Rubaalhamad

FLUID RESUSCITATION

There are myriad options for fluid resuscitation available to the emergency physician. They can be categorized as crystalloids, colloids, and blood products.

Crystalloids

Isotonic electrolyte solutions, including normal saline (0.9% NaCl) and Ringers lactate (NaCl, CaCl2, KCl, Na-lactate) CHARACTERISTICS Do not aid in O2 transport. Are hypooncotic one-third of the volume infused remains in the intravascular space after 20 minutes

CLINICAL INDICATIONS Clinically significant hypovolemia Regardless of the cause of hypovolemia, crystalloids should always be the first type of fluid given.

Note : One-third of the volume of infused crystalloid remains intravascular after 20 minutes

Colloids Colloid solutions contain large-molecular-weight particles of high osmolarity that cause fluid to move into the intravascular space. They do not augment O2 transport.AVAILABLE PRODUCTS Albumin Bovine or human protein Twenty-five percent solution administered in 50-mL or 100-mL aliquots 100 mL felt to be equivalent to 1 L of crystalloid Potential for infectious complications

Dextrans Highly branched polysaccharides Various formulations available May interfere with hemostasis Maximum dosage 20 mL/kg Gelatins Modified derivatives of bovine collagen Various formulations available Dilutional coagulopathy seen with higher volumes Polystarches Pentastarch and hexastarch most commonly used Limited usefulness secondary to dilutional coagulopathy and possible

CLINICAL INDICATIONS Colloid solutions are never indicated as primary therapy for volume resuscitation. Possible negative impact on mortality for sepsis Indicated for the treatment of spontaneous bacterial peritonitis and for patients receiving large volume paracentesis

Note :There is no proven benefit of colloids over crytalloids in volume resuscitation

Albumin has the potential for infectious complications

Blood ProductsPACKED RED BLOOD CELLS (PRBCS)Packed red blood cells have the additional benefit of augmenting O2 transport.Typically, begin by administering 2 units in adults or 15 mL/kg in children.One unit of PRBCs is sufficient to raise Hgb by 1.0 g/dL.RBC storage: All products are packaged with anticoagulant preservative of citrate, phosphate,dextrose, and adenine. Storage results in RBC changes. Levels of 2,3 DPG Leakage of potassium Spherical and rigid shape of cells

AVAILABLE PRODUCTS Typed and cross-matched is preferred over type-specific, which is preferredover O negative. Women of child-bearing age or younger should not receive Rh-positiveblood until testing indicates they are Rh-positive. Adult unit = 350 mL, HCT 57% Pediatric unit = 60 mL, HCT 72% Leukocyte-poor PRBCs will: Prevent febrile nonhemolytic reactions Prevent sensitization to patients eligible for bone marrow transplant Prevent platelet alloimmunization in some cases Minimize risk of virus (CMV, HIV) transmission

CLINICAL INDICATIONS Any cause of acute hemorrhage that does not respond to crystalloid Known ongoing hemorrhage Symptomatic anemia (ischemia, organ dysfunction, hypoxia)RESUSCITATION

COMPLICATIONS In massive transfusion (>10 units of PRBCs) Coagulopathy Routine transfusion of platelets and FPP is discouraged. Transfuse platelets and FFP based on clinical evidence of abnormal bleeding and abnormal laboratory values. Hypothermia Hypocalcemia (from binding to citrate preservative).

Treat symptomatic hypocalcemia with calcium gluconate. Febrile transfusion reaction Most common transfusion reaction Characterized by fevers/chills, malaise Treatment is symptomatic. Hemolytic transfusion reaction Most serious transfusion reaction, typically due to clerical error ABO incompatibility lysis of transfused RBCs hemoglobinemia and hemoglobinuria. Characterized by immediate fevers/chills, headache, N/V, dark urine, hypotension Treatment includes stopping the transfusion, immediate vigorous crystalloid infusion, and diuretic therapy to maintain urine output at 12 mL/kg/hr.

Allergic reaction

Urticaria or hives (rarely anaphylaxis) Treatment is symptomatic.

Transfusion-related acute lung injury (TRALI) Indistinguishable from acute respiratory distress syndrome Treatment is supportive. Stop transfusion. No evidence for use of steroids, antihistamines, or diuretics

Delayed transfusion reaction May occur within 34 weeks after transfusion as a primary or amnestic to RBC antigen Characterized by fall in hemoglobin and rise in bilirubin Treatment is supportive. Transfusion-associated graft versus host disease Occurs in immunocompromised patients from infusion of immunocompetent T lymphocytes, effectively resulting in an unintentionalbone marrow transplant; carries 80% mortality Characterized by rash, elevated LFTs, pancytopenia Prevention is key: Use irradiated blood products in immunocompromised patients. Transmitted viral infection Hepatitis B (1:60,000 units transfused) > hepatitis C (1:1.6 million) >HIV (1:2 million). May transmit CMV, EBV, parvovirus

PLATELETSOne unit of platelets is sufficient to raise platelet count by 10,000/L. Crossmatching is not necessary (though Rh matching is recommended). The normal dosage is 46 units of platelets (200 mL volume) per transfusion. CLINICAL INDICATIONS Significant hemorrhage or major procedure with platelets < 50,000/L Life-threatening hemorrhage and abnormal platelet level or function Platelets < 10,000/L for bleeding prophylaxis, except in ITP, TTP, HIT

FRESH FROZEN PLASMA (FFP)One unit of FFP contains 1 U/mL of each clotting factors in addition to12 mg/mL of fibrinogen. It must be ABO compatible and is typically dosed as 46 units (200250 mL volume per unit) in adults or 15 mL/kg in children.

CLINICAL INDICATIONS Significant hemorrhage secondary to coagulopathy (dilutional-infusion/ transfusion-related or warfarin-induced) Significant hemorrhages include external or internal bleeds. Not indicated as primary intravascular volume expander

CRYOPRECIPITATECryoprecipitate contains concentrated factors VIII and XIII, fibrinogen, and von Willebrand factor. Standard dosage is 610 units (1040 mL volume per unit). Does not require ABO matching.

CLINICAL INDICATIONS Significant hemorrhage in the setting of low fibrinogen states May be used to treat bleeding in hemophilia or von Willebrand disease, although specific factor replacement is preferred over cryoprecipitate

Notes :The most common transfusion reaction = febrile transfusion reaction.

The most serious transfusion reaction = hemolytic transfusion reaction

Patient receiving blood transfusion may develop urticaria or hives, but anaphylaxis is rare

Graft versus host disease is an extremely rare but usually fatal complication of a transfusion. Give irradiated blood products to immunocompromised patients.

One unit of platelets will raise the platelet count by 10,000 mL.

FFP contains fibrinogen and all clotting factors.

Cryoprecipitate contains factors VIII, XIII, fibrinogen, and von Willebrand factor

Hypovolemic shock

TREATMENT Ensure adequate oxygenation and ventilation. Volume resuscitation NS or Ringers lactate boluses through large peripheral intravenous lines, central lines, or intraosseous lines. 12 L in adults 1020 cc/kg in neonates, infants, and young children Blood products if no response to two fluid boluses, ongoing hemorrhage, or if impending cardiovascular collapse When time is critical, the use of O-negative blood is standard (O-positive in men is also acceptable). Two units PRBC in adults 1015 mL/kg PRBC in neonates, infants, and young children

Hemorrhage control Control source of bleeding. Fix hereditary or acquired bleeding diatheses: Platelets when platelet count is

Indications for PRBC tranfusion in hemorrhagic shock:No response to two fluid bolusesOngoing hemorrhageImpending CV collapse