acetate or lactate.
The solutions are used in patients suffering from a fluid deficiency and unknown renal
function. If the patients kidneys work properly infusion of a sufficient quantity of those
solutions leads to the formation of urine. In case of improper renal function production
of urine is disturbed and the patient would not be able to tolerate large quantities of
sodium particularly well. The same is true for the administration of potassium and
calcium which might also entail severe problems for the patient.
Important
Rehydration solutions serve to supply large quantities of

water to patients with unknown renal function.
7.2.3.1 GLUCOSE 5 %
Pure water may make the red blood cells burst. So, if water shall be supplied
parenterally without sodium being added, a 5 % glucose solution should be given.
The addition of glucose prevents the undesired side effects of pure water.
Actually, the administration of water without adding sodium is an exception which
does only make sense in patients suffering from a renal impairment. In those patients
the quantity of sodium supplied cannot be compensated by excretion in urine thus
leading to an increase of sodium in blood with a great deal of problems involved.
Glucose 5 % is therefore often used together with other solutions, e.g. in order to
complete parenteral nutrition with regard to the total demand of water, or as carrier
solution for drugs.
Important
Glucose 5 % is used for the administration of water. It

further serves as carrier solution for drugs in injections or
infusions
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7.3 Administration of Further Electrolytes

A lack of external supply will soon result in a deficiency of water and sodium as well
as of potassium, magnesium, calcium and phosphate. If a patient is not supplied with
electrolytes for a period of a few days even life-threatening deficits my develop within
a very short period of time. Electrolyte concentrates are designed to be administered
in quantities covering the daily demand. They are added to other solutions and are
mainly used in parenteral nutrition.
Electrolyte concentrates, for example, are sodium chloride 5.85 % (1 molar),
potassium chloride 14.9 % (2 molar), potassium phosphate acc. to USP (United
States Pharmacopeia), magnesium sulphate 50 % (2 molar) and calcium gluconate
10 % (0.225 molar).
Important
Electrolyte concentrates serve to add electrolytes to

infusion solutions to be administered.
7.4 Partial and Total Parenteral Nutrition

To get through a short-term nutrient deficiency adult patients with good nutritional
status and normal metabolic activity do require the administration of water and
electrolytes in quantities that meet the daily demand as well as of about 100 150 g
of glucose per day. This quantity does not cover the daily demand, it suffices,
however, to reduce the degree of protein catabolism considerably (see chapter 5.1).
Among the typical solutions for partial parenteral nutrition are Sterofundin BG-5 and
Normofundin (see table 8). These solutions are also termed basic solutions, 2.5 3 l
of them covering the basic needs. Since the combination of calcium and phosphate
entails the precipitation of calcium phosphate the two substances must not be
contained in one and the same solution.
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Tab. 8
Constituents of typical basic solutions (Sterofundin BG-5 and

Normofundin G-5)
Sterofundin BG-5
Normofundin G-5
Sodium (mmol/l)
53,7
100,0
Potassium (mmol/l)
24,2
18,0
Calcium (mmol/l)
0,0
2,0
Magnesium (mmol/l)
2,5
3,0
Chloride (mmol/l)
53,5
90,0
Phosphate (mmol/l)
7,3
0,0
Acetate (mmol/l)
0,0
38,0
Lactate (mmol/l)
25,0
0,0
Glucose (g/l)
50,0
50,0
Important
Basic solutions serve to supply sufficient quantities of

water and electrolytes as well as a minimal quantity of
glucose in case a short-term nutrient deficiency shall be
got through.
In adult patients with bad nutritional status and/or strongly increased metabolic rate
parenteral nutrition should be started as early as possible. In this case all nutritive
substances should be contained in quantities that do cover the respective
requirements. This kind of parenteral nutrition is called total parenteral nutrition
(TPN). Among the nutritive substances used are amino acids (e, g. Aminoplasmal),
highly concentrated glucose solutions (> 20 %), fat emulsions such as Lipofundin
MCT/LCT, and electrolytes, vitamins and trace elements (Tracutil) in the form of
concentrates. The criteria that are decisive for the composition of the parenteral
nutrition regimen are subject of a one-week training course and are therefore not
treated in more detail now.
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7.5 Plasma Substitutes (Plasma Volume Replacement

Fluids)
A major deficiency of fluid in the circulation (so-called plasma volume) is hardly
tolerated and leads to shock and if not compensated - finally to organ failure and
death. Possible reasons for such a fluid deficiency in the circulation are blood looses
or an enlargement of the blood vessels (vasodilation). While in former times whole
blood had been supplied as substitute, nowadays much more caution is exercised in
view to the risks involved, particularly the risk of life-threatening infections that might
be transmitted. If blood losses amount to 30 40 % of the total blood volume it is
often sufficient to substitute the volume which has been lost intravascularly. The
solutions used for this purpose are formulated as full electrolyte solutions with a
macro-molecular substance. These solutions are termed plasma volume substitutes
or plasma volume replacement fluids, typical examples being Gelafundin 4 %
(abroad: Gelofusine) and Hemohes 6 % or 10 %. Plasma volume substitutes are
often supplied together with blood components or blood.
Important
Plasma volume substitutes serve to compensate for a loss

of plasma volume or to fill the additional plasma space in
case of a vasodilation
Trend
Due to the considerable risks involved in homologous blood transfusion the
concept of autologous blood transfusion (transfusion of the patients own stored
blood) is playing an increasingly important role. In advance of planned operations
the patients own blood is taken which is then being re-transfused during surgery.
In surgery blood may also be drawn and replaced with a plasma volume substitute
within certain limits. The patients blood is re-transfused during the operation.
7.6 Osmotic Diuretics

