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Sickle Cell infusion

Discussion in 'Emergency Medicine' started by Notzfall, Apr 27, 2004.

  1. Notzfall

    Notzfall NREMT-P, MS-IV
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    When hydrating a pt in sickle cell crisis, I have been told by a physician in a sickle cell clinic to administer D5 1/2NS as the fluid of choice because it assists with "rounding out" the sickled cell. What is the mechanism by which this works. I would imagine that the hypertonic solution would pull intracellular fluid and cause LESS of a sickled shape.

    An article on emedicine.com directs Normal Saline (3-4L; although cautions hyperhydration).

    Could someone explain?
     
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  3. DrQuinn

    DrQuinn My name is Neo
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    Interesting question, as I never really think of using anything besides NS. Basically, anyone who comes into my ED in FL is probably a quart low. So I initially use a liter of NS to correct for any deficits. Once you tank them up, its a wise thing to change to a maintenance fluid, like d5 1/2NS. NS and LR are your initial fluids of choice.

    I did a quick literature search and couldnt' find much about specific fluids to use... just talks abot oxygen, hydration, and pain management for the SC crisis.

    Interesting though. I'll ask some of my attendings tomorrow in Grand Roudns, see what they think.

    Q, DO
     
  4. mikecwru

    mikecwru M.D. = Massive Debt
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    Our SCC protocol calls for D51/2, the theoretical reason being (1) more free water to balloon up cells and (2) SC patients get renal papillary necrosis and have sodium concentration problems and you can make them hypernatremic. I don't know how common either of these two are, but that's the reasoning I've been given for our protocol.

    mike
     
  5. DrQuinn

    DrQuinn My name is Neo
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    Int'ri'stin. I'll have to check out our SCC protocols. We have them but we really only use the "Chest Pain Protocol" sheets.

    Q, DO
     
  6. EMT036

    EMT036 MS-III/AEMT/Rescue Diver
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    Interesting, wonder if the hospital I work at has SCC protocols... Seems that ever since the physician's group decided to stop giving Demerol, there hasn't been much need for them...
     
  7. docB

    docB Chronically painful
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    This is a good question for some of the academics on the board. I'd be curious what the EBM answer is. I use NS and that's what we did in Philly where we were up to our eyeballs in sicklers.
     
  8. mikecwru

    mikecwru M.D. = Massive Debt
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    Like I said, I've seen it elsewhere, and those are the reasons I've seen in texts, how "real" of a worry it is, I'm kind of doubtful. Now you've got me curious! :)

    mike
     
  9. Notzfall

    Notzfall NREMT-P, MS-IV
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    Here in Atlanta we have many sicklers as well, and that is what has prompted my question. I posted because of the wide range of answers from physicians, whom I believed to have frequent experience with such treatment. The reason for the answers were based on the balloning of cells rather than the renal papillary necrosis. Although, when I mentioned it, the concern of renal papillary necrosis was justified.

    I've heard D51/2 throughout treatment, D51/4 throughout treatment, and NS initial bolus (10-20mL/kg/60min) and then D51/2 for maint. Thanks to everyone for a collaboration of responses. Keep 'em coming.
     
  10. docB

    docB Chronically painful
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    Clearly we've reached a solid consensus that these patients need "some kind of fluid."
     
  11. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    Hypertonic saline will result in "dehydration" of the sickle cells which induces the sickle conformation.

    If you give them hypotonic saline, then H2O will be pulled into the RBC and reduces the risk of sickle formation.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14663274

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1987310

    J Lab Clin Med. 1991 Jan;117(1):60-6. Related Articles, Links

    Morphology of sickle cells produced in solutions of varying osmolarities.

    Hijiya N, Horiuchi K, Asakura T.

    Division of Hematology, Children's Hospital of Philadelphia, PA 19104.

    The effect of varying osmolarities (0.6% to 1.5% NaCl solutions, 213 to 492 mOsm/kg H2O) on the morphology of deoxygenated sickle cells was studied quantitatively with a computer-assisted image analysis system. Discocyte-rich, less dense fractions of sickle cells (density less than or equal to 1.11) were suspended in buffered NaCl solutions (pH 7.4) of various osmolarities, deoxygenated at room temperature for up to 5 hours, and stained by Wright's solution. Microscopic images were analyzed by circular shape factor (CSF = 4 pi x [area]/[perimeter]2) and elliptical shape factor (ESF = [short axis]/[long axis]). Since these two parameters yield different values for elongated cells and for cells of other shapes, such as maple-leaf- or star-shaped cells, the morphologic changes of sickle cells can be analyzed numerically. We found that both the rate and the degree of deformation depended highly on the osmotic pressure of the media in which the cells were suspended. In hypertonic solution, most sickle cells assumed a maple-leaf shape. The deformation occurred quickly, but the degree of deformation (circular shape factor and elliptical shape factor) was lower than that found in isotonic and slightly hypotonic solutions. Although elongated cells were formed in hypotonic and isotonic solutions, deformation was slower in these solutions than in hypertonic solutions. These results indicate that the shape and the degree of deformation of deoxygenated sickle cells are highly dependent on the osmolarity of the suspending medium and that the rate of deformation is inversely related to osmolarity. The relationship between morphology of deoxygenated sickle cells and osmotic pressure of the suspending media is discussed.
     
  12. Seaglass

    Seaglass Quantum Member
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    Andrew Doan you are the Austin Powers of the medical literature world. Now we just need to find you a Dr. Evil. :thumbup:
     
  13. 12R34Y

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    so are you saying that you should NOT give sicklers Dextrose in their NS because it will make it hypertonic and thus further dehydrate the cells?
     
  14. southerndoc

    southerndoc life is good
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    Have you seen my "laser"? Throw me a freakin bone. :)

    Yea baby yea!
     

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