IV Access/Fluids ================ LR: # 130 mEq of sodium ion = 130 mmol/L. # 109 mEq of chloride ion = 109 mmol/L # 28 mEq of lactate = 28 mmol/L # 4 mEq of potassium ion = 4 mmol/L # 3 mEq of calcium ion = 1.5 mmol/L . Hartmann's # 131 mEq of sodium ion = 131 mmol/L. # 111 mEq of chloride ion = 111 mmol/L . # 29 mEq of lactate = 29 mmol/L . # 5 mEq of potassium ion = 5 mmol/L . # 2 mEq of calcium ion = 2 mmol/L þ Central line complications 821 patients at M.D. Anderson 411 with ultrasound, 410 without Complication rate of 9.75% Misplacement 6% Arterial puncture 2.7% Pneumothorax 1.5% Mediastinal hematoma 0.6% Predictors of failed cannulation BMI > 30 and prior catheterization Mansfield, PF, et al., NEJM, 1994 þ Intraosseous References Iserson KV. Intraosseous infusions in adults. J Emerg Med 1989;7:587. Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations. Glaeser PW; Hellmich TR; Szewczuga D; Losek JD; Smith DS. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med, 22: 7, 1993 Jul, 1119-24 STUDY OBJECTIVE: To evaluate the ability of emergency medical technician-paramedic (EMT-P) units to become and remain proficient in the performance of the intraosseous infusion procedure. DESIGN AND SETTING: Descriptive nonrandomized trial open to all patients meeting protocol criteria over a five-year period; prehospital urban and suburban area with a population of 951,000. PARTICIPANTS: One hundred fifty-two consecutive patients (age range, newborn to 102 years) who had intraosseous infusion line placement attempted by EMT-Ps. INTERVENTION: Jamshidi sternal intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring emergency vascular access for fluid and/or medication administration. RESULTS: EMT-Ps performed 165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt. Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years; and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in landmark identification and needle bending were the most frequent identifiable causes for unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28 patients (24%). CONCLUSION: EMT-P units can successfully perform the intraosseous infusion line procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by individual EMT-Ps. Valdes MM. IO fluid administration in emergencies. Lancet 1977; June 11, p.1235. þ Choice of IV Fluid - acid content of various IV fluids - for hemorrhagic shock, either NS or LR are OK. Comments from Harvey Louzon: The great debates in fluid resuscitation have traditionally been 1) colloid vs crystalloid and 2) hypertonic vs isotonic saline. A meta-analysis of the former problem seems to give the nod to crystalloid solutions, at least for hemorrhagic shock. With respect to the latter issue, recent studies appear to show some advantages in the use of hypertonic saline in terms of improved cardiac output and possibly cerebral protection provided that severe hypernatremia (> 170) is avoided. It appears as if the use of hypertonic saline (and possibly isotonic saline (1)) may worsen acidosis early on in the resuscitation phase of hypovolemic shock (I gave a reference yesterday in support of the former assertion). A slightly less contested issue has been whether the use of lactated ringer's (LR) may perpetuate or worsen acidosis because of the inability of the liver in low flow states to metabolize the lactate to bicarb. 'Buffering' the LR with bicarb, however, does not appear to offer any particular advantages (2). Both LR and NS are *unbuffered* solutions with a very small amount of free [H+] (3). Whatever effects these solutions may have transiently upon acid-base balance are more than offset, in even the short term, by their effects in expanding intravascular volume and improving tissue blood flow and oxygen delivery. With normal renal function the kidneys should automatically correct any acid-base imbalances that result once renal blood flow is restored. Thus I think that the argument over LR vs NS in fluid resuscitation is somewhat akin to that over tPA vs SK in acute MI. I.e., it is far less important exactly *what* is used, provided we are not parlayed by indecision over too many options that are more important theoretically than they are practically. I ran across an article with some historical information about the origins of Ringer's solution (4). H. Louzon MD "Nurse, please administer one liter of Sidney Ringer's solution to the GI bleeder in room 5." (1) The effect of various resuscitative regimens on hemorrhagic shock in puppies. Strodel WE; Callahan M; Weintraub WH; Coran AG J Pediatr Surg, 12: 