History of 0.9% saline (Clin Nutrition 2008;27:179)<\/p>\n
![\"fluid-sids\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/07\/fluid-sids-600x506.png\")
<\/a><\/h2>\n<\/span>Terminology<\/span><\/h2>\nDehydration is intracellular fluid loss and it is characterized by hypernatremia<\/p>\n
Water deficit can be calculated by TB Water x (Na Now\/Na Normal – 1)<\/p>\n
replace with D5W<\/p>\n
Volume depletion refers to intravascular fluid loss<\/p>\n
(Ann Intern Med 1997;127(9):848)<\/p>\n
<\/span>What is a “Balanced” Solution<\/span><\/h2>\nfrom Curr Opin Crit Care 2013;19(4):299<\/p>\n
80% of crystalloid spills into the insterstitium<\/p>\n
Unfortunately colloids are no better when the pt is ill<\/p>\n
The goal of a buffer base is not to form bicarb, but to disappear rapidly<\/p>\n
pH must be maintained between 4.0-8.0<\/p>\n
L-lactate up to doses of 100 mmol\/h will not accumulate unless there is severe liver dysfunction[53,54] or major resection<\/p>\n
So you can give 3.3 liters\/hour without accumulation. Up to 70% goes through gluconeogenesis raising glucose levels<\/p>\n
Acetate can be givien 300 mmol\/h without accumulation, metabolized extra-hepatically, esp. in muscle<\/p>\n
But it has caused hypotension during RRT<\/p>\n
Gluconate may be the best as it has no reported toxicity with accumulation, and may protect against post-ischemic dysfunction<\/p>\n
Tonicity<\/strong><\/p>\ntonicity is effective osmolality–normal is 275-295 mOsm\/kg. Normal tonicity is 270-290 mOsm\/kg<\/p>\n
Ringers can cause marked decrease in osm<\/p>\n
This was enough to raise ICP in healthy volunteers [88]<\/p>\n
Albumin 4% is also low osm compared to normal (260 mOsm\/kg); thismay explain increased mortality in SAFE [89]<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
From Resus.me<\/strong><\/p>\nIndependent\u00a0of underlying disease, CVP and GEDVI increased more after colloid than saline loading (P = 0.018), so that CI increased by about 2% after saline and 12% after colloid loading (P = 0.029).<\/p>\n
Their results agree with the traditional (pre-SAFE) idea of ratios of crystalloid:colloid, since the difference in cardiac output increase multiplied by the difference in volume infused was three for colloids versus saline.<\/p>\n
Take home message? Even though an outcome benefit has not yet been conclusively demonstrated, colloids such as albumin increase pre-load and cardiac index more effectively than equivalent volumes of crystalloid in hypovolaemic critically ill patients.<\/p>\n
Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia<\/strong> Intensive Care Med. 2010 Apr;36(4):697-701<\/a><\/p>\n <\/p>\n
<\/p>\n
![\"\"](\"\/wp-content\/images\/part1\/effects%20of%20fluid%20on%20CO_small.png\")
<\/a>![\"\"](\"\/wp-content\/images\/part1\/catheter%20flow%20rates_small.png\")
<\/a>![\"\"](\"\/wp-content\/images\/part1\/effects%20of%20different%20fluids_small.png\")
<\/a><\/p>\nThe relation between the flow in a long narrow tube, the viscosity of the fluid, and the radius of the tube is expressed mathematically in the Poiseuille\u0096Hagen formula: where![\"\"](\"\/wp-content\/images\/part1\/poiseuilleformula.gif\")
\u00a0 or ![\"\"](\"\/wp-content\/images\/part1\/poiseuilleformula3.gif\")
<\/p>\n
<\/p>\n
![\"\"](\"\/wp-content\/images\/part1\/poiseuilleformula.2gif.gif\")
<\/p>\n
Since flow is equal to pressure difference divided by resistance (R), Since flow varies directly and resistance inversely with the fourth power of the radius, blood flow and resistance in vivo are markedly affected by small changes in the caliber of the vessels. Thus, for example, flow through a vessel is doubled by an increase of only 19% in its radius; and when the radius is doubled, resistance is reduced to 6% of its previous value. This is why organ blood flow is so effectively regulated by small changes in the caliber of the arterioles and why variations in arteriolar diameter have such a pronounced effect on systemic arterial pressure.<\/p>\n
How it works: <\/strong> Poiseulle’s law states that the flow rate Q is also dependant upon fluid viscosity \u03b7, pipe length L and the pressure difference between the ends P by ![\"\"](\"\/wp-content\/images\/part1\/enClip-337-0001-PoiseuillesLaw002.gif\")
