# IV Fluids used in your system



## thegreypilgrim (Sep 18, 2009)

The title says it all. What IV fluids do you guys carry on your units? Around here we have lots of choices - we can use NS or we can use NS or we can use...NS. :glare:

Yeah we don't do anything _*crazy*_ and _*advanced*_ like expose our patients to D5W or LR (although we can transport variants of these for IFT's). 

So what about you guys? Anybody actually do something interesting and deviate from the standard run-of-the-mill isotonic solutions?


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## ResTech (Sep 18, 2009)

We only carry one type of fluid which is lactated ringers.


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## Akulahawk (Sep 18, 2009)

I've seen D5W be carried, but rarely. One of the EMS systems I've been in prefers to use LR over NS (at least it did about 10 years ago), but everywhere else I've seen use NS. If D5W is carried, it's in addition to NS or LR.


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## PapaBear434 (Sep 18, 2009)

We call it a "Normasaline Bag" in front of patients sometimes.  We never expressly say that it's medicine, so we aren't open to liability, but it makes some of the more hypocondriac among our patients to calm down, because saying "Normal Saline" that fast makes them think there is something good coming.

You wouldn't believe how many of them just fall asleep after we start the flow, thinking they are getting something a little more powerful than fluids.


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## ResTech (Sep 18, 2009)

I have yet to see any point in carrying multiple IV fluids. NSS or LR is all you need. Both have small pros and cons in reference to EMS use.. but all in all I don't think it really matters between NSS and LR.


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## usalsfyre (Sep 18, 2009)

NS and LR with a couple of 250mls of D5 for mixing meds.


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## ResTech (Sep 18, 2009)

why do u need D5 for med mixing? Im asking just out of curiosity.... why not just use 250 bag of NSS or LR whichever u may carry?


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## Ridryder911 (Sep 18, 2009)

ResTech said:


> I have yet to see any point in carrying multiple IV fluids. NSS or LR is all you need. Both have small pros and cons in reference to EMS use.. but all in all I don't think it really matters between NSS and LR.



Some med's are not to be mixed in NSS and definitely not RL (i.e Cordorone is incompatible with NSSS). A little physiology will teach you osmotic changes occurs with fluids and thus medications and changes within the body also. Please, the use of "well we are only with them 10 minutes" don't buy it as well. The patient IV then has to be changed out and charged for another. 

Truthfully, yes there is little change we will see but again many and majority of the time the initial bag maybe infused. 

The main reason most EMS got away from carrying multiple fluids is costs and let's be honest most medics are too stupid to understand the changes that occurs with different types of fluids. 

R/r 911


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## ResTech (Sep 18, 2009)

Rid... can you give some examples? My thinking is if this was a huge concern and an absolute contraindication was present with certain EMS meds, than why are physician medical directors okay with EMS services carrying one type of fluid?

What meds do we carry pre-hospital can't be mixed with NSS or LR?


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## ResTech (Sep 18, 2009)

I did a bit of research and found that bolus doses of Cordorone can be administered with NSS or LR.


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## Akulahawk (Sep 18, 2009)

I would suspect that the meds that you'd carry in your local system would normally be able to be used with the crystaloid fluid that's approved... However, some meds can be incompatible with each other if put through the same line...

Cordarone is an example. It should be just fine for bolus with NSS/LR but if you're going to hang a drip, it should be D5W... IIRC.


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## thegreypilgrim (Sep 18, 2009)

ResTech said:


> why do u need D5 for med mixing? Im asking just out of curiosity.... why not just use 250 bag of NSS or LR whichever u may carry?


 As others have pointed out, some meds are incompatible with NS and/or LR if they're going to be infused. For example, some corticosteroids and antidysrhythmics such as amiodarone [1] are incompatible with NS & LR and can only be mixed with D5.

Also for fluid resuscitation in trauma cases LR is (somewhat) preferable to NS due to its balanced electrolytes. The differences are somewhat negligible in said cases, however. 

[1] According to Medsafe: _*"Amiodarone Hydrochloride Injection Concentrate is incompatible with saline and should be administered solely in 5% glucose solution."*_


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## usalsfyre (Sep 18, 2009)

D5W is usually considered to be "more inert" than crystaloids for medication purposes. Hence why we carry it for mixing certain meds, amiodarone and Levophed are the two that come immediately to mind. 

"Nexterone" is the newly FDA approved plastic compatible version of amiodarone. I don't know about it's compatibility with NS.


