Emergency Medicine/Blood and Fluids

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. ==