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University of Manchester 1st MB lecture on Infusions

A basic guide to resuscitative fluids: crystalloids v. Colloids v. blood; who, how, where and when
by

Alan Grayson

on 29 April 2016

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Transcript of University of Manchester 1st MB lecture on Infusions

Alan Grayson
Consultant Emergency Physician
Central Manchester Foundation Trust
@dralangrayson
prezi.com/user/alangrayson
The story of Bethan
ED
Operating Theatre
ICU
Rehab
Infusions
Definitions
Transfusion: the therapeutic administration of blood or blood products
Infusion: the therapeutic administration of a fluid other than blood
Why do we give fluids?
Replace volume
Administer drugs
Replace component of blood
Fluids increase venous return
which increases preload
which increases blood pressure
which is usually a good thing!
History of infusions
Some assumptions
70kg man
60% water = 40 litres
2/3 ICF ~ 25 litres
1/3 ECF ~ 15 litres
of which
1/5 plasma ~ 3 litres
Components of plasma:
90% water
7-8% proteins
1% electrolytes
1% elements in transit
Proteins include:
Albumin (a buffer and for oncotic pressure)
Globulins (immune performance)
Clotting factors
ECF ICF
Osmolality (mOsm) 290 290
Na + (mmol/l) 140 15
Ca 2+ (mmol/l) 2.2 <10-6
Cl - (mmol/l) 110 10
HCO3 - (mmol/l) 30 10
K + (mmol/l) 4 150
Mg 2+ (mmol/l) 1.5 15
PO4 3+ (mmol/l) 2 40
pH 7.4 7.1
Colloids:
Blood components (PRC/platelets/FFP)
Albumin solution
Man-made
(starch/gelatin etc)

Exert oncotic pressure
Crystalloids
Clear fluids
No oncotic pressure
Include saline, hartmanns
and dextrose
pH SOsm Na Cl K Ca Mg Buffer
Plasma 7.4 289 142 103 4 5 2 HCO3 – 22-32
Normal Saline 5.5 308 154 154
Ringer’s Lactate 6.5 273 130 109 4 3 Lactate – 28
Plasmalyte A 6.5 295 140 98 5 3 Gluc 23/Acetate 27
Gelofusin (colloid) 5.5 308 154 154 + ground up cow hoof
*Shamelessly nicked from the rather wonderful boringem.org*
What does Bethan need?
Hypotension + bleeding
=
Need for volume
raised lactate
suggests a lack of
oxygen delivery to tissues
Bleeding from fractures:
Pelvis >2000ml
Femur >1000ml
Tibia >750ml
Humerus >500ml
Radius >250ml
Rib >125ml
Coagulopathy of trauma

=
3-4 x increased risk of death

longer ICU stay

more blood products
Hypoxia
Acidosis
Tissue ooze
Hypothermia
Hypoxia

ensure adequate O2 delivery
ensure adequate O2 carrying capacity
Hypothermia

Always give warmed fluids to sick patients
AND
warm your patient
EXCEPT
isolated head injury
post-ROSC in cardiac arrest
Acidosis

ensure adequate perfusion of tissues
fluids, blood, vasopressors
Cross-matching

serological analysis of blood to determine compatibility
Types of
cross-match
O negative

For emergencies
Kept in areas of need
Instant delivery
Full XM

Excludes all antigens
Takes around an hour
Safest way of transfusion
Type specific

takes 15-20 mins
Major OAB compatibility
Small chance of reaction
Ways of
giving fluids
Colloids
An attractive option in resuscitation as have oncotic effect and therefore theoretically expand plasma volume better
In trauma:
colloids have no beneficial effect on mortality
HES increases mortality
CDSR 2013;2; CD000567
In sepsis:
8% extra mortality using colloids in resus
6S, PDBRCT, NEJM 2012
Please use crystalloids for resuscitation!
Consider albumin
Blood is good!
Balanced v unbalanced
OR
Saline v Hartmanns
Large volumes often required in resus:
Saline contains 154 mmol/l chloride
MINIMUM of 3l NaCl can cause
hyperchloraemic metabolic acidosis
(This is a bad thing!)
Balanced crystalloids have better profile in terms of:
blood loss,
haemostasis,
kidney function,
blood products used
Please consider using balanced crystalloids at all times, apart from maybe in TBI
Crystalloids v albumin v blood
Consider what you want to give and why
Warm most resus fluids
Short fat tubes allow better flow
?
thanks
in sick people
Odd stuff in ICU
Full transcript