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## lightsandsirens5 (Sep 19, 2009)

We carry NS and D5W. Wish we could have LR.


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## Smash (Sep 19, 2009)

lightsandsirens5 said:


> We carry NS and D5W. Wish we could have LR.




Why do you wish you carry LR?


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## MrBrown (Sep 19, 2009)

We carry 5% glucose (to mix amiodarone and ketamine), 10% glucose for hypoglycemia and NS for everything else


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## Flight-LP (Sep 19, 2009)

ResTech said:


> I have yet to see any point in carrying multiple IV fluids. NSS or LR is all you need. Both have small pros and cons in reference to EMS use.. but all in all I don't think it really matters between NSS and LR.



Oh, but it does.............

As already mentioned, Amiodorone should not be mixed with saline, it was created and intended to be used with a dextrose solution, mainly to reduce the possibility of phlebitis. There are many drugs that must be specifically mixed with the appropriate fluid. Another good example of an up and coming pre-hospital drug is Cardene. Mixing it with LR is contraindicated.

http://www.health.state.ri.us/hsr/professions/ems/downloads/07-004_Amiodarone.pdf

http://www.circ.ahajournals.org/cgi/content/full/92/11/3154

And there are very subtle differences in the need for LR vs. NS. For instance, LR is the fluid of choice for OB patients. However, if your OB pt. has a severe case of PPH, LR is contraindicated due to possible citrate toxicity. Another situation would be your trauma pt. with an insufficent MAP secondary to hypovolemia that is experiencing anerobic metabolism. Keep that LR going and see how quickly you kill them.

Rid hit the nail on the head as to why many services reduced to just one fluid. Most chose NS, the lesser of the three evils with the minimum amount of interaction issues. Some chose LR which isn't a horrible option, but nonetheless one that needs special emphasis on particular situations. Honestly, most can go with access alone (i.e. saline or heparin lock).

To answer the OP, we carry NS, LR, D5W, and Hespan.


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## Crepitus (Sep 19, 2009)

ResTech said:


> why do u need D5 for med mixing? Im asking just out of curiosity.... why not just use 250 bag of NSS or LR whichever u may carry?





usalsfyre said:


> D5W is usually considered to be "more inert" than crystaloids for medication purposes. Hence why we carry it for mixing certain meds, amiodarone and Levophed are the two that come immediately to mind.



Isn't the other reason that D5W is isotonic in the bag, but becomes hypotonic in the vasculature, thus helping facilitate the uptake of the mixed medication?


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## Ridryder911 (Sep 19, 2009)

Crepitus said:


> Isn't the other reason that D5W is isotonic in the bag, but becomes hypotonic in the vasculature, thus helping facilitate the uptake of the mixed medication?



To a degree.... have to review to discuss more in detail. I also want to add the debate between RL and NSS on trauma. Listen to PHTLS podcasts and the Doc describes the reason for RL in lieu of just saline. Yes, saline should be instituted with blood tubing for those that will need fluids and to make things easier when administering blood. I do pose this question though; what is the pH of NSS and the by-product of shock is? ... Then ask yourself, if even infusing 500-2000ml of NSS in the very first few minutes of the development of shock beneficial or maybe even harmful? 

R/r 911


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## Crepitus (Sep 19, 2009)

Ridryder911 said:


> I do pose this question though; what is the pH of NSS and the by-product of shock is? ... Then ask yourself, if even infusing 500-2000ml of NSS in the very first few minutes of the development of shock beneficial or maybe even harmful?
> 
> R/r 911



I haven't listened to the podcasts you refer to, but I have seen a study where folks were infused with 50 ml/kg of LR or NS over an hour.  The NS group had a decrease in venous PH attributed to hypochloremic metabolic acidosis.  The study noted that the acidosis was not profound, though it did not return to baseline on it's own over a 120 minute period of time either.  Study participants were then treated with Lasix to promote urination.  So I agree, with a pt with their own condition that can create acidosis, why assist them along the way.  I would tend to grab an LR over an NS.

The next question I would have is  what can we really do to improve the pt.  Is the decreased osmolality of LR infusion the desired effect?  Is a change in osmolality really important?  Or is the ability to improve oxygen saturation?  If the latter, then a transport to a place where they can receive blood or blood substitutes remains my best option, doesn't it?  

Of course they were promising us field blood options 25 years ago . . . 

For the OP, most services around here carry 1000 cc bags of NS, with 250's or 500's of D5W for mixing and one to a few bags of LR.  I believe the state requires a rig to have one bag of LR, thus the reason it is on our truck.


