IV Fluids used in your system

[thegreypilgrim]

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?

 

[ResTech]

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

 

[Akulahawk]

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.

 

[PapaBear434]

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.

 

[ResTech]

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.

 

[usalsfyre]

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

 

[ResTech]

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?

 

[Ridryder911]

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

 

[ResTech]

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?

 

[ResTech]

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

 

[Akulahawk]

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.

 

[thegreypilgrim]

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."

 

[usalsfyre]

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.

 

[lightsandsirens5]

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

 

[Smash]

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

Why do you wish you carry LR?

 

[MrBrown]

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

 

[Flight-LP]

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.

 

[Crepitus]

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?

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?

 

[Ridryder911]

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

 

[Crepitus]

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.