6, 1977 Dec, 809-19 Since shock secondary to hemorrhage is not infrequently encountered in the pediatric patient, a puppy model was devised to help measure and monitor cardiovascular and metabolic changes that occur before and after resuscitation from hypovolemic shock (mean arterial pressure of 50 mm Hg for 1 hr). Three resuscitation protocols were compared: whole blood (replacement:shed) 1:1, 5% albumin in Ringer's lactate 1:1; and Ringer's lactate 3:1. All dogs survived the experiment and responded similarly during the shock period. Thermal dilution cardiac output rose in all groups after resuscitation; however, in the Ringer's lactate and 5% albumin groups, cardiac output was statistically greater than that observed in the blood group. In all groups, pH and blood pressure approached but did not return completely to baseline levels after resuscitation. In addition, early resuscitation demonstrated a further decrease pH ("hidden acidosis") before it began to return toward normal as resuscitation progressed. This study suggests that the infusion of large volumes of Ringer's lactate or 5% albumin in Ringer's lactate are equally efficacious in the treatment of hemorrhage. However, 5% albumin seems to be preferable because it allows infusion of a smaller quantity of electrolyte solution with equivalent physiologic benefits. (2) McGovern PJ Jr Machiedo GW; Rush BF Jr The effect of pH of resuscitative fluids in treatment of severe hemorrhagic shock. Adv Shock Res, 5:1981, 133-41 Commercially available Ringer's lactate solution has a pH of approximately 6.5. In a situation such as shock, which is normally accompanied by a metabolic acidosis, this additional acid load could have an adverse effect on resuscitation when massive amounts of fluid are required. We prepared a similar solution with a pH of 7.4 and compared the two solutions. Fourteen dogs were shocked according to a Wiggers' hemorrhagic shock model. Six dogs (43%) died during shock, 8 dogs survived the model, 4 were resuscitated over a 150-minute observation period to a pulmonary capillary wedge pressure (PCWP) of 8-12 mmHg with Ringer's lactate with a pH of 7.4. The cardiac output, lactate levels, amount of fluid required to maintain the PCWP, and arterial and mixed venous pH were measured at 30, 60, 90, 120, and 150 minutes. No significant differences were found except for occasionally higher arterial pH values in the group treated with Ringer's lactate with a pH of 7.4. There was no difference between the groups in any measurement at the end of the observation period or in survival. All dogs died within 12 hours of the end of the shock period. Our data indicate that the somewhat acidic pH of standard Ringer's lactate does not adversely affect the adequacy of resuscitation. There is no advantage to using Ringer's lactate with a pH of 7.4 (3) Traverso LW; Medina F; Bolin RB The buffering capacity of crystalloid and colloid resuscitation solutions. Resuscitation, 12: 4, 1985 Mar, 265-70 The buffering capacities of common colloid and crystalloid resuscitation solutions were compared in vitro. An equal volume of each resuscitation solution was titrated above and below its initial pH with 0.14 N sodium hydroxide or 0.11 N hydrochloric acid. The volume (+/- S.D.) of titration solution necessary to lower the pH one unit (7.1-6.1) in these solutions was less than 0.5 ml for normal saline, less than 0.5 ml for Ringer's lactate, 1.9 +/- 0.1 ml for Plasmalyte-A, 2.0 +/- 0.23 ml for Plasmalyte-R, 8.8 +/- 0.17 ml for human serum albumin (HSA), 45 +/- 2.2 ml for human fresh frozen plasma (FFP), and 50 +/- 6.6 ml for swine FFP. With the method of this in vitro study, human fresh frozen plasma was 25-50 times better as an acid buffer than the crystalloid solutions and approx. 5 times better than human serum albumin (HSA). On an equal volume basis, it was the superior resuscitation solution as a buffer, probably because of combined bicarbonate and protein content. (4) Sternbach G Sydney Ringer: water supplied by the New River Water Company. J Emerg Med, 6: 1, 1988 Jan-Feb, 71-4 Lactated Ringer's solution has been used for decades in the resuscitation of hypovolemia and hemorrhagic shock. Its origin relates to a serendipitous substitution of water in the London laboratory of Sydney Ringer in the 1880s. A number of controversies have related to the use of lactated Ringer's solution. Some of these have involved the potential exacerbation of lactic acidosis and the question of whether administration of colloid or crystalloid is preferable in severe hypovolemia. The