Volume, Electrolyte, and

Blood Product Replacement

W. Clay Jackson, MD, DipTh
Assistant Professor, UT Dept. of Family Medicine
Indications for Intravenous Tx
Volume replacement
Biochemical correction
Retention of RBCs
Provision of nutrition
Filtering of noxious products
Signs of Dehydration
Poor skin turgor
Tachycardia
Poor capillary refill (>3 sec)
Dry mucous membranes

Sunken eyes
Sunken fontanelles
No tears
Rehydration Solutions
Crystalloids
Distribute across ECF
Colloids
Remain intravascular
Rehydration Solutions
Crystalloids
Normal saline (NS)
Lactated Ringers (LR)
Normosol
Plasma-Lyte



NS vs. LR
154 meq Na, Cl
Often has 20 meq
KCl/L added
NEVER bolus fluid
with KCl added
pH 5.7; 308 mOsm/L
$7 / L
130 meq Na
109 meq Cl
4 meq K
3 meq Ca
28 meq lactate

pH 6.4; 273 mOsm/L
$22 / L
Cant use with blood

Normal Saline Lactated Ringers
n.b. Plasma-Lyte and Normosol approximate plasma more closely.
Rehydration Solutions
Colloids (Greek: glue)
Dextrans (anaphylaxis, bleeding)
10% Dex-40
6% Dex-70
Starch
6% Heta- (T
1/2
17 d, but oncotic 24 h)
10% Penta-
Albumin (expensive)
5%
25% (not for volume rescusc; ICF)
Rehydration

BOLUS
1-2 L (NS or LR)
MAINTENANCE
75-125 cc/hr
REPLENISH
20 meq KCl/L
BOLUS
20 cc/kg (NS or LR)
MAINTENANCE (with ?-NS)
4 cc/kg/hr (1
st
10 kg)
2 cc/kg/hr (2
nd
10 kg)
1 cc/kg/hr (additional kg)
REPLENISH
20 meq KCl/L

Adults Children
Na requirement: 3 meq/kg/d
K requirement: 2 meq/kg/d
A good heart and kidneys can
surmount all but the most
willfully incompetent of
fluid regimens.

The Whole Internists Catalog
What about D
5
W?
Poor volume expander (50 cc intravascular/L)
Poor supply of calories (170 kcal/L)
Hypertonic (278 mOsm just from dextrose)
Increased CO
2
, lactate production
NOT recommended for ill patients
EXCEPT patients with DKA
on insulin drips
Electrolyte Replacement
MS changes, szs
Must determine type
Hypovolemic
Euvolemic
Hypervolemic
Pseudo?
(+1.6 meq/L for each
100 glc above 100
mg/dL)
Treatment varies (<125)
Slow replacement (CPM)
1 meq/hr; <10 meq/24hr
Tx of underlying cause
Fluid restriction

Sodium
136-145
Electrolyte Replacement
Muscle weakness, cardiac
toxicity <3.0
Vast majority is
intracellular
Insulin pushes K into cells
Correction of acidosis
pushes K into cells
KCl or KP0
4
po (bitter)
KCl IV 10 meq/h (X 4h)
Potassium
3.5-5.1
Electrolyte Replacement
Tetany
(Chvosteks sign--cheek)
(Trousseaus sign--tourniquet)
Correction factor
(1.0 albumin : 0.8 Ca)
OsCal (CaCO
3
) po
1 amp 10% soln
(1000 mg/10 cc)
CaCl
2
Ca gluconate

Calcium
8.8-10.5
Electrolyte Replacement
Muscle weakness

Neutra-Phos or K-Phos po
Severe (<1.0 mg/dL):
0.08-0.16 mmol/kg IV
(over 6 hr)

Phosphate
2.5-4.9

Electrolyte Replacement
N/V, tetany
2-6 gm bolus
1-2 gm/hr (for 2-4 hrs)
Acidosis renders heart
arrhythmias refractory
to tx
Some advocate
amps of HCO
3
44 meq IV
Magnesium
1.8-2.4
HCO
3

21-32
William Harvey 1578-1657
University of Cambridge; University of Padua
Personal physician to Charles I
1628: Anatomical Exercises on the Motion
of the Heart and Blood in Animals
1651: Essays on the Generation of Mammals
Blood Products
Whole blood
Packed RBCs
Fresh frozen plasma (FFP)
Cryoprecipitate
Platelets
Blood is Blood, right?
Whole blood
Volume expander
35 d shelf life d
Washed RBCs
Pts with allergic
reactions to plasma
proteins

Packed RBCs
Saves volume (250 cc)
42 d shelf life
Leuko-poor RBCs
Pts with febrile, non-
hemolytic reactions to
plasma WBCs

The Compatibility Game
ABO compatibility
Recipient can only
receive ABO proteins
he/she has previously
seen
O can donate to any
recipient
O recipients can only
receive O blood

Rh compatibility
Rh- recipient
should receive Rh-
blood
Rh+ recipient can
receive Rh+ or Rh-
blood
Blood Loss:
How much is too much?
5% body wt. in
intravascular space
10% blood loss =
hypovolemic shock
1 unit blood = 500cc
(raises HCT 2-3%)


80 cc/kg in intravascular
space
20% blood loss =
hypovolemic shock
Transfuse 10 cc/kg
Adults Neonates
To transfuse or not to transfuse
HCT <30
Acute onset
Pt symptomatic
Presyncopal
Hypotensive
Tachycardic
Tachypneic
Other stressors imminent
Platelets
Danger zone: <50 K plts
Frank bleeding: <10 K plts
Each unit of plts count by 10 K
6-8 units usually transfused
Clotting Factors
Fresh frozen plasma (FFP)
All clotting factors; no
platelets
Can supplement RBCs
when whole blood not
available for exchange
transfusion
Cryoprecipitate
Initially a tx for VW
Dz, Hemophilia
Now a source of
fibrinogen in
cardiothoracic surgery,
obstetric emergencies
Doctor, Doctor!
Weve lost our IV!
Subclavian*
Internal Jugular (IJ)*
Femoral*
Umbilical Artery (UAC)
Umbilical Vein (UVC)
Intraosseus (IO)

All patients Peds only
* Utilize Seldinger technique; see handout
Femoral Line
Sir William Osler
www.utmem.edu/fpsa/