# Fluid Selection



## slepyii (Aug 2, 2008)

Which fluid would you select to start at a KVO/TKO rate on a CHF patient if you did not have a saline lock available when starting an IV?  Could you please explain why you choose the solution you did over the others.  

This is a question that was brought up in our I85 class and we were told to always start NS on all medical patients while trauma would get LR.  If rapid fluid replacement was needed we would start bilateral IV's with one running LR and the other running NS, both wide open.

We are getting conflicting answers when asking a medic, as they said for a CHF patient they would start LR. They stated that NS would cause fluid retention, which could further aggravate the problems of congestion.  I could see this also being a problem on a patient with pneumonia.

I understand that the IV would only be used as a medication route and that at a TKO rate they amount of fluid being delivered would not be enough to add to the problem significantly by time we could get them to the ED.  I am looking for a better explanation than "medical get NS and trauma get LR" as to why you would choose one solution over the other.


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## MSDeltaFlt (Aug 2, 2008)

slepyii said:


> Which fluid would you select to start at a KVO/TKO rate on a CHF patient if you did not have a saline lock available when starting an IV?  Could you please explain why you choose the solution you did over the others.
> 
> This is a question that was brought up in our I85 class and we were told to always start NS on all medical patients while trauma would get LR.  If rapid fluid replacement was needed we would start bilateral IV's with one running LR and the other running NS, both wide open.
> 
> ...



It's six to one and half a dozen to the other.  For a CHF pt, the KVO rate would be so slow that the amount given would be not unlike spitting in the ocean.  It really doesn't matter... so long as it's not D5 and they are not hypoglycemic.


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## Ridryder911 (Aug 2, 2008)

Definitely NOT R L as "Hartman's Solution"; contains a higher sodium level and lactate level. Yes, the amount of fluid is the key but we do know that there is runaway IV's occasionally. I even have some difficulty of even using saline for that same reason. 

When looking at the osmlarity range, most fall within the isotonic range but when given in large amounts you need to consider what occurs at the cellular level. 

Unfortunately, most in EMS do not have a good comprehension of fluids & electrolytes. Look at the true concentration level and the shift of fluids. I worked at a service where we carried 5 flavors of fluid, dependent upon the problem of the patient. 

R/r 911


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## ILemt (Aug 2, 2008)

D5W, LR, and NS ... what were the other two ridryder?


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## Ridryder911 (Aug 2, 2008)

ILemt said:


> D5W, LR, and NS ... what were the other two ridryder?



We also carried 0.45 NaCl and D5RL, as well as Plasmanate & Hespan....

R/r 911


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## firecoins (Aug 2, 2008)

Ridryder911 said:


> Definitely NOT I worked at a service where we carried 5 flavors of fluid, dependent upon the problem of the patient.
> 
> R/r 911



Why were you tasting fluids?  B)


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## MSDeltaFlt (Aug 2, 2008)

Ridryder911 said:


> Definitely NOT R L as "Hartman's Solution"; contains a higher sodium level and lactate level. *Yes, the amount of fluid is the key but we do know that there is runaway IV's occasionally*. I even have some difficulty of even using saline for that same reason.
> 
> When looking at the osmlarity range, most fall within the isotonic range but when given in large amounts you need to consider what occurs at the cellular level.
> 
> ...



Touche'.  However, *depending on your transport time*, you can start a line, clamp it off, and flush it with a ten cc syringe.  That way it'll be an INT with a _REALLY_ big flush on the other end of it...*that you should never use*.

My apologies if the bold and the italics are a bit much.  Those buttons are fun to use.


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## rhan101277 (Aug 2, 2008)

Ridryder911 said:


> Definitely NOT R L as "Hartman's Solution"; contains a higher sodium level and lactate level. Yes, the amount of fluid is the key but we do know that there is runaway IV's occasionally. I even have some difficulty of even using saline for that same reason.
> 
> When looking at the osmlarity range, most fall within the isotonic range but when given in large amounts you need to consider what occurs at the cellular level.
> 
> ...



Its nice to see someone so knowledgeable.  When I went to my drivers course today, some basics said they were just glorified first responders.  Like they really didn't have any satisfaction doing their job.  I know it will be sometime before I start paramedic school but I am looking forward to it.  Read almost every chapter of my anatomy book the easy way, hope the school book isn't to hard.  I am just now on fluids, electrolyte's chapter.