but all these factors are kept constant for this demo so that the effect of radius is clear. The apparatus consists of two 12 liter Plexiglass tanks, one to be emptied through a single 6mm bore capillary tube and the other through sixteen 3mm bore tubes. All tubes are 60cm in length. For direct comparison, all tubes need to be opened to the tanks simultaneously and this is achieved using a valve consisting of a long steel rod with 17 holes drilled through it, corresponding to the 17 tubes (figure<\/em> 1b). The rod runs the length of the tanks and has a handle that rotates it to align the holes in the rod with those in the tank. figure<\/em> 1a. Poiseulles’s apparatus, and 1b. detail of valve.<\/p>\n<\/span>Elmhurst Equipment<\/span><\/h3>\ntimings of 100 cc of NS <\/strong> saline lock 3:09<\/strong> ext+cap 1:31<\/strong> ext \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a01:15<\/strong><\/p>\n<\/span>Saline Locks Slow Everything Down<\/span><\/h2>\n(PMID 23659827)<\/p>\n
<\/p>\n
<\/span>EMJ Study on In Vivo Fluid Flow Rates<\/span><\/h3>\n![\"\"](\"\/wp-content\/images\/part6\/fluid-flow-rates.jpg\")
<\/p>\n
<\/p>\n
In situations where rapid fluid resuscitation is needed fluid delivery by a peripheral cannula of size 18G or greater is preferableto infusion by central line. If a central line is the onlyobtainable access then the addition of a pressure bag makesa greater difference to rate of flow than it would witha peripheral cannula.An over the needle FEP large-bore cannula inserted into a largevein is likely to give a greater flow rate than a Seldinger typepolyurethane catheter and would be preferable if all otherfactors are equal.A needle-free intravenous access connector should not be usedwhen rapid fluid resuscitation is required as it slows the rate offlow by up to 40% with peripheral cannulae. (Emerg Med J 2011;28:201)<\/p>\n
<\/span>Perioperative<\/span><\/h2>\nanesth 2008;109(4):736=last page<\/p>\n
1. extracellular deficit after usual fast is low<\/p>\n
2. Use crystal only for insensible and urine output. Insensible=0.5 ml\/kg\/hr or 1 ml\/kg\/hr in open abdominal<\/p>\n
3. primarily fluid-consuming third space does not exist<\/p>\n
4. replace circulatory plasma loss with iso-oncotic colloid<\/p>\n
Choice of colloid:<\/h4>\n
agents differ by half-life, mw, colloid oncotic pressure, side effects, and cost; albumin small molecule at 69,000 daltons (d); Hespan\u0097much larger (450,000 d) than albumin; has anticoagulant effect (lowers factor VIII and von Willebrand\u0092s factor); dosage limited to 20 mL\/kg per day; however, since large- mw molecules persist in circulation, speaker recommends 20-mL\/kg total dose; most studies conclude Hespan increases risk of bleeding in risk-prone surgical procedures; Hextend similar to Hespan, but in balanced salt solution rather than normal saline; several studies suggest lower risk for coagulopathy with Hextend; trial that randomized patients to receive Hextend or standard hetastarch solution found both equally efficacious in treating hypovolemia; patients received >1.5 L on average; almost two fifths of patients received >20 mL\/kg; coagulopathy found only in hetastarch group; trend toward lower bleeding, red blood cell, and platelet transfusions among Hextend patients; new medium-weight starches\u0097under study; not associated with coagulopathy, even in large doses; they may reduce permeability of blood vessels by plugging holes; animal studies suggest they also decrease inflammation, neutrophil activation, ischemia-reperfusion injury, and improve microcirculatory flow; hypertonic saline\u0097 greater than or equal to 3% saline solution given primarily in prehospital phase to draw water out of cells and interstitium; each mL given causes 3-mL increase in circulating blood volume; decreases extravascular fluid, cerebral edema, and intracranial pressure; may improve myocardial contractility, microcirculatory flow, and decrease inflammation; one meta-analysis showed it was not effective alone, but somewhat beneficial in combination with dextran<\/p>\n
<\/p>\n
