Emergency Medicine/Blood and Fluids

      Fluid & Blood Resuscitation

      Topics

      • Available IV Fluids ==
      • Blood products ==
      • Fluid Selection Exercises ==
      • IV Drips with Exercises ==

      Which Fluid to use?

      What are you fixing?

      • Hypoperfusion / hypotension ==
        • Dehydration ===
        • Symptomatic anemia ===
        • Acute blood loss ===
        • Ongoing hemorrhage- Coagulopathy? ===
      • Maintenance / NPO ==
      • Electrolyte imbalances ==

      Fluids

      • Dextrose / Free Water ==
      • Crystalloid ==
        • NS, LR, Ringer’s Acetate ===
      • Colloid ==
        • Albumin, Hetastarch, Modified gelatin, Dextran ===
      • Hypertonic Saline ==
      • Non blood-based Oxygen Carrying ==
        • Hemoglobin-based, fluorocarbon-based ===
      • Blood products ==

      Dextrose

      • D5 ==
        • 1 Liter = 170 calories ===
      • D10, D20*, D50* ==
      • *= requires central line ==

      Crystalloids

      • Hypo-oncotic ==
        • Ratio of 3:1 for acute blood loss ===
      • 1 L NS → 275 cc into vascular space ==
      • + 825 cc into interstitial volume ==
      • 1100 cc = 1.1 L ??? ==

      Crystalloids

      • Saline ==
        • NS, ¼ NS, ½ NS ===
      • LR ==
      • Hypertonic Saline ==
      • Others ==
        • Normosmol (acetate) ===
        • Plasma-Lyte (gluconate) ===

      LR

      • [Cl]LR → [Cl]plasma ==
      • Calcium can bind to rx’s, including citrated anticoagulant in blood products ==
        • → Cannot use LR as the diluent for blood transfusions ===

      Crystalloids

      • NS or LR? ==
        • Lots of NS can ↓ intracellular K and cause ↑Cl acidosis ===
        • LR can increase lactic acidosis ===
        • Neither one has been shown to be superior ===
      • ¼ NS, ½ NS ==
      • Hypertonic Saline ==
      • Others ==
        • Normosmol (acetate) ===
        • Plasma-Lyte (gluconate) ===

      Others

      • Normosmol (acetate), Plasma-Lyte (gluconate) ==
      • Additional buffers: pH → pHplasma ==
      • Mg ==
        • Careful in RF or insufficiency ===

      Others (cont’d)

      • 8% Amino Acids ==
        • Osmolality 950 mOsm/L ===
        • provides protein in varying percentages; assists with tissue repair and to correct negative nitrogen balance ===
      • Intralipids 10%, 20% ==
        • isotonic ===
        • provides fatty acids and calories ===
      • EtOH ==
        • 5% Alcohol in 5% Dextrose ===
        • 10% ===

      +/- Dextrose

      • All of the crystalloid fluids ==
        • D5, D10, D20, D50 ===

      Colloids

      • Albumin 5%, 25% ==
      • Hetastarch ==
      • Dextran 6%, 10% ==
      • Gelatin ==

      Why Colloids

      • Oncotic pressure → fluid remains intravascular ==
      • No risk of infection ==
        • Heat treated albumin ===

      mainly used in acute hemorrhage management

      Albumin as plasma expander

      • Albumin 5% ==
        • 1 L → ↑ intravasc vol by 0.7–1.3 L ===
      • Albumin 25% ==
        • 1 L → ↑ intravasc vol by 4–5 L ===
      • Oncotic effects lasts 12-18 hrs ==

      Hetastarch

      • Similar to albumin except cheaper ==
      • T1/2 = 17 days except… ==
      • Oncotic effects last < 24 hrs (albumin 12-18 hrs) ==
      • ↑ Amylase ==

      Cost

      • Crystalloids ~ $11/L ==
      • Colloids ~ $65-100/L ==
      • No survival benefit with colloids ==

      Dextran

      • Dextran 6%, 10% ==
        • Dextran 6% = Dextran-70 ===
        • Dextran 10%=Dextran-40 ===
        • 40 causes ↑ plasma vol but 70 lasts longer ===
        • Can cause anaphylaxis ===
        • Dose-related bleeding, give < 20 cc/kg ===
        • Can affect the type-and-crossmatching (“wash” specimens to eliminate this problem) ===
        • Increases ESR ===
        • Rare reports of RF ===

      = NaCl 3%, 7.5%- Fluid or Medication? =

      • Systems-engineering approach ==
        • Remove from IV cart ===
        • Treat as rx, not IVF ===
      • Trauma resuscitation fluid- except it doesn’t work ==

      Hypertonic Saline

      • Rapidly expands intravasc vol ==
      • Limits edema ==
      • Beneficial effects beyond vol expansion ==
        • Extravasc → intravasc ===