The kidney produces urine by filtering plasma water (blood without cells and plasma
proteins) off the functional units (nephrons). Along with the nutritive substances
dissolved in the plasma water this primary urine contains susbtances originating
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from the metabolic process which the body needs to eliminate. Filtering of plasma
water is followed by a process where water and nutritive substances are taken back
almost completely from the primary into the blood. Finally, the actual urine, the socalled secondary urine reaches the bladder.
In case, the primary urine contains a substance which is filtered off but cannot be
returned into the blood, this substance carries some of the water into the secondary
urine which results in an increase of the urinary volume. This is the case for
mannitol, for example. Upon infusion of mannitol solutions (e. g. Osmofundin 15 %)
the volume of urine is increased thus flooding out water and keeping the kidney
functioning.
Areas of application for mannitol solutions:
! Reduction of the intra-ocular and cerebral pressure (dehydration of the tissues is
the decisive aspect).
! Prevention of an acute renal insufficiency provided failure is only about to develop
and a certain critical stage has not yet been exceeded (keeping the kidney
functioning is the decisive aspect).
A further field of application is the forced diuresis (forced increase of urine
excrection) combining infusions of a mannitol solution with the administration of a
crystalloid solution. Since crystalloid solutions are excreted as urine rapidly and in
almost unchanged form, the urine volume may be significantly increased which helps
to flood water-soluble and glomerularly filtrated poisons out of the body.
Important
Mannitol solutions serve to flood out water. In combination

with crystalloid solutions they help to eliminate
glomerularly filtrated poisons.
7.7 Solutions Regulating the Acid-base Balance

The body produces large quantities of carbon dioxide. Acids and bases are supplied
by nutrient intake. While carbon dioxide is eliminated via the lungs the other acids
and bases are excreted via the kidneys ensuring that the pH of the extracellular fluid
is kept within limited bounds (7.35 7.45). Shifts of the pH outside these bounds are
life-threatening and need to be treated with regard to their cause. In case of lung and
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respiration being the cause, correction is made by ventilation, for example. If

metabolism is concerned the primary disease is to be treated. In the latter case an
acute shift of the pH is to be regulated by additional supply of either an acid or a
base.
While a metabolic acidosis (metabolism-induced reduction of the pH-level to < 7.35)
is treated by the administration of the base sodium bicarbonate a metabolic
alkalosis (metabolism-induced increase of the pH-level to > 7.45) is regulated by
supplying hydrochloric acid.
Important
Sodium bicarbonate serves to treat a metabolic acidosis

while hydrochloric acid is supplied in case of a metabolic
alkalosis.
7.8 Infusion Solutions and Filters

Infusion solutions and preparations may contain particles and germs. In order to
reduce any resulting risks involved for the patient two different types of infusion filters
are used:
! Particle filters
are often made of a synthetic wire-cloth screen with pores usually having a size of
5 m (m = micrometer = 1 (/1000 millimetre). This size corresponds to the diameter
of the smallest capillaries in the blood stream. Larger particles of firm components
such as glass, for example, would occlude these capillaries thus causing a micro
embolism. Filtration of infusion solutions using 5 m particle filters helps to prevent
this kind of complication, some bacteria, however, still being small enough to pass
these filters.
! Bacterial filters
Due to the smallness of bacteria it is required to use a 0.2 m filter to ensure their
proper retention. They are too large to pass it, however, after some time bacteria
tend to grow through such a filter. This is the reason why nowadays membrane filters
are usually used. Instead of a wire-cloth screen they have got a porous membrane,
the size of their largest pores corresponding to the nominal size. Since this
membrane is relatively thick, growth of bacteria takes place only very slowly. The
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membrane is able to filter much smaller particles. The size of the pores is too small to
be measured and is therefore validated, this means they are compared with
calibrated sizes. To do so, air is pressed through these pores. The moment of
passage is called bubble point. By comparing this value with standardised filters the
largest pore size can be determined. Since those pressures exceed by far the
pressures that are usually exerted these filters do also ensure reliable air venting.
Viruses cannot be retained by filters since they are even smaller and enter the body
using further pathways.
A further aspect to consider is the kind of fluid which is to be infused. Lipids or Lipidcontaining drugs cannot be supplied via bacteriatight filters, since lipid emulsions
contain small lipid droplets in a carrier solution. These droplets would immediately
obstruct 0.2 m. filters. It is therefore recommended to use so-called lipid filters which
have a pore size of 1.2 m.
A further problem are the so-called endotoxins which are fractions of the coat of a
certain type of bacteria, that develop as the bacterium is deactivated. These
endotoxins may cause reactions such as fever and even shock and therefore need to
be retained. Since their size is not exactly known retention cannot be done
mechanically but by way of an electrically charged filter membrane which attracts
these endotoxins and keeps them. Along with a pore size of 0.2 m these charged
filters ensure both, retention of bacteria and endotoxins.
Due to the absolutely different profile of blood a different type of filter is used for
transfusions.
For the administration of blood usually filters with a pore size of 200 m, i. e.
0.2 millimetres are being used. Such a pore size is adequate to retain major blood
clots which would obstruct the catheter or needle thus causing an interruption of
transfusion. Use of these filters does ensure prevention of microembolisms.
For more effectiveness micro filters with a pore size of 40, 20 and even 10 m may
be used. These filters are designed to retain significantly more and particularly
smaller clots, and even some of the larger blood cells. Since erythrocytes having a
diameter of about 7 m are by far the most important component in transfusion of
whole blood the smallest available filter has got a pore size of 10 m.
These very small pores tend to obstruct rather quickly, however, this means the
capacity of a filter (quantity of filtered blood) and its flow rate are considerably
reduced.
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A blood filter with an adequate pore size is to be used, depending on the area of
application, the quantity of blood to be transfused as well as the patients state of
health.
Important
Due to their very small pore size infusion filters are