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## mikeylikesit (Aug 3, 2008)

Normal saline with a twist of lime for flava.B) Would never do the D5 unless my patient was Hypoglycemic, that being the case it would also mean that he 1 in 10 of the diabetics who's blood sugar goes down as adrenaline hits thier system.


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## Ridryder911 (Aug 3, 2008)

I find it amusing, no one recommends D5w when in fact that used to be the choice for all cardiac and medical patients. I ask why not? 

So many are concerned over the "glucose" or sugar level.. which informs me that they know very little about the concentration level of D5W. Remember there is only 5 grams of glucose per 1000ml of fluid.. and when administering a KVO/TKO (<10ml/hr) range that would me a minute amount. 

D5w has gotten a bad rap because of poor medics allowing fluid overload.. (which can happen as fast with NSS). In fact, many physicians prefer the glucose to promote and aid in cellular energy as well as aid in allowing medication molecules to cross over the cellular membrane. 

R/r 911


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## Rangat (Aug 3, 2008)

Ridryder, how does CHF affect the long term Na, Ca, Mg and K plasma levels?


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## slepyii (Aug 4, 2008)

Thanks everyone.  This has cleared up a few things for me, though it looks like I still need to do some research on the subject to fully understand some of the answers.  If I have any other questions I can't find answers for I will be back.


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## Ridryder911 (Aug 4, 2008)

Rangat said:


> Ridryder, how does CHF affect the long term Na, Ca, Mg and K plasma levels?



Multi question really. I will not directly answer, wanting you to investigate but remember that CHF is primarily caused by "pump problems". With such increasing fluid overload from poor circulation through the lymphatic systems, increasing amount of interstitial fluid (edema) and poor v-Q ratio.

As well, review the major medications that CHF patients are placed upon. Now consider the effects of such medications.. (Diuretics- and their side effects, Beta I, II, Channel calcium blockers, HTN medications, etc.) all interfere with the homeostasis of the body. 

R/r 911


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## Ridryder911 (Aug 4, 2008)

slepyii said:


> Thanks everyone.  This has cleared up a few things for me, though it looks like I still need to do some research on the subject to fully understand some of the answers.  If I have any other questions I can't find answers for I will be back.



Be sure to really understand the BASICS. I mean active transport, diffusion, elective transport, K+ pump; as well as understanding the pressure gradients to see which way the fluid will travel (into or out of the cell). This is what each and every Paramedic should understand when they are placing fluids into the body...

I ask this questions to all those that answered saline. 

What do you use for trauma? I am sure most would or will answer NSS. Is this really a good thing? Now, recall that trauma produces ... Lactic Acidosis (= free radicals) and increases the level of shock. Then we administer NSS and the pH is 6.0 ... Is this really good for our patient? 

R/r 911


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## Hebl (Jul 12, 2011)

*Normothermic fluid ?*

When looking at fluid resuscitation - shouldn't we also consider the temperature of the fluid we are administering? Hypothermia in the trauma patient increases mortality and morbidity. The sick and injured bodies must work very hard increasing the temperature of the fluid that is given at less than the normal body temperature, in order to maintain homeostasis.


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## the_negro_puppy (Jul 12, 2011)

Hebl said:


> When looking at fluid resuscitation - shouldn't we also consider the temperature of the fluid we are administering? Hypothermia in the trauma patient increases mortality and morbidity. The sick and injured bodies must work very hard increasing the temperature of the fluid that is given at less than the normal body temperature, in order to maintain homeostasis.



Strong thread resurrect. But yes you do have a very valid point.


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## 8jimi8 (Jul 12, 2011)

slepyii said:


> Which fluid would you select to start at a KVO/TKO rate on a CHF patient if you did not have a saline lock available when starting an IV?  Could you please explain why you choose the solution you did over the others.
> 
> This is a question that was brought up in our I85 class and we were told to always start NS on all medical patients while trauma would get LR.  If rapid fluid replacement was needed we would start bilateral IV's with one running LR and the other running NS, both wide open.
> 
> ...



I see that this is an old thread, I didn't read past the initial responses, who are some heavy hitters.  I must disagree.  The reason to choose LR is because it is balanced to be proportionally pH neutral after the fluid shifting occurs.  D5 is essentially, eventually, water and NS will end up giving your pt hyperchloremic metabolic acidosis.  If you are looking for an alkalinizing solution reach for the plasmalite.  So my poll answer is LR for most everyone unless I'm trying to intentionally affect their pH.


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