use of hypertonic saline solutions in shock is an issue of current investigative interest. Sydney Ringer was a London physician and physiologist who had conducted experiments on the effects of various electrolyte solutions on the contractile function of denervated frog hearts in the 1880's. He observed that the addition of small amounts of K+ to a saline solution had beneficial effects on contractility. Unbeknownst to him at the time was that the saline solution that he was using had not been prepared with distilled water but, rather, from water which had been supplied by the New River Water Company. It turns out that this solution contained several other electrolytes most notably calcium which Sydney demonstrated was beneficial in stimulating contractility of the ventricles. Thus was born the idea of adding K+ and Ca++ to a saline solution. Sidney went on to make greater discoveries including the fact that minnows placed in distilled water die within 4.5 hours, but that the addition of small amount of Na+ or Ca++ salt greatly prolongs their existence. Subsequently, in 1932, an American pediatrician named Hartman, wishing to provide a base precursor to his acidotic patients, decided to add sodium lactate to this solution. And thus was born Lactated Ringer's (or, as it is sometimes known abroad) Hartman's solution. Bicarb was rejected because it was felt that it would correct the acidosis too rapidly. This article mentions that studies have confirmed that the infusion of 1 liter of LR will increase plasma volume about 175 cc. (and is comparable to the increase in plasma volume resulting from the infusion of 1 L NS. If LR is distributed evenly throughout the ECF then this is somewhat less than the 250 cc predicted. It is also considerably less than the oft quoted 3:1 ratio of fluids needed to replace an equivalent volume of blood. No doubt ICF to ECF movement of fluids occurs in shock to partially adjust for this). The article also mentions the hypothesis that has been raised concerning the inability of the liver to metabolize lactate in low flow states and that this may contribute to a metabolic acidosis. They reference a study that looked at patients who had received blood + NS compared to blood + LR. Although patients had received an average of 10 L of crystalloid no significant differences in pH or lactate levels were noted. I will never again be able to order LR on anyone without remembering its origins and the serendipitous contribution of London's 'New River Water Company'. --------------------------------- Cervera AL; Moss G Dilutional re-expansion with crystalloid after massive hemorrahage: saline versus balanced electrolyte solution for maintenance of normal blood volume and arterial pH. J Trauma, 15: 6, 1975 Jun, 498-503 When administered in sufficient amounts, normal saline and Lactated Ringer's Solution are equally effective in maintaining adequate circulatory volumes despite severe blood loss and resultant hypoproteinemia. Arterial pH is maintained within normal limits when either solution is used for resuscitation provided the circulatory volume has been re-expanded to adequate levels for good tissue perfusion and support of aerobic metabolism. The pH of the infused solutions has no effect on blood pH under these circumstances. Fourteen splenectomized dogs were subjected to continuous hemorrhage and simultaneous replacement with either normal saline or Lactated Ringer's Solution. The cumulative replacement volume ratio necessary for equilibration after 61% RBC depletion was 7:1 crystalloid to the whole "undiluted" blood shed, in both groups. Indicators of pulmonary-circulatory physiology remained stable within normal limits. Arterial pH did not exhibit significant changes from normal values after resuscitation with NS or LRS. The group infused with LRS exhibited no change in arterial pH, 7.40 plus or minus .07 initial and 7.40 plus or minus .09 final; in the group with NS replacement a slight decrease from control was noted, 7.40 plus or minus .07 initial and 7.36 plus or minus .06 final. These differences, however, are not statistically significant. Of the 14 subjects, 13 were long-term survivors. The one death was associated with a technical mishap shortly after completion of the experiment. Because banked blood imposes a "net" alkaline metabolic load (sodium citrate), patients expected to be transfused with large volumes of stored blood might be better resuscited with normal saline than with Ringer's Lactate Soultions, to minimize or avert the otherwise resultant metabolic alkalosis.