absolutely unsuitable for the administration of blood.
7.9 Summary
Infusions serve the intravenous administration of large quantities of substances or
fluids, usually for a longer period of time. Basic physiological interrelations need to be
observed such as the concentration of electrolytes in the different fluid spaces of the
body or the interchange between these fluid spaces. Sodium plays a particular role
with regard to distribution of the fluid supplied between the intracellular- and
The administration of water, sodium and chloride is of major importance in infusion
therapy. A solution which has got an electrolyte composition similar to the one in
plasma is termed crystalloid solution. It is indicated as substitute for the loss of
extracellular fluid and as carrier solution for drugs. Half-strength electrolyte solutions
do only contain 50 % of the sodium concentration contained in plasma. Above all
they serve the administration of water and sodium. If water is to be made available to
the cells (e. g. in patients suffering from a fluid deficiency and unknown renal
function) rehydration solutions are to be used. They have got a quarter of the sodium
concentration contained in plasma and do neither contain potassium nor calcium. If
water shall be supplied parenterally without the simultaneous administration of
sodium 5 % glucose is the solution of choice. While pure water can make the red
blood cells burst this is prevented by the addition of glucose. In fact, glucose 5 %
serves the administration of water and is also used as carrier solution for the injection
of drugs. Along with the administration of water and sodium electrolyte concentrates
need to be supplied in case of a several days lasting lack of external supply.
Short-term nutrient deficiency may be compensated by supplying water, electrolytes
and glucose in quantities that cover the actual demand. This partial parenteral
nutrition makes use of so-called basic solutions. If the patient is suffering from a bad
nutritional state and/or a considerably increased metabolic rate a total parenteral
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nutrition (TPN) is required supplying all nutrients in quantities that cover the actual
demand.
Volume substitutes represent a further group of infusion solution serving the
compensation of a plasma deficiency. In case of blood losses amounting to 30 40%
of the total blood volume solutions are given, their composition being the same as in
crystalloid solutions with a macromolecular substance. In order to prevent the risk
involved in homologous blood transfusion, autologous transfusion i. e. transfusion of
the patients own stored blood is more and more considered to be the method of
choice.
For flooding out water mannitol solutions are supplied since they serve the increase
of the quantity of urine and keep the kidney function. If supplied along with full
electrolyte solutions the elimination of glomerularly filtrated poisons is achieved..
Shifts of the pH are regulated by treating the actual cause. It is supported by
additional supply of an acid or a base. Metabolic acidosis, i. e. a metabolism-induced
decrease of the pH is treated by supplying sodium bicarbonate while in case of a
metabolic alkalosis, i. e. a metabolism-induced increase of the pH-value, hydrochloric
acid is given.
When administering infusion solutions different types of filters are used which serve
to prevent damage to the patient caused by particles and germs. There are two
different types of filters, particle filters and bacterial filters. Furthermore, lipid filters
are used for the filtration of lipids while invasion of endotoxins is prevented by using
electrically charged filter membranes.
Due to their small pore size infusion filters are not suitable to be used for blood
transfusion. There is a number of blood filters with different pore sizes available.
Depending on the quantity of blood to be transfused and the patients state of health
pore sizes between 10 and 200 m may be chosen.

! What is the meaning of parenteral?
! What is the decisive difference between injection solution/emulsion and infusion
solution/emulsion?
! Please define the term infusion solution!
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! Intra cellular and extra cellular space are distinguished with regard to the
concentration of electrolytes. Please give the main differences!
! What is the decisive parameter regarding distribution of an infusion solution
between intracellular and extracellular space?
! What substances need to be contained in infusion solutions in order to provide
water to the cells (intra cellular)?
! Please describe situations where the use of crystalloid solutions is indicated!
! Which fluid does the electrolyte composition of a crystalloid solution correspond
to?
! Name some typical crystalloid solutions?
! What function do half-strength electrolyte solutions have?
! Describe the electrolyte concentration of rehydration solutions!
! Please name the fields of indication for the use of rehydration solutions!
! What purpose does glucose 5 % serve?
! What function do electrolyte concentrates have?
! Please describe the indication for the infusion of basic solutions!
! Please name some typical plasma volume substitutes!
! What purpose do plasma volume substitutes serve?
! What is to be understood by autologous transfusion?
! Please describe the reaction triggered off by the infusion of mannitol solutions?
! Please name the areas of application for mannitol solutions!
! What substances are to be used for treating a metabolic acidosis and alkalosis?
! What diameter do the following filters have? Particle filter, bacterial filter, lipid
filter, standard blood filter and microfilter?
! What is to be observed when using blood filters?
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Gain an overview of the various infuson access points
and their areas of application
Knowledge of the criteria for the respective venous
access
Be familiar with the infusion solutions used in connection
with venous access
Knowledge of the risks associated with the various sites
of infusion access
APPLICATION
POSSIBILITIES
The chapter Application Possibilities identifies different possibilities of infusion
access. A basic distinction is made here between venous, arterial and subcutaneous
infusion.
8.1
Venous Access
Via a cannula or a catheter the desired agents are infused directly into the vein and
very quickly (dilution) conducted to the heart. From there, they are evenly distributed
throughout the entire body (systemic effect).
A distinction is made with venous access between peripheral venous access and
central venous catheter accesses.
8.1.1 PERIPHERAL VENOUS ACCESS