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## medic417 (Sep 19, 2009)

NS, LR, D5W, Hetastarch


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## daedalus (Sep 19, 2009)

PapaBear434 said:


> We call it a "Normasaline Bag" in front of patients sometimes.  We never expressly say that it's medicine, so we aren't open to liability, but it makes some of the more hypocondriac among our patients to calm down, because saying "Normal Saline" that fast makes them think there is something good coming.
> 
> You wouldn't believe how many of them just fall asleep after we start the flow, thinking they are getting something a little more powerful than fluids.



What??

(10char)


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## PapaBear434 (Sep 19, 2009)

daedalus said:


> What??
> 
> (10char)



A little trick I picked up from my proctor.  If you have someone who thinks they are dying, but are actually by all accounts fine ("I'm having a heart attack!" with a completely normal rhythm but they are just freaking out over indigestion), you hang a bag, start an IV, and let it flow.  You at some point say Normal Saline real fast to your partner, pronounced "normasalin" or something similar. 

Patient feels gentle cool feeling flowing at the site, and think they are getting something powerful and tasty.  You never expressly say that it's medicine, and if they ask you tell them what it really is.  But most of the time, the suggestion is enough to get them nice and happy.  It's a nice trick to see if they are imagining the pain and/or discomfort or if they are really having some trouble.

Of course you never delay REAL treatment (nitro, asprin where appropriate) to do this.  But if nothing is warranted by what you find, and you are going to start an IV anyway, it can't really hurt to try.

That was my round about way of saying "We only have NS on our trucks."


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## Epi-do (Sep 19, 2009)

We currently just have NS.  In the past we also carried 250 ml bags of D5W for amio, but no longer carry it.  We were told to just administer it in the NS instead.  At one time, some of the services in the Indy metro area carried RL, but I don't know off-hand of anyone who still carries it.


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## Jon (Sep 20, 2009)

Most services just carry LR, and pre-mixed Dopamine and Lidocaine drips... One service has a set-up with 250cc D5W and a label that gives them the amount of drug to add to get different drips... like Amiodarone and Epi drips, and the concentrations. Oh... and the label lets them label the bag, too... so that everyone knows what drug/concentration is in the bag.


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## Sasha (Sep 20, 2009)

NS and D5W for mixing meds.


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## FireMedic254 (Sep 20, 2009)

We carry NaSL, LR, and D5W. We carry them in 1000mL, 500mL and 250mL bags.


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## FireMedic254 (Sep 20, 2009)

Oh and we do have 250mL Dopamine mix. Our Lidocaine or Marcaine isnt in a bag, but is readily available to draw up.


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## fma08 (Sep 20, 2009)

Ridryder911 said:


> To a degree.... have to review to discuss more in detail. I also want to add the debate between RL and NSS on trauma. Listen to PHTLS podcasts and the Doc describes the reason for RL in lieu of just saline. Yes, saline should be instituted with blood tubing for those that will need fluids and to make things easier when administering blood. I do pose this question though; what is the pH of NSS and the by-product of shock is? ... Then ask yourself, if even infusing 500-2000ml of NSS in the very first few minutes of the development of shock beneficial or maybe even harmful?
> 
> R/r 911



NS pH is around 5.5 (http://www.rxlist.com/normal-saline-drug.htm). By-product of shock = anaerobic respiration = acid by-products i.e. lowering of the body's pH even more. So infusing acid on top of potentially producing more acid... Well, I'll argue the point that while NS may be acidic, if infusing enough of it in the first few minutes of shock resolves the inadequate tissue perfusion, then one would not have to worry about the problem of anaerobic respiration (in the short run). However, if the fluid bolus is not enough to restore the perfusion, then there will be some complications coming up... And fast.

But that's what bicarb is for right? 

To answer the OP, we get to choose from NS, NS and NS


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## Katie (Sep 20, 2009)

LR 

*lengthens to 10 characters*


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## Akulahawk (Sep 20, 2009)

Just remember that LR's normal pH is 6.5...

http://www.rxlist.com/lactated-ringers-drug.htm

click on the link for the table pop-up...  the info is there.


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## Melclin (Sep 22, 2009)

*Here in Aussie land.*

Our state service recently switched from Hartmann's to NS for fluid replacement.

I've been told that the following are the reasons behind the change. 

-Too little evidence for efficacy.
-Concern over major trauma pts and kidney problems.
-compatibility issues with other drugs.
-To expensive given the lack of efficacy.

