Emergency Medicine/Blood and Fluids

= Fluid & Blood Resuscitation =

= Topics = = Which Fluid to use? = = What are you fixing? = = Fluids = = Dextrose = = Crystalloids = = Crystalloids = = LR = = Crystalloids = = Others = = Others (cont’d) = = +/- Dextrose = = Colloids = = Why Colloids =
 * Available IV Fluids ==
 * Blood products ==
 * Fluid Selection Exercises ==
 * IV Drips with Exercises ==
 * Hypoperfusion / hypotension ==
 * Dehydration ===
 * Symptomatic anemia ===
 * Acute blood loss ===
 * Ongoing hemorrhage- Coagulopathy? ===
 * Maintenance / NPO ==
 * Electrolyte imbalances ==
 * 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 ==
 * D5 ==
 * 1 Liter = 170 calories ===
 * D10, D20*, D50* ==
 * *= requires central line ==
 * 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 ??? ==
 * Saline ==
 * NS, ¼ NS, ½ NS ===
 * LR ==
 * Hypertonic Saline ==
 * Others ==
 * Normosmol (acetate) ===
 * Plasma-Lyte (gluconate) ===
 * [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 ===
 * 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) ===
 * Normosmol (acetate), Plasma-Lyte (gluconate) ==
 * Additional buffers: pH → pHplasma ==
 * Mg ==
 * Careful in RF or insufficiency ===
 * 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% ===
 * All of the crystalloid fluids ==
 * D5, D10, D20, D50 ===
 * Albumin 5%, 25% ==
 * Hetastarch ==
 * Dextran 6%, 10% ==
 * Gelatin ==
 * Oncotic pressure → fluid remains intravascular ==
 * No risk of infection ==
 * Heat treated albumin ===