      Hypertonic NaCl limits

      • Hypernatremia ==
      • Addition of dextran ==
        • May be helpful in serious trauma ===
        • Military? ===

      Oxygen-carrying fluids

      Types

      • Fluorocarbon-based ==
      • Hemoglobin-based ==
        • Human ===
        • Bovine ===
        • rDNA ===

      Fluorocarbon-based

      • Dissolve gasses (O2 and CO2) in fluid ==
      • Linear- requires FiO2 > 70% ==
      • Toxic at high doses ==

      Hemoglobin-based

      • So far, no safe formulations ==
      • Vasoconstriction ==
      • No 2,3-diphosphoglycerate ==

      Blood

      Blood Products

      • Whole blood ==
      • PRBC’s ==
      • Platelets ==
      • FFP ==
      • Specific factors ==

      Whole Blood

      • Generally not available in US except ==
      • Autotransfusion ==
        • Requires training to operate the equipment ===
        • Setup time ===

      Blood Products

      • Whole blood ==
      • PRBC’s ==
      • Platelets ==
      • FFP ==
      • Specific factors ==

      PRBC’s

      • Acute blood loss with s/s ↓O2 delivery and two of the following: ==
      • Estimated 15% blood loss
      • Hotn
      • Tachycardia
      • Oliguria
      • AMS
      • Symptomatic anemia ==
      • Myocardial ischemia ==
      • AP
      • SOB
      • Dizziness with mild exertion

      When not to give PRBC’s

      • Hgb > 10 (men), > 7 (women) if otherwise stable and/or asymptomatic ==

      PRBC Numbers

      • 1 U → ↑ hgb by ~ 1g/dl, ↑ hct by ~ 3% ==

      PRBC Administration

      • Large-bore IV line with NS ==
      • Can give 50-100 cc NS to dilute and infuse faster ==
      • Usually 1 U over 60-90 minutes, but within 4 hrs ==
      • If PRBC unrefrigerated for > 30 min, cannot return to blood blank ==

      Blood Products

      • Whole blood ==
      • PRBC’s ==
      • Platelets ==
      • FFP ==
      • Specific factors ==

      Platelets

      • Give whenever plts < 20,000 ==
        • or ===
      • < 50,000 and oozing or pt going for invasive procedure ==
      • ABO matching unnecessary but should Rh match ==

      Platelets

      • 1 bag containts 5.5 x 1010 in 50-70 cc plasma ==

      Blood Products

      • Whole blood ==
      • PRBC’s ==
      • Platelets ==
      • Fresh Frozen Shrimp Plasma ==
      • Specific factors ==

      FFP

      • Emergent reversal of warfarin ==
      • Correction of known coagulation deficiencies ==
      • DIC if PT/PTT > 1.5x nl ==

      FFP Administration

      • Must be ABO compatible ==
      • 1 ml of FFP is ≈ 1 unit of activity for any clotting factor ==
      • For warfarin reversal give 5-8 ml/kg ==
      • Otherwise, give for 30% of nl plasma factor concentration, usually 10-15 ml/kg ==

      Blood Products

      • Whole blood ==
      • PRBC’s ==
      • Platelets ==
      • FFP ==
      • Specific factors ==

      Bleeding Problems

      • Hemophilia A → Give Factor VIII ==
      • Hemophilia B → Give Factor IX ==
      • vWF deficiency → FFP, Factor VIII, Desmopressin ==

      Factor VII

      • rFVIIa = recombinant factor VIIa ==

      Universal Donor

      • O+ for all pts except women of, and before, childbearing age ==
      • O- for women of childbearing, and pre-childbearing ages ==

      Time

      • Type O: immediately ==
      • Type-specific: 5-10 min ==
      • Incomplete Type and Crossmatched: 30 min ==
      • Fully crossmatched: 45 min ==

      Infection Risk

      Alex’s Recommendations

      • Saline ==
        • Consider colloids in certain situations such as ↑ICP, anaphylaxis ===
      • Blood products when appropriate (absolute or relative low O2 delivery, thrombocytopenia, coagulopathy, ongoing bleeding) ==
      • Keep eyes out for blood-replacement products ==

      Exercise #1

      • Mom brings in her 7 yo, 22 kg son for altered mental status. He was marching in a parade without access to any water source. ==
      • What fluid(s), and how much? ==

      Answer #1

      • Crystalloid (NS or LR) ==
      • 22 kg x 20 cc/kg = 440 cc, wide open ==
      • He perks right up and is now tolerating PO. ==

      Exercise #2

      • Mom brings in her 7 yo, 22 kg son for altered mental status. He was playing in the snow, bundled in 3-4 layers of clothes, but he has not been drinking recently because of throat pain. On PE you notice he has vesicles over his palatoglossal fold. ==
      • What fluid(s), and how much? ==

      Answer #2- Part I

      • Crystalloid (NS or LR) ==
      • 22 kg x 20 cc/kg = 440 cc, wide open ==
      • But he’s still not tolerating PO → Admit ==
      • Now what? ==