Using a cannula, the veins of the lower arm (from the elbow downwards) and the
back of the hand as well as the veins of the top of the foot (in exceptional cases) are
punctured. This puncture is performed with:
! stiff cannulas (Venofix): Only for short infusions and one-time administrations
(ca 20 - 100 ml, e.g. antibiotics, asthma drugs) or
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! flexible I.V. cannulas (Braunula, Vasofix, Introcan) for repeated

infusions, larger fluid quantities or also blood transfusions.
Solutions which can be infused over a peripheral venous access are, for example:
! Glucose 5%, 280 mOsmol/l
! Crystalloid solutions 300 -320 mOsmol/l
! Sodium chloride solution 0.9%, 310 mOsmol/l
! Lipid emulsions 10%, 300 - 380 mOsmol/l
! Glucose 10%, 555 mOsmol/l
! Mixed solutions for parenteral nutrition of about 570 - max 900 mOsmol/l
(depending on the length of the infusion therapy and the state of the patient).
Important
Only isoosmolar and slightly hyperosmolar solutions

should be infused via a peripheral access. Highly hyperosmolar solutions can damage and even destroy the veins.
8.1.2 CENTRAL VENOUS CATHETER ACCESS

The veins which are solidly fixed in the tissue of the chest and neck area known as
central veins.
In a state of shock, the peripheral veins collapse so that only a central access is
possible. If even this form of access is not possible then a vena sectio must be
performed (operative opening and cannulation of the vein).
The tip of all of these catheters is located in the superior vena cava. Because of the
high rate of blood flow there, the greatest dilution effect is achieved.
Solutions which must be infused with a central venous access are, for example:
! Mixed and combination solutions for parenteral nutrition of ca. >1 000 (m Osmol)
! Aggressive drugs (Note: pH > 9), e.g. cytostatic agents, some antibiotics.
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Detailed information is provided in the script Background Information on

Venipuncture.
8.2
Arterial Access
In arterial infusion or injection, the agents are administered in a specific artery with a
defined distribution area (regional effect). The agents reach this area in a relatively
undiluted form and come to other regions of the body in a highly diluted form only
after passing through the capillary bed and the veins.
Attention should be paid to the following factors:
! The pressure in the arteries allows infusions only to be made by way of
pressure infusion or an infusion pump.
! There is a risk of arterial spasms, which are difficult to subdue and result in a
suspension of the supply of blood and/or necrosis (devitalisation of the affected
tissue area).
! The development of an aneurysm (arterial dilation) following puncture of an artery
has been frequently observed in patients suffering from arteriosclerosis
(calcification of the arteries) and should be mentioned as a possible risk.
Important
Arterial infusion is performed relatively rare. Possible

indications include measures to stimulate blood flow in the
periphery or local chemotherapy.
8.3 Subcutaneous Infusion

Subcutaneous infusions make use of the slow diffusion of agents from the interstitial
space into the vascular system to achieve a long-term effect (depot effect).
In exceptional cases infusions are made in the areas between the cells (interstitial
space) e. g. if small fluid amounts are involved and if there is no puncturable vein
available (as with infants and geriatrics). In those cases the subcutaneous adipose
tissue in the abdomen or thigh is used for puncture.
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Important
Solutions which are supplied subcutaneously must be

histocompatible
8.4 Summary
Among the different methods of applying an infusion distinction is made between
venous, arterial and subcutaneous access.
With venous infusion, the desired agents are infused directly into the vein by means
of a cannula or catheter and conducted very quickly to the heart. From the heart they
are evenly distributed throughout the whole body. Talking of venous access a
distinction is made between peripheral venous access and central venous catheter
access. Only isoosmolar and slightly hyperosmolar solutions should be infused
peripherally because highly hyperosmolar solutions can damage or destroy the veins.
In a state of shock, the peripheral veins collapse so that only a central access is
possible. Central veins are those which are solidly fixed in the tissue of the chest and
neck region.
In arterial infusion or injection, agents are administered into a specific artery with a
defined distribution area. The agents reach this area in a relatively undiluted form
and reach other regions of the body in a highly diluted form only after passing
through the capillary bed and the veins. It should be noted that pressure in the
arteries allows infusions to be made by way of pressure infusion or an infusion pump
only.
Subcutaneous infusions make use of the slow diffusion of agents from the interstitial
space into the vascular system to achieve a long-term effect. In exceptional cases
infusions are made in the areas between the cells (interstitial space) e. g. when small
fluid amounts are involved and there is no puncturable vein available. Solutions
which are given subcutaneously must be histocompatible.
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! Describe the process of puncture using a peripheral venous access and a central
venous catheter access.
! Which infusion solutions can/must be infused peripherally or centrally?
! Describe the course of arterial and subcutaneous infusion.
! What is to be considered when an arterial infusion is performed?
! What is to be considered when a subcutaneous infusion is performed?
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Knowledge of the factors that affect the flow of an

infusion
Gain an overview of the way of function of the various
infusion techniques
Knowledge of the indication and dosage exactitude of
the various infusion techniques
Comprehension of the effects which the individual
technical approaches have got for the user
DOSAGE OF INFUSIONS
This chapter starts describing the factors which determine the necessity of exact
dosage as well as those which affect the flow of the infusion. In the following the
various infusion techniques are treated gravity infusion, pressure infusion as well as
various kinds of infusion equipment and information about their function and their
areas of application are provided.
9.1 General Considerations

