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    In treating hypovolaemia (caused by blood loss), which infusion would benefit the patient the most and why?

    - 5% dextrose
    - 0.15M saline
    - Colloid solution?

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    Different people will tell you different things, no one really has the right answer

    I would personally go for colloids, cause it stays in the intravascular space more.....

    Edit: If it is caused by blood lose, perhaps a transfusion is warranted?
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    (Original post by Lu-x)
    In treating hypovolaemia (caused by blood loss), which infusion would benefit the patient the most and why?

    - 5% dextrose
    - 0.15M saline
    - Colloid solution?

    Cheers
    You need to think about the fluid compartments in this case.
    - intracellular = ~2/3rds of body fluid
    - extracellular = ~1/3rd of body fluid
    Then making up extracellular you have
    - interstitial = ~2/3rds
    - intravascular = ~1/3rd
    (Distributions very rough, as told to me by an anaesthetist).

    5% dextrose is basically water and goes into all the fluid compartments where for hypovolaemia, you really want to be expanding the intravascular compartment in particular.
    0.15M saline is isotonic and distributes throughout the extracellular compartment.
    Colloids are the fluid that remain longer in the intravascular compartment (due to their structure) so are most useful of those 3 for managing hypovolaemia.

    If you've not come across it before, I find fluid balance without tears very helpful.

    In practice I've seen alternating infusions of saline/Hartmann's and a colloid (or one going in each arm) used and then if it's caused by blood loss, transfusions as well.
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    (Original post by Hygeia)
    You need to think about the fluid compartments in this case.
    - intracellular = ~2/3rds of body fluid
    - extracellular = ~1/3rd of body fluid
    Then making up extracellular you have
    - interstitial = ~2/3rds
    - intravascular = ~1/3rd
    (Distributions very rough, as told to me by an anaesthetist).

    5% dextrose is basically water and goes into all the fluid compartments where for hypovolaemia, you really want to be expanding the intravascular compartment in particular.
    0.15M saline is isotonic and distributes throughout the extracellular compartment.
    Colloids are the fluid that remain longer in the intravascular compartment (due to their structure) so are most useful of those 3 for managing hypovolaemia.

    If you've not come across it before, I find fluid balance without tears very helpful.

    In practice I've seen alternating infusions of saline/Hartmann's and a colloid (or one going in each arm) used and then if it's caused by blood loss, transfusions as well.
    Wow thanks that was very helpful
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      (Original post by Lu-x)
      In treating hypovolaemia (caused by blood loss), which infusion would benefit the patient the most and why?

      - 5% dextrose
      - 0.15M saline
      - Colloid solution?

      Cheers
      Not dextrose
      Haven't a fudging clue what 0.15M saline is meant to be. Never use that term again.
      Hartmanns is by far and away the best stuff and you haven't got that as an option.
      And then there is colloid.

      For reasons Hygeia has already said I would tend to give a stat 500ml of colloid to an adult with blood loss related hypovolaemia and then use hartmanns.
      But what they are losing is blood so the best thing for them is more blood.
      Not 'water transfusions'.
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      Like with like, therefore, the solution is blood (+/- FFP and cryo).

      In the interim any fluid will do - current ATLS guidelines call for 2L warmed crystalloid (any flavour). Colloids have plenty of disadvantages to argue against their use.
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      As said above, dextrose is essentially water so doesn't deliver very effectively to the intravascular compartment where you want it.

      Crystalloid solutions (Saline and Hartmann's) are better but still end up interstitially. Of these, Hartmann's has a composition more similar to that of plasma so will cause less electrolyte disturbance.

      Colloids stay longer intravascularly but are still inadequate. They are better, but not that much better as I understand it ("sticky saline") and what you really need to replace blood with is blood.

      Note that any fluid other than blood won't replace red blood cells and will dilute clotting factors.
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        (Original post by Renal)
        Like with like, therefore, the solution is blood (+/- FFP and cryo).

        In the interim any fluid will do - current ATLS guidelines call for 2L warmed crystalloid (any flavour). Colloids have plenty of disadvantages to argue against their use.
        I would just go with hartmanns myself - colloids tend to raise the BP for a few hours then it crashes. Invariably when there is no one looking.

        But some of the surgical numpties have a hissy fit and believe religiously that no colloid = murder.
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        there is a recently revised cochrane review on the merits of colloid/crystalloid resuscitation that may be worth looking at.

        If there has been significant haemorrhage and you cram lots of fluids in you will inevitably cause dilutional coagulopathy. I know, I have done it. In similar situations (admittedly post-surgery) I have found it easier to give colloid bolus as resuscitation and then give packed cells, platelets and ffp (and cryo but its very rarely required). The trust I work in now recommends the combination for haemorrhage because just giving blood results in coagulopathy.

        So which ever fluid you give, bare in mind that you could be doing them very few favours without blood products.

