# 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. ==