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. ==