        Hartmanns is by far and away the best stuff and you haven't got that as an option.
        And then there is colloid.
        I do like a nice bag of Volulyte 6%. in terms of fluid resuscitation using a crystalloid though, in hypovolaemia (rather than dehydration), the excessive salt load of normal saline could be argued as preferable to hartmann's? when you want to increase intravascular volume.

        for maintenance fluid I do like hartmann's, I'm also a fan of the underdog; dex saline with 20 mmol of KCl.

        Any thoughts?
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          (Original post by davey jones)
          there is a recently revised cochrane review on the merits of colloid/crystalloid resuscitation that may be worth looking at.

          If there has been significant haemorrhage and you cram lots of fluids in you will inevitably cause dilutional coagulopathy. I know, I have done it. In similar situations (admittedly post-surgery) I have found it easier to give colloid bolus as resuscitation and then give packed cells, platelets and ffp (and cryo but its very rarely required). The trust I work in now recommends the combination for haemorrhage because just giving blood results in coagulopathy.

          So which ever fluid you give, bare in mind that you could be doing them very few favours without blood products.
          Obviously (for those who joined late) this conversation is very much one of hypovolaemia secondary to blood loss. Very different approach than in other hypovolaemic states.

          The whole don't just give pRBC thing is very old news, the only debate is the ratio of replacement. Recent evidence based int he battlefields have shown that for massive transfusions (replacing more than 1xtotal circulating volume) you should use 1PRBC:1FFP:1Platelet.

          (Original post by davey jones)
          I do like a nice bag of Volulyte 6%. in terms of fluid resuscitation using a crystalloid though, in hypovolaemia (rather than dehydration), the excessive salt load of normal saline could be argued as preferable to hartmann's? when you want to increase intravascular volume.

          for maintenance fluid I do like hartmann's, I'm also a fan of the underdog; dex saline with 20 mmol of KCl.

          Any thoughts?
          Volulyte is far better in my opinion amonsts the colloids (only worked in 1 trust that stocks it though!). Plus in big transfusions its quite handy because it contains calcium.
          But amonst crystalloids is always hartmanns. The sodium makes no difference at all. The difference between 140 (body/ECF) and 150 (NaCl) is not enough to draw significant fluid into the intravascular space. [compare this with 5% dextrose having 0 NaCl and body having 140 - much bigger gradient!]

          Dexsaline with 20 is good for maintenance, always fun to chuck in once ina while to keep the nurses on their toes (and so you know the bag running isn't the same one from this morning). But the pottasium level in it makes it dangerous to give in an hour or less.
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          not that dangerous, I am quite comfortable administering 20mmol KCL over 20 minutes and the difference it actually makes in most patients is really not as marked as you would think. But it goes without saying that I am in a comfortable position of having only one patient, alongside ECG and ABG/ABP monitoring.

          The transfusion thing I was referring to was a recent change in policy at my trust in the way they administer it for massive transfusion, i suspect we are on about same thing, but I can't remember the ratios. I don't prescribe so not I gave the email only the briefest of glances, but the bulk of it was about not just replacing packed cells.

          I much prefer volulyte, and I just cannot work out why some people won't prescribe it even when you ask nicely and the chloride is 120 and BE is -5? Reluctance to change practice?
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            (Original post by davey jones)
            not that dangerous, I am quite comfortable administering 20mmol KCL over 20 minutes and the difference it actually makes in most patients is really not as marked as you would think. But it goes without saying that I am in a comfortable position of having only one patient, alongside ECG and ABG/ABP monitoring.

            The transfusion thing I was referring to was a recent change in policy at my trust in the way they administer it for massive transfusion, i suspect we are on about same thing, but I can't remember the ratios. I don't prescribe so not I gave the email only the briefest of glances, but the bulk of it was about not just replacing packed cells.

            I much prefer volulyte, and I just cannot work out why some people won't prescribe it even when you ask nicely and the chloride is 120 and BE is -5? Reluctance to change practice?
            Reluctance to change practice?
            Nah its just no one other than ITU docs jerk themselves off to Chloride values
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            (Original post by Renal)
            Like with like, therefore, the solution is blood (+/- FFP and cryo).

            In the interim any fluid will do - current ATLS guidelines call for 2L warmed crystalloid (any flavour). Colloids have plenty of disadvantages to argue against their use.

            yep


            three most important fluids in pre-hospital care

            - patient's own blood (i.e. control bleeding)
            -oxygen
            - diesel
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            (Original post by Hygeia)
            You need to think about the fluid compartments in this case.
            - intracellular = ~2/3rds of body fluid
            - extracellular = ~1/3rd of body fluid
            Then making up extracellular you have
            - interstitial = ~2/3rds
            - intravascular = ~1/3rd
            (Distributions very rough, as told to me by an anaesthetist).

            5% dextrose is basically water and goes into all the fluid compartments where for hypovolaemia, you really want to be expanding the intravascular compartment in particular.
            0.15M saline is isotonic and distributes throughout the extracellular compartment.
            Colloids are the fluid that remain longer in the intravascular compartment (due to their structure) so are most useful of those 3 for managing hypovolaemia.