mainly used in acute hemorrhage management

= Albumin as plasma expander = = Hetastarch = = Cost = = Dextran = = NaCl 3%, 7.5%- Fluid or Medication? = = Hypertonic Saline = = Hypertonic NaCl limits = = Oxygen-carrying fluids = = Types = = Fluorocarbon-based = = Hemoglobin-based = = Blood = = Blood Products = = Whole Blood = = Blood Products = = PRBC’s = = When not to give PRBC’s = = PRBC Numbers = = PRBC Administration = = Blood Products = = Platelets = = Platelets = = Blood Products = = FFP = = FFP Administration = = Blood Products = = Bleeding Problems = = Factor VII = = Universal Donor = = Time = = Infection Risk = = Alex’s Recommendations = = Exercise #1 = = Answer #1 = = Exercise #2 = = Answer #2- Part I = = Answer #2- Part II = = 100/50/20 = = 4/2/1 = = Answer #2- Part II: 22 kg = = Which Fluid? = = Exercise #3 = = Answer #3 = = How many drops can an IV drip? = = A pt needs 1 Liter over the next 8 hours, and all IV pumps are being used. Now what? = = What do we have? = = The Equation = = Quicker Alternative = = Drop Factor = = Common drop factors = = Back to our problem = = Solution = = Logic = = Questions? = = References =
 * 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 ==
 * Similar to albumin except cheaper ==
 * T1/2 = 17 days except… ==
 * Oncotic effects last < 24 hrs (albumin 12-18 hrs) ==
 * ↑ Amylase ==
 * Crystalloids ~ $11/L ==
 * Colloids ~ $65–100/L ==
 * No survival benefit with colloids ==
 * 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 ===
 * Systems-engineering approach ==
 * Remove from IV cart ===
 * Treat as rx, not IVF ===
 * Trauma resuscitation fluid- except it doesn’t work ==
 * Rapidly expands intravasc vol ==
 * Limits edema ==
 * Beneficial effects beyond vol expansion ==
 * Extravasc → intravasc ===
 * Hypernatremia ==
 * Addition of dextran ==
 * May be helpful in serious trauma ===
 * Military? ===
 * Fluorocarbon-based ==
 * Hemoglobin-based ==
 * Human ===
 * Bovine ===
 * rDNA ===
 * Dissolve gasses (O2 and CO2) in fluid ==
 * Linear- requires FiO2 > 70% ==
 * Toxic at high doses ==
 * So far, no safe formulations ==
 * Vasoconstriction ==
 * No 2,3-diphosphoglycerate ==
 * Whole blood ==
 * PRBC’s ==
 * Platelets ==
 * FFP ==
 * Specific factors ==
 * Generally not available in US except ==
 * Autotransfusion ==
 * Requires training to operate the equipment ===
 * Setup time ===
 * Whole blood ==
 * PRBC’s ==
 * Platelets ==
 * FFP ==
 * Specific factors ==
 * 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
 * Hgb > 10 (men), > 7 (women) if otherwise stable and/or asymptomatic ==
 * 1 U → ↑ hgb by ~ 1g/dl, ↑ hct by ~ 3% ==
 * 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 ==
 * Whole blood ==
 * PRBC’s ==
 * Platelets ==
 * FFP ==
 * Specific factors ==
 * Give whenever plts < 20,000 ==
 * or ===
 * < 50,000 and oozing or pt going for invasive procedure ==
 * ABO matching unnecessary but should Rh match ==
 * 1 bag containts 5.5 x 1010 in 50-70 cc plasma ==
 * Whole blood ==
 * PRBC’s ==
 * Platelets ==
 * Fresh Frozen Shrimp Plasma ==
 * Specific factors ==
 * Emergent reversal of warfarin ==
 * Correction of known coagulation deficiencies ==
 * DIC if PT/PTT > 1.5x nl ==
 * 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 ==
 * Whole blood ==
 * PRBC’s ==
 * Platelets ==
 * FFP ==
 * Specific factors ==
 * Hemophilia A → Give Factor VIII ==
 * Hemophilia B → Give Factor IX ==
 * vWF deficiency → FFP, Factor VIII, Desmopressin ==
 * rFVIIa = recombinant factor VIIa ==
 * O+ for all pts except women of, and before, childbearing age ==
 * O- for women of childbearing, and pre-childbearing ages ==
 * Type O: immediately ==
 * Type-specific: 5-10 min ==
 * Incomplete Type and Crossmatched: 30 min ==
 * Fully crossmatched: 45 min ==
 * 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 ==
 * 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? ==
 * Crystalloid (NS or LR) ==
 * 22 kg x 20 cc/kg = 440 cc, wide open ==
 * He perks right up and is now tolerating PO. ==
 * 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? ==
 * Crystalloid (NS or LR) ==
 * 22 kg x 20 cc/kg = 440 cc, wide open ==
 * But he’s still not tolerating PO → Admit ==
 * Now what? ==
 * “100/50/20” or “4/2/1” Rule ==
 * 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 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 ==
 * 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 ==
 * D5 ___ NS + 20 mEq/L KCl ==
 * < 20–25 kg → D5¼NS + 20 mEq/L KCl ==
 * >25 kg → D5½NS + 20 mEq/L KCl ==
 * 10 yo M, 24 kg, with ongoing diarrhea ==
 * What fluids, how much, and add what to fluid? ==
 * 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 ==
 * Volume to be infused, drop factor, gtt’s, and other fun stuff ==
 * 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 ==
 * Total volume / hours → cc/hr ==
 * Cc/hr ÷ 60 → cc/min ==
 * We need to get from cc/min to drops/min ==
 * Manufacturer Specification ==
 * In drops/ml ==
 * Only required if not using an infusion pump or if using an old pump ==
 * Macrodrip tubing: drop factor 10-20 ==
 * Microdrip tubing: drop factor 60 ==
 * We have a few in our ED ==
 * 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? ==
 * 1 Liter in 8 hours = 1000 cc in 8 hrs ==
 * = 125 cc/hr ==
 * =      cc/min ==
 * 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 ==
 * Comments? Email address is  alex.flaxman@rcn.com  ==
 * Criticism? Mailbox in the PA office ==
 * 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. ==