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Which crystalloid?

Discussion in 'Clinical Rotations' started by ericdamiansean, May 2, 2007.

  1. ericdamiansean

    ericdamiansean High Profiler
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    I'm just doing a general survey, in a patient who has severe hemorrhagic shock (more than 40%), for initial fluid resus, what is the choice of cystalloid and the regime (amount) used for according to the hospital's protocol?
     
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  3. colbgw02

    colbgw02 Delightfully Tacky
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    If someone acutely loses 40% of their blood volume from hemorrhage, then you need to be hanging something more than just crystalloid.

    To answer your question, there is some emerging data that LR contributes to acidosis, so I would reach for NS.

    Out of curiosity, why must there be a protocol for this? I'm not aware of one at any of the hospitals at which I've trained.
     
  4. ericdamiansean

    ericdamiansean High Profiler
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    Of course if someone has lost more than 40%,you need something more than crystalloids but that is probably the only thing you have if you're a paramedic. So, lets say about 30%.
    I have heard too that LR causes lactic acidosis, so there is a move towards using more NS and Hartmann's. So, now, if given a choice, NS or Hartmann's?

    A protocol would be good to standardize things, it would give a junior attending an educated guess on which fluids to start first, be it crystalloids or colloids
     
  5. dynx

    dynx Yankee Imperialist
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    The hyperchloremic acidosis caused by use of LR is also caused by over infusion with NS and hasn't been linked to an increase in mortality when compared with equivalent levels of acidosis with other causes in shock patients. I think the major problem with LR is the increase in inflammatory response, not the acidosis.
     
  6. Tired

    Tired Fading away
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    I've always wondered if the potassium in LR ever causes problems in patients with pre-existing but undetected renal insufficiency?

    For the record, I've done rotations in probably 9-10 hospitals, and I have yet to see one that routinely uses Hartmann's solution.
     
  7. dynx

    dynx Yankee Imperialist
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    I don't know. That seems like it would be a legit concern in a patient in shock regardless of if they had pre-existing renal failure, they may very well have renal insult 2dary to the hypovolemia. But at my institution they always use LR anyway and I never bothered to ask. Never seen Hartmann's used but as i mentioned above, even with less Cl it may induce less acidosis with no real benefit...also has K, maybe a problem.
     
  8. Samoa

    Physician Pharmacist 10+ Year Member

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    Even if someone lost 40% of their blood volume, I'd hang NS until I got blood for transfusion. Is there really anyone here who'd stand around waiting for the blood to arrive?
     
  9. Tired

    Tired Fading away
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    If I were an ER doc, and EMS was bringing in a guy with >40% blood loss, and they didn't call me in advance so I could have trauma blood on its way . . . well, they'd be the first ambulance crew with two mouths and four anuses.
     
  10. Samoa

    Physician Pharmacist 10+ Year Member

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    Yeah, but what about the patient who walks in off the street with a 19% hematocrit, with a pulse >100 and a BP of 100/60. And yes, now that you mention it, he does get tired pretty easily.
     
  11. Tired

    Tired Fading away
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    Amazing how divergent my education is from the recent literature on this topic.

    Things I've been taught

    - isotonic crystalloids are essentially equivalent, and it doesn't matter which one you use
    - NS & LR are cheap and available, pick one and use it
    - aggressive fluid resuscitation is the cornerstone of shock treatment in most cases
    - LR may reduce the risk of fluid-induced hyperchloremic metabolic acidosis, because it is closer to physiologic pH than NS
    - Give 3L of crystalloid (or equivalent 20cc/kg x 3 in kids), if no response, then consider blood transfusion


    And here's what a 2-minute PubMed search says:

    Shock. 2006 Aug;26(2):115-21.
    "Increasing evidence has demonstrated that aggressive crystalloid-based resuscitation strategies are associated with cardiac and pulmonary complications, gastrointestinal dysmotility, coagulation disturbances, and immunological and inflammatory mediator dysfunction. As large volumes of fluids are administered, imbalances in intracellular and extracellular osmolarity occur. Disturbances in cell volume disrupt numerous regulatory mechanisms responsible for keeping the inflammatory cascade under control. Several authors have demonstrated the detrimental effects of large, crystalloid-based resuscitation strategies on pulmonary complications in specific surgical populations. Additionally, fluid-restrictive strategies have been associated with a decreased frequency of and shorter time to recovery from acute respiratory distress syndrome and trends toward shorter lengths of stay and lower mortality. Early resuscitation of hemorrhagic shock with predominately saline-based regimens has been associated with cardiac dysfunction and lower cardiac output, as well as higher mortality. Numerous investigators have evaluated potential risk factors for developing abdominal compartment syndrome and have universally noted the excessive use of crystalloids as the primary determinant. Resuscitation regimens that cause early increases in blood flow and pressure may result in greater hemorrhage and mortality than those regimens that yield comparable flow and pressure increases late in resuscitation. Future resuscitation research is likely to focus on improvements in fluid composition and adjuncts to administration of large volume of fluid."

    Surg Clin North Am. 2007 Feb;87(1):55-72, vi.
    "LR may be safe in small doses that the body can obviously tolerate, but not in larger amounts given over short periods following hemorrhagic shock and trauma. Modifications of LR, such as elimination of d-lactate, can decrease these adverse effects, and complete substitution of lactate with other monocarboxytates (eg, ketone bodies or pyruvate) seems to be beneficial. . .
    In trauma, fluid resuscitation is only needed in patients who have lost blood. It is clear that not all the trauma patients need fluid resuscitation. For bleeding patients intravenous access is critical but should not be synonymous with fluid infusion. In the absence of traumatic brain injury, “permissive hypotension” with systolic pressures greater than 80 mm Hg, consciousness, or palpable pulse are reasonable goals until hemorrhage has been controlled. Rather than resuscitating the patient before definitive hemorrhage control, emphasis should be on controlling hemorrhage and using fluids only to keep the patient alive during the process. It can be argued that the initial fluid of choice among commercially available fluids in the United States should be 5% HTS because it is commercially available. Two 250-mL boluses are safe and offer many potential advantages. This should be followed by infusion of l-isomer LR (Baxter, Deerfield, Illinois) if further volume expansion is needed. For the hypotensive bleeding patient, initiation of blood transfusion should be early, and blood component therapy should be initiated immediately without waiting for the development of coagulopathy. Thawed fresh frozen plasma should be given in a 1:1 ratio to packed red blood cells."
     
  12. ericdamiansean

    ericdamiansean High Profiler
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    I've been taught that for someone with more than 40%, initial fluid resus should be at least 2 L of fluids bolus before blood is available, thus, if we are utilizing information from the research above, 1L of NS followed by 1L of Ringer's lactate?
     
  13. dynx

    dynx Yankee Imperialist
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    So it should be chosen because it is available since it is available? I see, no...wait, what? Was this study done by Dr. Hartmann and Galaxo-smith-kline?
     

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