            If you've not come across it before, I find fluid balance without tears very helpful.

            In practice I've seen alternating infusions of saline/Hartmann's and a colloid (or one going in each arm) used and then if it's caused by blood loss, transfusions as well.
            Can I ask you what the difference is between "group and save" and "cross match"?
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              (Original post by Wild_Precious_Life)
              Can I ask you what the difference is between "group and save" and "cross match"?
              Group and save basically means ABO and rhesus matching. (Group) and save the sample. It takes a short amount fo time but is a step that is always needed.

              Crossmatch is the next step. Once one has identified the group and rhesus status then you have a smaller 'pool' size of blood units that you can use.
              In ye olde days you would then take a sample from the blood unit and mix it some blood from the patient. If you saw a reaction you couldn't use that blood unit. If you didn't see a reaction it was fine. THe reactive agents are the minor antigens/antibodies.

              Nowadays we have 'electronic crossmatching' which basically means an automated system finds which of the main minor antigens/phenotypes the patient is e, E, K etc.
              THey can then issue bloods which match these criteria.

              Hence going back 10 years ago the crossmatch would be for a certain number of units. It would take circa30-40mins for each unit (although several can be done at once you wouldn't ask for 6 units if you needed 2)

              Nowadays the crossmatch still takes about 30mins but once its done you can then issue as many units as you want in seconds based on that profile.

              THe old 'rules' about how long the sample is valid for still apply.

              Hope that helps.
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              (Original post by Jamie)
              Group and save basically means ABO and rhesus matching. (Group) and save the sample. It takes a short amount fo time but is a step that is always needed.

              Crossmatch is the next step. Once one has identified the group and rhesus status then you have a smaller 'pool' size of blood units that you can use.
              In ye olde days you would then take a sample from the blood unit and mix it some blood from the patient. If you saw a reaction you couldn't use that blood unit. If you didn't see a reaction it was fine. THe reactive agents are the minor antigens/antibodies.

              Nowadays we have 'electronic crossmatching' which basically means an automated system finds which of the main minor antigens/phenotypes the patient is e, E, K etc.
              THey can then issue bloods which match these criteria.

              Hence going back 10 years ago the crossmatch would be for a certain number of units. It would take circa30-40mins for each unit (although several can be done at once you wouldn't ask for 6 units if you needed 2)

              Nowadays the crossmatch still takes about 30mins but once its done you can then issue as many units as you want in seconds based on that profile.

              THe old 'rules' about how long the sample is valid for still apply.

              Hope that helps.
              Wow, thanks that was really useful. Silly q but where are the blood samples stored?
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                (Original post by Wild_Precious_Life)
                Wow, thanks that was really useful. Silly q but where are the blood samples stored?
                Errrrm in haematology..?

                Best thing really is go to your haematology lab and ask if you can see what they do there.
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                (Original post by Wild_Precious_Life)
                Wow, thanks that was really useful. Silly q but where are the blood samples stored?
                In the blood bank, usually somewhere around the pathology labs. Each hospital has a set procedure for retrieving blood from there and usually you can't do it unless you've been trained in this procedure.

                The other thing I would add to Jamie's G&S/XM description is that XM is more expensive, and means (as I understand it) once a particular unit of blood has been matched to a patient, it is labelled with that patient's details and only available for their use - so if it turns out they don't need it, it goes to waste. This is why you would G&S for someone who you think MAY need a transfusion, and only X-match if you are sure you're going to be giving it.
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                  (Original post by Helenia)
                  In the blood bank, usually somewhere around the pathology labs. Each hospital has a set procedure for retrieving blood from there and usually you can't do it unless you've been trained in this procedure.

                  The other thing I would add to Jamie's G&S/XM description is that XM is more expensive, and means (as I understand it) once a particular unit of blood has been matched to a patient, it is labelled with that patient's details and only available for their use - so if it turns out they don't need it, it goes to waste. This is why you would G&S for someone who you think MAY need a transfusion, and only X-match if you are sure you're going to be giving it.
                  Slightly disagree there Helenia.
                  Modern 'electronic crossmatching' might label the bags, but the old style could still be put back in the 'pool' if not used within 48 hours.

                  Any rules that you describe will be on a trust by trust basis and are not inherent to testing of the samples.
                  i.e. Most hospitals do not bin unused crossmatched units (unless they have left the bloodbank department and thus quality control is lost)
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                  (Original post by Jamie)
                  Slightly disagree there Helenia.
                  Modern 'electronic crossmatching' might label the bags, but the old style could still be put back in the 'pool' if not used within 48 hours.

                  Any rules that you describe will be on a trust by trust basis and are not inherent to testing of the samples.
                  i.e. Most hospitals do not bin unused crossmatched units (unless they have left the bloodbank department and thus quality control is lost)
                  Oh ok, didn't know that - was the case when we had our med school teaching and at my hospital last year.
                 
                 
                 
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