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IV fluidsFunctionRestore IV vol sufficient for critical organ perfusion; maintain O2-carrying capacity of blood for adequate delivery; correct derangement in coagN salineNa 150 Cl 150 Osm 300 pH 5.3Indications: replacement of ECF losses, hypoNa, shocked paedsSE: hyperCl metabolic acidosis if large amountsCI: hyperNa, hyperCl, maintenance in paedsHypertonic saline (7.5%)Na Cl Osm pHDraws water from ISF to IVF rapid expansion of intravascular space in minimal time; decr SVR (due to vasoD); interstitial dehydration decr ICP and cerebral oedemaIndication: HIDose: 250ml dose (equivalent of 2L saline)SE: phelbitis, fluid overload, hyperNa, osmotic demyelination syndrome0.45% salineNa 75 Cl 75 Osm pHIndication: in 2nd hr of trt of DKA (avoid hyperCl), trt of hyperNa due to ECF lossHartmann’sNa 131 Cl 111 K 5 Ca 2 Osm 278 pH 6 Lactate 29Physiological electrolyte replacementCI: lactic acidosis, hyperCa/K, hypothermia, clots with blood transfusionRinger’s lactatePros: buffers acidaemiaCons: hyperK if renal insufficiency5% dexNa Cl Osm 278 pH Glu 50g/LIndications: DM, hyperNa, most effective for establishing urine flow in euvolaemic patient10% dexNa Cl Osm pH Glu 100g/LIndications: DKA where normoG but still incr ketones; persistent hypoG unable to eat; sick neonateNaHCO3See belowGelofusinNa 154 Cl 120 Osm 274 pH; vascular expansion lasts 3-4hs; anaphylactoid reactions4% AlbuminNa 140 Cl 128 K 0.12 Osm 250 pH 7 Alb 40g/LIndications: hypoV with incr cap perm or hypoAlb; burns after 12hrs; shock and alb <20; therapeutic plasma exchangeSE’s: fluid overload, infection, expensive20% AlbuminNa 5.5 Cl Osm 80 Alb 20g/100mlIndications: diuresis in hypoproteinaemia; shock and alb <20; haemolytic disease of newbornMannitol0,.5-1g/kg over 30minsCrystalloids vs colloidsSAFE study: No significant difference between albumin (colloid) and saline (crystalloid) in fluid resus of ICU patients in terms of ICU/hospital LOS, duration of mechanical ventilation; subset showed decr mortality in sepsis (statistically insignificant), incr mortality in HIInterstitial dehydration may be good in some circumstances (eg. ARDS, HI)PRBC300ml bags (500ml in whole blood)Indications: Hb <7, Hb <10 and symptoms or active bleedingO neg low titre: immediateGroup specific: 10mins; O 46% > A 39% > B 11% > AB 3.5%; Rh +ive 80%, Rh-ive 20%XM: 30mins; clinically significant ab’s present in 2% ED patients (5% haem/onc patients), incr with ageEffects of storage: incr pH, K, rigidity of cell membrane, citrate decr T, Ca (due to citrate), 2,3,DPG L shift no factor V/VIII activity, no pltsTechnique: infuse no faster than 5ml/min for 1st 15mins; compatible only with N saline and 4% alb; slowest rate is 1iu/4hrs; can be stored for up to 30/7; Hct 60-70% (35-40% in whole blood)Pros: longer life, less storage problems, less AgsCons: slower flow, smaller vol, higher viscosity; can’t give meds through same lineComplications: Microaggregates (activate coagulation cascade and complement, impairs microcirculation and O2 delivery) ABO incompatibility (usually misidentification error) Citrate toxicity (if >100ml/min; decr ionised Ca, metabolic acidosis, metallic taste / perioral paraesthesia) HyperK (usually if blood >2/52 old); hyperNa Hypothermia (shifts curve to L, decr CO) Febrile non-haemolytic reaction (incidence 0.1-1%; often in multip/multiple transfusions; recipient ab to donor RBC; dose related, towards end of transfusion 30-120mins in or after transfusion; stop transfusion, check pt and blood details if mild (T change <1.5, no rash), restart / if mod (T incr >1.5, urticaria), give anti-histamines and paracetamol, restart after 20mins / if severe stop, send rpt sample; more common with plts) Allergy (recipient reaction to pp’s in donor blood; most common with FFP; 1-3% incidence mild reaction, 1:20- 50,000 anaphylaxis; trt as fever) Haemolysis (1:12-77,000; shock, fever, headache, pain, Hburia, ARF, DIC) Tranfusion related acute lung inj (1:5-10,000; can be fatal; donor ab’s to patient’s WBC’s pul damage SOB, cough, fever, APO within 1-6hrs) Bacterial contamination (1:500,000; more common with plt) Immune suppression Jaundice (30% transfused RBC don’t survive) Transfusion related