Venous or arterial application of a liquid into the circulatory system always requires a
more or less exact dosage. The infusion technique employed determines the
accuracy of the dosage. The required dosage accuracy is generally dependent on
the patients status as well as on the type and amount of fluid to be infused, the
infusion equipment used and the surrounding conditions.
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The flow of the infusion is affected by a range of factors:

! Resistance in the channel of the piercing spike
! Resistance in the tubing and in the connector pieces
! Speed of drop formation
! Constancy of the delivery pressure
! Physical and chemical characteristics of the solution
! Surrounding conditions
Over the years, a standardised infusion set (DIN 58362 and following) has been
developed (see Illustration 9). It consists of the following elements.
! Piercing spike: Depending on the type of container to be used with, the piercing
spike is sharp (for rubber stoppers) or rounded and blunt (for bag insertion sites).
It contains one channel for fluid and optionally a second channel for venting.
! Vent (usually present): Upon opening of a cap or stopper air flows into the
container. The vent usually is equipped with a bacterial filter.
! Drop chamber: A drop generator is located at the top of the drop chamber,
which produces drops of a certain size. The chamber is partially filled with liquid
in order to prevent air bubbles from entering the tubing. A particle filter is often
located at the bottom outlet of the chamber.
! Connection tubing: Usually 150 cm long and made of PVC; for special
applications also available in other lengths and materials.
! Roller clamp: Regulates the flow rate of infusion by controlled compression of
the tubing.
! Luer fitting: The Luer fitting guarantees a secure connection to all other
products by means of the standardised Luer cone. In the lock version the lock
connection is further secured against jerks and pressure by means of a screw
thread.
! Protective cap on the spike: This prevents damage to the packaging and thus
loss of sterility. Sets where caps have fallen off must not be used because of this
risk.
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Piercing spike
Venting
Drop chamber
Roller clamp
Luer fitting
Figure 9: Standardised infusion set
9.2 Gravity Infusion

The technique most frequently used more than 80 percent of all infusions
performed is the gravity infusion. The accuracy of the dosage and the infusion rate
requirements are low for this type of infusion (+50%). The volume supply is
dependent on the hydrostatic pressure differential between the patient and the
infusion bottle. The rate of fluid supply can only be accelerated through compression
of the container or through raising the internal pressure.
Components used for this type of infusion are: infusion container (bottle, bag),
infusion or giving set (drop chamber and infusion tubing) as well as the roller clamp.
The rate of the infusion is mainly regulated by means of the roller clamp. The roller
clamp is positioned on the infusion tubing of the infusion set in such a way that the
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lumen of the infusion tubing is compressed from outside. Over time the tubing
material gives way to the pressure and the diameter of the tubing lumen decreases
resulting in a corresponding decrease of the flow rate (see fig. 10). After a few
minutes the roller clamp must be readjusted to achieve the originally set rate of
infusion.
Figure 10: Roller clamp in longitudinal section together with enlarged details showing
a cross section view at the point of the roller. As time passes, the tubing material
gives way to the pressure, decreasing the diameter of the tubing lumen and the rate
of flow.
Important
With gravity infusion, the infusion volume is calculated on

the basis of the number of drops per minute. Standard
infusion sets are designed in a way that 20 drops equal
1 ml. With the so-called micro-droppers (e.g. Dosifix B|BRAUN) 60 drops equal 1 ml.
Tubing-independent flow regulator

This unit replaces the traditional roller clamp. The flow rate is controlled by
varying the size of the flow channel. Shifts in the selected drop rate resulting from
changes in the tubing are ruled out. Possible settings range from 3 - 200 ml/hour.
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These units are used for infusion solutions which are carrier solutions for drugs
that need to be administered as constantly as possible.
Product: Exadrop (see fig. 11)
Figure 11: Exadrop - B|BRAUN. The flow rate is controlled by varying the
size of the flow channel in the flow regulator.
Drops/min
Roller clamp
Figure 12: Comparison of the accuracy of a roller clamp and Exadrop B|BRAUN. While the number of drops per minute reduces considerably with
the roller clamp, it remains relatively constant with Exadrop
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Note
Changes which are not due to the tubing, e. g. changes of

the infusion height, patient activities etc. are not affected
by the flow regulator.
9.3 Pressure Infusion

When using infusion or transfusion bags, a pressure infusion may be performed. For
this purpose a pressure cuff is used which is pumped up with an inflation bulb (as
with a blood pressure measurement instrument), thus exerting pressure on the
container. A pressure of up to a maximum of 300 mm Hg can be exerted.
9.4 Infusion Equipment

Additional infusion equipment is required when the dosage accuracy should be
increased, the rate of infusion should be raised or when a constant rate of delivery
during long-term infusions should be achieved. The infusion equipment used should
meet certain requirements if the medical and nursing measures are not to pose
additional risks for the patient.
The following criteria, established by the Berlin Technical Hospital Service Center,
should be fulfilled:
! Requirement-based infusion rate
! Sufficiently exact dosage
! Good sturdiness
! Quick functional readiness
! Simple and safe operation
! Alarm and interruption of infusion in the event of danger (a must requirement)
! Mains-independent operation
! Easy cleaning
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In accordance with the various tasks to be performed, the required infusion rates
extend over a wide range. Rates vary from 1 ml per hour (e.g. keeping open a central
venous catheter, infusion for infants) and > 1,000 ml per hour (e.g. forced diuresis,
shock therapy) for adult patients. This kind of equipment is therefore mainly unsed in
intensive care medicine (since high costs are associated with it).
9.4.1 TYPES OF INFUSION EQUIPMENT

