Last modified on 25 June 2006, at 17:50

Emergency Medicine/Blood and Fluids

Fluid & Blood ResuscitationEdit

TopicsEdit

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

Which Fluid to use?Edit

What are you fixing?Edit

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

FluidsEdit

  • 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 ==

DextroseEdit

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

CrystalloidsEdit

  • 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 ??? ==

CrystalloidsEdit

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

LREdit

  • [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 ===

CrystalloidsEdit

  • 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) ===

OthersEdit

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

Others (cont’d)Edit

  • 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% ===

+/- DextroseEdit

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

ColloidsEdit

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

Why ColloidsEdit

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

mainly used in acute hemorrhage management

Albumin as plasma expanderEdit

  • 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 ==

HetastarchEdit

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

CostEdit

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

DextranEdit

  • 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 SalineEdit

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

Hypertonic NaCl limitsEdit

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

Oxygen-carrying fluidsEdit

TypesEdit

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

Fluorocarbon-basedEdit

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

Hemoglobin-basedEdit

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

BloodEdit

Blood ProductsEdit

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

Whole BloodEdit

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

Blood ProductsEdit

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

PRBC’sEdit

  • 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’sEdit

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

PRBC NumbersEdit

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

PRBC AdministrationEdit

  • 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 ProductsEdit

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

PlateletsEdit

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

PlateletsEdit

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

Blood ProductsEdit

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

FFPEdit

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

FFP AdministrationEdit

  • 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 ProductsEdit

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

Bleeding ProblemsEdit

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

Factor VIIEdit

  • rFVIIa = recombinant factor VIIa ==

Universal DonorEdit

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

TimeEdit

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

Infection RiskEdit

Alex’s RecommendationsEdit

  • 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 #1Edit

  • 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 #1Edit

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

Exercise #2Edit

  • 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 IEdit

  • 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 IIEdit

  • “100/50/20” or “4/2/1” Rule ==

100/50/20Edit

  • 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 ==

4/2/1Edit

  • 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 kgEdit

  • 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?Edit

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

Exercise #3Edit

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

Answer #3Edit

  • 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?Edit

  • 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?Edit

What do we have?Edit

  • 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 EquationEdit

Quicker AlternativeEdit

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

Drop FactorEdit

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

Common drop factorsEdit

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

Back to our problemEdit

  • 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? ==

SolutionEdit

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

LogicEdit

  • 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?Edit

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

ReferencesEdit

  • 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. ==