disease (eg. HIV 1:5400000, Hep C 1:2700000, Hep B 1:739000, malaria etc..) GVHD (transfusion of immunocompetent WBC to immunosupp patient; onset 10-14/7 fever, skin rash, pancytopenia, diarrhoea, abnormal LFT’s; prevent by irradiating blood products)FFP180ml bagsAvailable in 30mins; do require ABO compatibility; contains all CF’s + fibrinogen; give at 10ml/min (ie over <1hr); give 4-6iu per 5L bloodIndications: haemorrhage and coagulopathy; reversal of warfarin OD; factor def; AT III def; TTPCryoAvailable in 30mins; better if ABO compatibility; contains VIII/XIII, fibrinogen, vWF; give at 10ml/min (ie over <1hr); give 1iu / 10kg body weight Indications: bleeding and fib <1Plt50ml bagsAvailable in 15-30mins; do not require ABO compatibility; can only be stored 3/7; 1iu incr plt 5; give 1-2 units per 5L bloodIndications: plt <10 <20 and fever / antibiotics / evidence of systemic haemostatic failure <50 and bleeding (or skin bleeding time >2x normal) or OT (<100 if eye / neuro); neurosurg OT on anti- plt DIC / ITP with life-threatening haemorrhagePTXContains II/V/VII/IX/X, anti-thrombin and heparin; DOA 12-24hrs; give 3ml/min; give 25-50iu/kg (50iu if INR >6, 35iu if INR 4-6, 25iu if INR 2-4) Indications: congenital CF def, warfarin OD and significant bleedingPros: small vol, rapid admin, no time delay in thawing (unlike FFP), no ABO typing (unlike FFP), INR reversal within 15mins, no disease transmissionFactor VIIaNot demonstrated to improve any clinically significant outcomes in trials; incr mortality in blunt trauma in CONTROL trial, expensive, requires normal pH and T to be effective; 5% absolute incr risk of VTE; give 90-120mcg/kgIndications: last resort in generalised bleeding only after control of bleeding obtained; inhibitors to CF VIII/X; congenital CF VII def; Glanzmann’s thrombastheniaNotes from: DunnUse of NaHCO3 8.4% = 1mmol/mlMOABicarbonate load buffer H, alkaline urineNa load additive effect to above to help with Na channel blockadeIndicationsHydrofluoric acid toxicityCorrection of severe metabolic acidosis: 0.5mmol/kg for each desired incr in HCO3; endpoint HCO3 >8, clinical improvement of shock / dysrhythmias; incr pH to no greater than 7.2HCO3 <3, pH <7.2, severe hyperchloraemic acidaemiaCyanide poisoningIsoniazid ODEthylene glycol, methanol, other toxic alcoholsProlonged cardiac arrest (evidence unclear): Cons: doesn’t improve ability to defib / survival rates in animals; can compromise coronary perfusion pressure; shifts Ox-Hb curve to L (Hb holds on to O2 tissue hypoxia); produces CO2 intracellular acidosis; causes hyperosm and hyperNa; exacerbates central venous acidosis; may inactive adrenaline given; precipitates with Ca; does not correct causes of acidosisCardiotoxicity 2Y to fast Na channel blockade (cardiac arrest, VF/VT, hypoT): repeated doses of 2mmol/kg IV until stability achieved 100mmol diluted in 1000ml N saline at 100-250ml/hr; aim pH 7.5-7.55; stop when no longer cardiotoxic; will likely need K supplementationTCA, Type 1a and 1c antiarrhythmics: flecainide, quinidineChloroquine / hydroxychloroquine Antihistamines Antimalarials (quinine) Phenothiazines (eg. Stemetil, chlorprom) Cocaine, carbamazepine Propanolol, LA, type IV, amantadineUrinary alkalinisation in OD enhanced elimination: 1-2mmol/kg IV bolus 100mmol in 1L 5% dex at 250ml/hr; add 20mmol KCl to infusion to maintain normal K; aim urinary pH >7.5Salicylate – moderate severity not requiring haemodialysis (pH <7.1)Phenobarbitone – if continued toxicity despite MDACMethotrexateMethanolRhabdo and myoglobinuria renal failure Urinary sepsis, RTA type 1Prevention of drug redistribution to CNS – incr unionized amount of drugSalicylateSevere hyperK: 50-100mmol slow IV (1mmol/kg in children)SE’sExtravasation, gastric distension, hyperNa, hyperosmolality, vol overload, pul oedema, alkalosis (pH >7.6 bad for CV function), L shift of O2-Hb diss curve (impaired O2 unloading), hypoK, hypoCa (usually not clinically significant); incr lactate production (decr citrate and lactate metabolism); resp acidosis (ventilation must account for incr CO2 production)CI’sHypoK, hypoCa, alkalosis, acute pul oedema, renal failure, severe hyperNatone ................
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