In equipment-supported infusion techniques, distinctions are made between:
! Infusion regulators
! Infusion pumps (e.g. Infusomat fmS/P - B|BRAUN) and
! Syringe pumps (Perfusor fm/compact
B|BRAUN)
INFUSION REGULATORS
Infusion regulators are electronic medical devices which do not have their own
delivery drive. They regulate and monitor the supply of fluid in the flow process.
Simply stated, they are mechanised roller clamps. The dosage accuracy is often
sufficient for everyday clinical purposes and ranges between +10 and 20 percent.
INFUSION PUMPS
In contrast to the regulators, infusion pumps have their own delivery drive. Depending
on the type of drive, it is to be distinguishes between roller pumps (fig. 13), peristaltic
pumps (fig. 14) and piston pumps. Control of infusion pumps can either be dropbased or volume-based. Pumps are comprised of a delivery drive, the control or
regulating system and the infusion set. The dosage mainly depends on how the
pump is regulated.
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Figure 13: Delivery principle of a roller pump. The rollers bring a set amount of fluid
into the tubing which is then transported by help of rotation in the flow direction
Figure 14: Delivery principle of a peristaltic pump (from MOTZKOW et al.) The
successive compression of the tubing by the individual fingers, makes the fluid be
advanced forward.
Drop-regulated infusion pumps

The dosage exactitude of these pumps relates to the number of drops (per
minute) and depends on the volume of the drops. The drop exactitude is
subject to several important conditions such as the viscosity of a solution, the
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solutions surface tension and the kind of flow behaviour (speed of flow)
resulting from these factors. Dosage accuracy is +10 percent.
Volumetric infusion pumps

With these pumps the dosage accuracy corresponds to the volume that is
delivered. The special sets with calibrated precision tubing required for these
pumps give a delivery accuracy of ca. +5 percent.
SYRINGE PUMPS
These are pressure infusion devices which supply the content of one or more
syringes simultaneously by means of a precision linear drive.
The dosage accuracy (see above) with these pumps is +2 percent since a precise
syringe volume is delivered through these pumps and all the error sources involved in
drop regulation do not apply. This form of infusion is particularly suited for an exact
administration of drugs with a dosage rate of 0.1 to 200 ml per hour. Special syringes
of 10, 20 and 50/60 ml are commercially available
0 0 0.0
4
1
5
2
6
3
Perfusorfm
Figure 15: Syringe pump. A defined syringe volume is administered over a specified
period of time by help of the action of a motorised drive.
Because infusion pumps work with a maximum pressure of 1 bar, all tubings
connected with such pumps need to be pressure resistant for safety reasons.
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Note
Exact functioning of infusion pumps is only ensured when

appropriate tubings or syringes are used.
The connection of an infusion pump with a gravity infusion
(so-called parallel infusion) involves a number of risks and
therefore requires particular controls and/or special safety
equipment.
9.5 Summary
The degree of accuracy a dosage must have depends on the status of the patient,
the solution to be infused and other factors. The degree of accuracy a dosage can
have is determined by the kind of infusion technique that is employed. With regard to
these techniques, distinctions are made between gravity infusion, pressure infusion
and the use of infusion equipment.
Gravity infusion (as the most frequent infusion technique) entails the disadvantage of
a low dosage accuracy. The volume supply depends on the hydrostatic pressure
differential between the patient and the infusion container. The rate of infusion is
mainly regulated by help of a roller clamp (declining number of drops as time passes)
or a tubing-independent flow regulator (relatively constant number of drops over
time).
When infusion or transfusion bags are used it is possible to perform a pressure
infusion.
Additional infusion equipment is required when the dosage accuracy should be
increased, the rate of infusion should be raised or when a constant rate of delivery
during long-term infusions should be achieved. In equipment-supported infusion
techniques, distinctions are made between infusion regulators (electronic medical
devices without an own delivery drive), infusion pumps and syringe pumps. In
contrast to the regulators, infusion pumps have their own delivery drives. Depending
on the type of drive, there is a distinction between roller pumps, peristaltic pumps and
plunger pumps. The accuracy of the dosage mainly depends on how the pumps are
regulated. Syringe pumps are pressure infusion devices which administer the content
of one or more syringes simultaneously using a precision linear drive. This form of
infusion is particularly suited for an exact administration of drugs.
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! Which factors indicate the necessity of the dosage accuracy?
! Which factors affect the flow of infusion?
! What is the dosage accuracy of the various infusion techniques?
! What are the typical sizes of drops?
! Which criteria must be met by infusion equipment?
! Name the different kinds of equipment-supported infusion techniques! What
functioning principles are they based upon?
! Explain the functional principle of a syringe pump.
! What must be kept in mind when using infusion pumps?
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10
PROSPECTS
The Current Situation
Infusions can be performed using very different technical devices for completely
different reasons. The physician or nurse will choose certain products taking into
account the patients state, the type and amount of solutions to be infused and also
the costs involved, the time required and the nursing aspects involved.
It is the task of the medical and pharmaceutical sales representative to present an
optimal therapy plan worked out on the basis of well-founded knowledge regarding
the advantages and disadvantages of the individual components. In addition, the
sales representative is expected to help the user avoid mistakes and ignorance by
providing relevant information regarding the risks and handling particulars of the
various products. To this end, comprehensive knowledge of anatomical and
physiological details is just as important as familiarity with the various technical
options, which are often offered by many manufacturers in nearly identical forms.
The Future
Ever greater technological progress in particular in electronic data processing will
be the basis for entirely new concepts of data management in intensive care therapy
and will also be used to manage the flood of measurement values and settings. The
operation of increasingly complex monitoring and therapy devices will place
increasing demands on nursing personnel as do cost pressure and time shortage. To
make it possible to operate this high-technology, new developments will be more and
more simple and safe to operate. The people operating the equipment will, however,
have ever greater and higher information needs.
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A Suggestion
Following the Fundamentals of Infusion Therapy, it makes good sense to work
through the lecture notes Background Information on Venipuncture, since all the
forms of infusion are always associated with the appropriate venous accesses. The
various ways and technical methods of providing safe venous access are the main
subject of these notes.
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GLOSSARY: EXPLANATION OF TECHNICAL TERMS

