Emergency Medicine/Blood and Fluids
Fluid & Blood Resuscitation
editTopics
edit- Available IV Fluids ==
- Blood products ==
- Fluid Selection Exercises ==
- IV Drips with Exercises ==
Which Fluid to use?
editWhat are you fixing?
edit- Hypoperfusion / hypotension ==
- Dehydration ===
- Symptomatic anemia ===
- Acute blood loss ===
- Ongoing hemorrhage- Coagulopathy? ===
- Maintenance / NPO ==
- Electrolyte imbalances ==
Fluids
edit- 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
edit- D5 ==
- 1 Liter = 170 calories ===
- D10, D20*, D50* ==
- *= requires central line ==
Crystalloids
edit- 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
edit- Saline ==
- NS, ¼ NS, ½ NS ===
- LR ==
- Hypertonic Saline ==
- Others ==
- Normosmol (acetate) ===
- Plasma-Lyte (gluconate) ===
LR
edit- [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
edit- 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
edit- 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% ===
+/- Dextrose
edit- All of the crystalloid fluids ==
- D5, D10, D20, D50 ===
Colloids
edit- Albumin 5%, 25% ==
- Hetastarch ==
- Dextran 6%, 10% ==
- Gelatin ==
Why Colloids
edit- Oncotic pressure → fluid remains intravascular ==
- No risk of infection ==
- Heat treated albumin ===
mainly used in acute hemorrhage management
Albumin as plasma expander
edit- 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
edit- Similar to albumin except cheaper ==
- T1/2 = 17 days except… ==
- Oncotic effects last < 24 hrs (albumin 12-18 hrs) ==
- ↑ Amylase ==
Cost
edit- Crystalloids ~ $11/L ==
- Colloids ~ $65–100/L ==
- No survival benefit with colloids ==
Dextran
edit- 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
edit- Rapidly expands intravasc vol ==
- Limits edema ==
- Beneficial effects beyond vol expansion ==
- Extravasc → intravasc ===
Hypertonic NaCl limits
edit- Hypernatremia ==
- Addition of dextran ==
- May be helpful in serious trauma ===
- Military? ===
Oxygen-carrying fluids
editTypes
edit- Fluorocarbon-based ==
- Hemoglobin-based ==
- Human ===
- Bovine ===
- rDNA ===
Fluorocarbon-based
edit- Dissolve gasses (O2 and CO2) in fluid ==
- Linear- requires FiO2 > 70% ==
- Toxic at high doses ==
Hemoglobin-based
edit- So far, no safe formulations ==
- Vasoconstriction ==
- No 2,3-diphosphoglycerate ==
Blood
editBlood Products
edit- Whole blood ==
- PRBC’s ==
- Platelets ==
- FFP ==
- Specific factors ==
Whole Blood
edit- Generally not available in US except ==
- Autotransfusion ==
- Requires training to operate the equipment ===
- Setup time ===
Blood Products
edit- Whole blood ==
- PRBC’s ==
- Platelets ==
- FFP ==
- Specific factors ==
PRBC’s
edit- 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
edit- Hgb > 10 (men), > 7 (women) if otherwise stable and/or asymptomatic ==
PRBC Numbers
edit- 1 U → ↑ hgb by ~ 1g/dl, ↑ hct by ~ 3% ==
PRBC Administration
edit- 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
edit- Whole blood ==
- PRBC’s ==
- Platelets ==
- FFP ==
- Specific factors ==
Platelets
edit- Give whenever plts < 20,000 ==
- or ===
- < 50,000 and oozing or pt going for invasive procedure ==
- ABO matching unnecessary but should Rh match ==
Platelets
edit- 1 bag containts 5.5 x 1010 in 50-70 cc plasma ==
Blood Products
edit- Whole blood ==
- PRBC’s ==
- Platelets ==
- Fresh Frozen Shrimp Plasma ==
- Specific factors ==
FFP
edit- Emergent reversal of warfarin ==
- Correction of known coagulation deficiencies ==
- DIC if PT/PTT > 1.5x nl ==
FFP Administration
edit- 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
edit- Whole blood ==
- PRBC’s ==
- Platelets ==
- FFP ==
- Specific factors ==
Bleeding Problems
edit- Hemophilia A → Give Factor VIII ==
- Hemophilia B → Give Factor IX ==
- vWF deficiency → FFP, Factor VIII, Desmopressin ==
Factor VII
edit- rFVIIa = recombinant factor VIIa ==
Universal Donor
edit- O+ for all pts except women of, and before, childbearing age ==
- O- for women of childbearing, and pre-childbearing ages ==
Time
edit- Type O: immediately ==
- Type-specific: 5-10 min ==
- Incomplete Type and Crossmatched: 30 min ==
- Fully crossmatched: 45 min ==
Infection Risk
editAlex’s Recommendations
edit- 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
edit- 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
edit- 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
edit- 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
edit- 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
edit- “100/50/20” or “4/2/1” Rule ==
100/50/20
edit- 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
edit- 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
edit- 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 #3
edit- 10 yo M, 24 kg, with ongoing diarrhea ==
- What fluids, how much, and add what to fluid? ==
Answer #3
edit- 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?
editWhat 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 Equation
editQuicker Alternative
edit- Total volume / hours → cc/hr ==
- Cc/hr ÷ 60 → cc/min ==
- We need to get from cc/min to drops/min ==
Drop Factor
edit- Manufacturer Specification ==
- In drops/ml ==
- Only required if not using an infusion pump or if using an old pump ==
Common drop factors
edit- Macrodrip tubing: drop factor 10-20 ==
- Microdrip tubing: drop factor 60 ==
- We have a few in our ED ==
Back to our problem
edit- 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
edit- 1 Liter in 8 hours = 1000 cc in 8 hrs ==
- = 125 cc/hr ==
- = cc/min ==
Logic
edit- 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 ==
References
edit- 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. ==