      Answer #2- Part II

      • “100/50/20” or “4/2/1” Rule ==

      100/50/20

      • 100 cc/kg/24 hr for each of the first 10 kg ==
      • Then 50 cc/kg/24 hr for each of the next 10 kg ==
      • Then 20 cc/kg for addt’l kg ==
      • Add together, then divide by 24 hr for hourly rate ==
      • Max total daily fluid 2-2.5 L ==

      4/2/1

      • 4 cc/kg/hr for each of the first 10 kg ==
      • 2 cc/kg/hr for each of the next 10 kg ==
      • 1 cc/kg/hr for each addt’l kg ==
      • Add together for hourly rate ==

      Answer #2- Part II: 22 kg

      • 100/50/20 ==
      • 100 x 10 = 1000 ==
      • 50 x 10 = 500 ==
      • 20 x 2 = 40 ==
      • 1000 + 500 + 40 = 1540 ==
      • 1540 / 24 = 64 cc/hr ==
      • 4/2/1 ==
      • 4 x 10 = 40 ==
      • 2 x 10 = 20 ==
      • 1 x 2 = 2 ==
      • 40 + 20 + 2 = 62 cc/hr ==

      Which Fluid?

      • D5 ___ NS + 20 mEq/L KCl ==
      • < 20-25 kg → D5¼NS + 20 mEq/L KCl ==
      • >25 kg → D5½NS + 20 mEq/L KCl ==

      Exercise #3

      • 10 yo M, 24 kg, with ongoing diarrhea ==
      • What fluids, how much, and add what to fluid? ==

      Answer #3

      • Diarrhea dehydration ==
        • Isotonic 60-70% ===
        • Hyponatremic 10-15% ===
        • Hypernatremic 10-20% ===
      • D5 1/4 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl ==
      • Replace stool mL/mL every 1–6 hr in addition to maintenance fluids ==

      How many drops can an IV drip?

      • Volume to be infused, drop factor, gtt’s, and other fun stuff ==

      A pt needs 1 Liter over the next 8 hours, and all IV pumps are being used. Now what?

      What do we have?

      • Stopwatch, eyes → can see how fast fluid is dripping ==
      • Given: Amount of fluid per hour ==
      • Given: 60 minutes in an hour ==
      • We can control: Drops/min ==
      • Given: Tubing’s drops/ml ==

      The Equation

      Quicker Alternative

      • Total volume / hours → cc/hr ==
      • Cc/hr ÷ 60 → cc/min ==
      • We need to get from cc/min to drops/min ==

      Drop Factor

      • Manufacturer Specification ==
      • In drops/ml ==
      • Only required if not using an infusion pump or if using an old pump ==

      Common drop factors

      • Macrodrip tubing: drop factor 10-20 ==
      • Microdrip tubing: drop factor 60 ==
      • We have a few in our ED ==

      Back to our problem

      • We need to give 1 Liter over 8 hours, but all of our computerized infusion pumps are broken or being used. ==
      • How can we use a standard IV set to give our IVF? ==

      Solution

      • 1 Liter in 8 hours = 1000 cc in 8 hrs ==
      • = 125 cc/hr ==
      • = cc/min ==

      Logic

      • For a drop factor of 10, a drip rate of 21 → 125 cc/hr ==
      • For a drop factor of 15, a drip rate of 31 → 125 cc/hr ==
      • Drip rate < 10 → IV clots ==

      Questions?

      • Comments? Email address is alex.flaxman@rcn.com ==
      • Criticism? Mailbox in the PA office ==

      References

      • Hedner U, “Recombinant factor VIIa (NovoSeven) as a hemostatic agent”, Dis Mon – Jan 1, 12003; 49(1): 39-48. ==
      • Rozycki GS, “What's new in trauma and critical care”, J Am Coll Surg, May 1, 2004, 198(5): 798-805. ==
      • Bickell, WH, “Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries”, NEJM, October 27, 1994, 331(5): 1105-1109. ==
      • Elliott, JE, RN, BSN, CCRN. “Intravenous Therapy”, http://www.nursewise.com. ==
      • LaBonne, CH, MA, CES, RNC. “NURS 1100”, Henry P. Becton School of Nursing & Allied Health, Fairleigh Dickinson University, http://www.fdu.edu ==
      • Marx, John, Rosen’s Emergency Medicine; Concepts and Clinical Practice, Fifth edition. Mosby, Philadelphia, 2002. p. 48-51, 64-100, 1767-1768. ==
      • Tintinalli, Judith E. Emergency Medicine: A Comprehensive Study Guide 6th edition. McGraw-Hill Professional, New York, 2003. p. 225-231. ==
      • Marino, Paul L. The ICU Book; second edition. Lippincott Williams & Wilkins, New York, 1997, p. 228-241, 691-720. ==
      Last modified on 25 June 2006, at 17:50