Albumin
Protein in the blood which binds the water in the vascular

space.
Alkalosis
An abnormal condition of increased alkalinity of the blood, e.g.

when acidic secretions are lost (vomiting).
Alkalinity
Excess of bases in a solution.
Amino acids
Protein components
Antibody titre
Antibody content of a solution (antibodies are substances

formed in the blood which protect the body against certain
diseases).
Atom
Basic component of the elements.
Acidity
Acid content of a solution.
Acidosis
Abnormal overly acidic condition of the blood.
Bicarbonate
Monobasic salt of carbonic acid. As a substance occurring in

the blood it binds hydrogen ions (H+) and thus prevents overly
acidic conditions (acidosis). In the event of disorders, it is
artificially added through infusion (buffer substance).
Blood plasma
Blood without cell components.
Buffer substance
Substance which can take on or give off hydrogen ions and

thus can neutralise disturbances in the acid-base balance.
Calorie
The amount of heat which warms 1 g water from 14.5 to

15.5 C.
Catabolism
Metabolism of breakdown of energy stores and protein.
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Carbon dioxide
Gas which is produced during metabolism of the cells and is

expired via the lungs. In pulmonary dysfunction its
accumulation in the blood results in so-called acidosis.
Colloids
Substances which are present in a solution in a very fine,

microscopically indiscernible distribution but which are not in
fact dissolved molecularly (protein, dextran).
Colloidal solution
Solution of colloids with high water-binding properties used for

plasma volume replacement.
Colloid-osmotic
Pressure exerted by colloids with high water-binding

properties on a membrane which they cannot pass through.
Compatibility
Tolerance
Dextran
High molecular sugar formed from glucose molecules which is

used in solutions for plasma volume replacement.
Diffusion
Gradual self-acting mixing of gaseous, fluid or solid

substances which are in contact with one another until
complete homogeneity.
Electrolyte
Substance which conducts electrical current in a solution, e.g.

acids, bases, salts. Opposite: Non-electrolyte, e.g. sugar.
Enteral
Through the gastrointestinal tract.
Ester
Bonding of alcohols and acids.
Extracellular
Outside of the cells.
Glycogen
Storage form of sugar in the body (liver, muscles).
Glycerine
Trivalent, syrup-like alcohol.
Homeostasis
Maintenance of stability in certain body functions such as

metabolism, temperature, blood pressure, etc. in the face of
diverse influences through regulation mechanisms.
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Hyper
Increased.
Hypo
Decreased.
Insufficiency
Inadequate performance.
Interstitial space Intercellular tissue.

Intracellular
Within the cells.
Incompatible
Intolerance.
Ions
Atoms or atom groups with positive (+ cation) or negative

(- anion) electrical charge.
Isotonic
Solution with the same number of osmotically active particles as

a comparable solution, e.g. blood (haemoisotonic).
Lactate
Salt of lactic acid, metabolic product of cells which accumulates

in the blood in the event of circulatory failure and results in socalled lactic acidosis.
Mannitol
Sugar alcohol.
Membrane
Soft skin; medical: Porous partition, separating surface between

cells and the surrounding.
Molecule
The smallest unit of a chemical bond. They consist of atoms of

the same or varying sorts.
Molecular weight Weight of a molecule. Indicates the size of the molecule which
influences the passage of molecules through membranes.
Oedema
Accumulation of aqueous fluid in the interstitial space.
Oncotic pressure See colloid-osmotic pressure.
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Osmosis
Equalisation of concentration through a porous partition

(membrane) between solutions of different concentrations.
Osmotic pressure
Osmotic pressure develops with the use of semipermeable

membranes because such membranes only allow the solvent
but not the dissolved substance to pass through, so that this
substance then creates pressure on the membrane.
Osmolarity
(Combination of osmosis and molecule) Concentration of all

of the osmotically active molecules in a solution expressed in
volume units.
Osmotic therapy and The infusion of a highly concentrated sugar solution

osmotic diruesis
(so as to increase the osmotic pressure of the blood) forces
the influx of tissue water into the blood (eliminating oedemas)
and thereby also increasing urinary excretion.
Parenteral
Circumventing of the gastrointestinal tract.
Phagocytosis
Engulfing and destruction of particulate matter by

phagocytes.
pH
Measure for the content of hydrogen ions (H+) in a solution

(values 0 - 14). This determines whether a solution reacts
acidically (higher content of H+ ions, values 0 - 7) or basically
(lower content of H+ ions, values 7 - 14).
Plasma expander
Plasma volume replacement solution which in addition to the

administered volume also brings fluid from the intercellular
tissue into the blood stream.
Proteins
Combinations of amino acids.
Rest-N
Total amount of non-protein nitrogen in the blood serum that

remains after complete precipitation of the protein from the
serum. The Rest-N mainly consists of metabolic waste
products usually excreted with the urine.
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Semipermeable
Partially permeable, e.g. with membranes that means they

are permeable for the solvent but not for the dissolved
substance.
Serum
Blood plasma after removal of the fibrin.
Sorbitol
Sugar alcohol.
Thrombophlebitis
Irritation of the inner walls of veins.
Viscosity
Thickness of a fluid.
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TABLE OF CONTENTS
INTRODUCTION
I BIOLOGICAL BACKGROUND INFORMATION ON INFUSION THERAPY
1
The Cell
1.1 General Cyto-Architecture
1.2 Important Cell Structures
1.3 Summary
The Blood
2.1 Tasks of the Blood
2.2 Composition of the Blood
2.2.1 Structured Components
2.2.2 Blood Plasma
2.3 Blood Clotting
2.4 Summary
The Cardiovascular System

