Emergency Medicine/Blood and Fluids

< Emergency Medicine

Topics

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

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? ===

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 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 ==

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 ==

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 ==

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. ==

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