Académique Documents
Professionnel Documents
Culture Documents
FLUID RESUSCITATION
There are myriad options for fluid
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).
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
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
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.
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