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 Products
PACKED 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 typespecific, which is preferred
over O negative.
Women of child-bearing age or younger should not
receive Rh-positive
blood 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
unintentional
bone 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

 PLATELETS
One 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 to
12 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

 CRYOPRECIPITATE
Cryoprecipitate 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 <50,000/L
Fresh frozen plasma (FFP), prothrombin complex

concentrate, or recombinant factor VIIa for

patients on
warfarin with an elevated INR
FFP and/or cryoprecipitate and specific factors
for
hemophiliacs

 Indications for PRBC tranfusion in

hemorrhagic shock:
No response to two fluid boluses
Ongoing hemorrhage
Impending CV collapse