Most services use NS as far as I know, some use Hartmann's (obviously along with D5W for medications on those trucks that have them; MICA, IC, MICU etc).


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## Jon (Sep 22, 2009)

Silly question - what exactly is Hartmann's, and why would it be used?


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## Ridryder911 (Sep 22, 2009)

Jon said:


> Silly question - what exactly is Hartmann's, and why would it be used?



It is almost exactly alike Ringers Lactate but the ionic is slightly different. Many Trauma Doc's like the solution...

R/r 911


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## SES4 (Sep 22, 2009)

The gold standard:  Normal Saline and Ringers Lactate.


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## fma08 (Sep 22, 2009)

Ridryder911 said:


> It is almost exactly alike Ringers Lactate but the ionic is slightly different. Many Trauma Doc's like the solution...
> 
> R/r 911



Was my answer even close to what you were looking for in the question about NS in shock?


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## Ridryder911 (Sep 22, 2009)

fma08 said:


> NS pH is around 5.5 (http://www.rxlist.com/normal-saline-drug.htm). By-product of shock = anaerobic respiration = acid by-products i.e. lowering of the body's pH even more. So infusing acid on top of potentially producing more acid... Well, I'll argue the point that while NS may be acidic, if infusing enough of it in the first few minutes of shock resolves the inadequate tissue perfusion, then one would not have to worry about the problem of anaerobic respiration (in the short run). However, if the fluid bolus is not enough to restore the perfusion, then there will be some complications coming up... And fast.
> 
> But that's what bicarb is for right?
> 
> To answer the OP, we get to choose from NS, NS and NS



Very good. Yes, the question or debate is should we "flooding" more fluid that is acidotic in lactic acidosis situation? Especially, in the early critical period of development of shock....Something to consider.. yes, it may matter. 

R/r 911


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## Tal (Sep 25, 2009)

MDA works with normal saline 0.9% and D5W (and there are 10cc amp. of WFI)

the IDF works with normal saline\ Ringer's Lactate (which is better in case of truama i guess)


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## Jon (Sep 25, 2009)

Tal said:


> MDA works with normal saline 0.9% and D5W (and there are 10cc amp. of WFI)
> 
> the IDF works with normal saline\ Ringer's Lactate (which is better in case of truama i guess)


What's WFI?


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## Tal (Sep 25, 2009)

Jon said:


> What's WFI?



water for injection


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## motomedic (Sep 28, 2009)

El Dorado Co, CA carries NS. fun times. be nice to have some LT are time with are lengthy transports and use of Helos.


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## MrBrown (Sep 28, 2009)

Epi-do said:


> We were told to just administer [amiodarone] in the NS instead.



... and how's that working out? Patients complaining of parts of the saline bag leeching out and into thier veins yet? :lol:



thegreypilgrim said:


> ...
> [1] According to Medsafe: _*"Amiodarone Hydrochloride Injection Concentrate is incompatible with saline and should be administered solely in 5% glucose solution."*_



Trust us Kiwi's to know how it is ^_^



			
				PapaBear434 said:
			
		

> We call it a "Normasaline Bag" in front of patients sometimes. We never expressly say that it's medicine, so we aren't open to liability, but it makes some of the more hypocondriac among our patients to calm down, because saying "Normal Saline" that fast makes them think there is something good coming.
> 
> You wouldn't believe how many of them just fall asleep after we start the flow, thinking they are getting something a little more powerful than fluids



That's *weird*.  I have yet to see a system that does not consider saline a medication (ok, it's an isotonic fluid, not going to do a hell of lot a damage unless you infuse so much you dilute fibrin/clotting factors/protiens or make a person hyponatremic or something); I do not know of any pharmacy I can roll up to and buy litre bags of NS without a prescription.

I am really interested to know *how* telling somebody you are giving them a medication (which you are) is somehow libel?

I just say that we are "[just] going to give you some fluid" nice and easy if there is a specific purpose I will say that too e.g. dehydration, hypotension, trauma etc

To the pharmacy to investigate the medication-ness of saline ... Brown away! h34r:


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## Melclin (Sep 29, 2009)

MrBrown said:


> I do not know of any pharmacy I can roll up to and buy litre bags of NS without a prescription.



We can here. I would imagine that most pharmacies wouldn't have litre bags, but any amount of injectable NS they do have, you can buy. Its stupidly expensive though for a wee bit of salt water.:wacko:


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