3.1 The Heart
3.2 The Vessels
3.3 Summary
Water and Electrolyte Metabolism

4.1 Water (H2O)
4.2 Salts
4.3 Osmosis
4.3.1 The Osmotic Pressure
4.3.2 The Colloid-osmotic or Oncotic Pressure
4.4 pH-Regulation
4.5 Hormonal Regulation
4.6 Water Metabolism in Healthy Persons
4.6.1 Fluid Intake
4.6.2 Fluid Excretion
4.6.3 Fluid Shifts in the Gastrointestinal Tract
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4.7 Summary
5
Nutrition of the Body

5.1 Nutrient Groups
5.2 Essential and Conditionally Essential Nutrients
5.3 Human Energy Requirements
5.4 Energy Requirements in Case of Disease
5.5 Enteral and Parenteral Nutrition
5.6 Summary
5.7 Comprehension questions
II
FUNDAMENTAL ELEMENTS OF INFUSION THERAPY
The Infusion Container

6.1 The Glass Bottle
6.2 Infusion Bags
6.2.1 Bags Made of PVC
6.2.2 Ecobag C.E. and Ecobag I.V. - Bags from B|BRAUN
6.2.3 The Mixing Bag (NUTRIMIX from B|BRAUN)
6.3 Plastic Bottles: Polyethylene Bottles
6.3.1 Plasco
6.3.2 Ecoflac plus, B|BRAUN
6.3.3 Mini-Plasco
6.4 Summary
The Infusion Solutions

7.1 Fundamental Physiology of the Fluid Spaces
7.1.1 The Fluid Spaces
7.1.2 Exchange Process Between the Fluid Spaces
7.2 Administration of Water, Sodium and Chloride
7.2.1 Crystalloid Solutions
7.2.2 Half-strength Electrolyte Solutions
7.2.3 Rehydration Solutions
7.2.3.1
Glucose 5 %
7.3 Administration of Further Electrolytes
7.4 Partial and Total Parenteral Nutrition
7.5 Plasma Substitutes (Plasma Volume Replacement Fluids)
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7.6 Osmotic Diuretics

7.7 Solutions Regulating the Acid-base Balance
7.8 Infusion Solutions and Filters
7.9 Summary
Application Possibilities
8.1 Venous Access
8.1.1 Peripheral Venous Access
8.1.2 Central Venous Catheter Access
8.2 Arterial Access
8.3 Subcutaneous Infusion
8.4 Summary
Dosing of Infusion Quantities

9.1 General Considerations
9.2 Gravity Infusion
9.3 Pressure Infusion
9.4 Infusion Equipment
9.4.1 Types of Infusion Equipment
9.5 Summary
10 Prospects
GLOSSARY: Explanation of Technical Terms
93

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B|BRAUN

Dr. Rolf Franke

in physiological and pharmacological trials as well as for therapeutic purposes,

INFUSION THERAPY TODAY

PURPOSE OF THE LECTURE NOTES

STRUCTURE OF THE LECTURE NOTES

1.1 General Cellular Structure

There are also cells without a nucleus, the erythrocytes (red

Fig. 1: The cell

1.2 Important Cellular Structures

The cell body

The cell membrane

Nucleus (or karyosome)

The nuclear membrane

The nuclear reticulum

Karyolymph (nuclear sap)

The cytological organelles

Golgis apparatus (Dalton complex)

1.4 Comprehension Questions

2.1 Functions of the Blood

! Protective and defence functions against invading micro-organisms.

Figure 2: Blood Composition

2.2.1 STRUCTURED COMPONENTS

Erythrocytes: (red cells)

Leukocytes (also called white blood cells)

2.2.2 BLOOD PLASMA

The electrolyte concentration in blood corresponds approx.

The Blood Coagulation

The blood has a number of important functions: transport of oxygen, maintenance of

2.5 Comprehension Questions

Description of the cardiovascular system

Fig. 3: The cardiovascular system

3.1 The heart

3.2 The vessels

3.4 Comprehension Questions

4.1 Water (H2O)

Intracellular Space (ICS)

Extracellular space (ECS)

Total body fluid

Intracellular space (ICS)

Extracellular space (ECS)

The fluid spaces are separated from one another both

Table 2: Cations and Anions

Positively charged ions

Negatively charged ions

4.3.1 OSMOTIC PRESSURE

300 mOsm/l = isoosmotic

4.3.2 COLLOID-OSMOTIC OR ONCOTIC PRESSURE

Figure 6: Acid-Base Balance

4.5 Hormonal Regulation

4.6 The Water Balance in a Healthy Person

Figure 7: The average adult water intake and output.

4.6.1 INTAKE OF FLUID

4.6.2 REMOVAL OF FLUID

4.6.3 SHIFTS IN GASTROINTESTINAL FLUID BALANCE

Saliva (1500 ml)

Gall (500 ml)

4.8 Comprehension Questions

NUTRITION OF THE BODY

5.1 Nutrient Groups

Calorific nutrients are proteins, carbohydrates and lipids:

Proteins are the functional mass of the body. All bodily

Gluconeogenesis is the production of glucose serving to

! By carbohydrates we understand a group of substances consisting of different