Colloids Acacia and albumin: in World War I, combat casualties resuscitated with acacia gum colloid until plasma introduced; in 1940s, \u0093no-salt theory\u0094 in vogue; during World War II, albumin separated from plasma and became popular resuscitative fluid; German military used colloid named Periston (povidone; osmotically active, high molecular-weight derivative of vinyl; found to accumulate in spleen and reticuloendothelial system [RES] of animals) Hetastarch (eg, Hespan, Hextend): \u0093just a saline solution with a little bit of cornstarch added to it\u0094; United States military Tactical Combat Casualty Care (TCCC) specifies 1 L of Hespan for fluid resuscitation; speaker\u0092s institution (large naval hospital) stocks only Hextend Gelatins\/Haemaccel (polygeline): only colloid available to speaker in Australia; unavailable in United States since 1978 because of high incidence of hypersensitivity reactions to gelatin Blood substitute prospects (intravascular O2 carriers) Perflurochemical (PFC) technology: Oxygent (perflubron) one example; pure PFCs not miscible with water; carry significantly more O2 than H2 O Hemoglobin-based O2 carriers: Oxyglobin (hemoglobin glutamer-200) approved by Food and Drug Administration (FDA) in 1998 for veterinary use; not approved for use in humans<\/p>\n
<\/p>\n
Use albumin in SBP (Sort P, Navasa M, Arroyo V, et al: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341:403\u0096409)<\/p>\n
<\/span>Colloids vs. Crystalloids<\/span><\/h2>\n <\/p>\n
Dehydration is intracellular fluid loss and it is characterized by hypernatremia<\/p>\n
Water deficit can be calculated by TB Water x (Na Now\/Na Normal – 1)<\/p>\n
replace with D5W<\/p>\n
Volume depletion refers to intravascular fluid loss<\/p>\n
(Ann Intern Med 1997;127(9):848)<\/p>\n
<\/span>What is a “Balanced” Solution<\/span><\/h2>\nfrom Curr Opin Crit Care 2013;19(4):299<\/p>\n
80% of crystalloid spills into the insterstitium<\/p>\n
Unfortunately colloids are no better when the pt is ill<\/p>\n
The goal of a buffer base is not to form bicarb, but to disappear rapidly<\/p>\n
pH must be maintained between 4.0-8.0<\/p>\n
L-lactate up to doses of 100 mmol\/h will not accumulate unless there is severe liver dysfunction[53,54] or major resection<\/p>\n
So you can give 3.3 liters\/hour without accumulation. Up to 70% goes through gluconeogenesis raising glucose levels<\/p>\n
Acetate can be givien 300 mmol\/h without accumulation, metabolized extra-hepatically, esp. in muscle<\/p>\n
But it has caused hypotension during RRT<\/p>\n
Gluconate may be the best as it has no reported toxicity with accumulation, and may protect against post-ischemic dysfunction<\/p>\n
Tonicity<\/strong><\/p>\ntonicity is effective osmolality–normal is 275-295 mOsm\/kg. Normal tonicity is 270-290 mOsm\/kg<\/p>\n
Ringers can cause marked decrease in osm<\/p>\n
This was enough to raise ICP in healthy volunteers [88]<\/p>\n
Albumin 4% is also low osm compared to normal (260 mOsm\/kg); thismay explain increased mortality in SAFE [89]<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
From Resus.me<\/strong><\/p>\nIndependent\u00a0of underlying disease, CVP and GEDVI increased more after colloid than saline loading (P = 0.018), so that CI increased by about 2% after saline and 12% after colloid loading (P = 0.029).<\/p>\n
Their results agree with the traditional (pre-SAFE) idea of ratios of crystalloid:colloid, since the difference in cardiac output increase multiplied by the difference in volume infused was three for colloids versus saline.<\/p>\n
Take home message? Even though an outcome benefit has not yet been conclusively demonstrated, colloids such as albumin increase pre-load and cardiac index more effectively than equivalent volumes of crystalloid in hypovolaemic critically ill patients.<\/p>\n
Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia<\/strong> Intensive Care Med. 2010 Apr;36(4):697-701<\/a><\/p>\n <\/p>\n
<\/p>\n
<\/a><\/a><\/a><\/p>\nThe relation between the flow in a long narrow tube, the viscosity of the fluid, and the radius of the tube is expressed mathematically in the Poiseuille\u0096Hagen formula: where\u00a0 or <\/p>\n
<\/p>\n
<\/p>\n
Since flow is equal to pressure difference divided by resistance (R), Since flow varies directly and resistance inversely with the fourth power of the radius, blood flow and resistance in vivo are markedly affected by small changes in the caliber of the vessels. Thus, for example, flow through a vessel is doubled by an increase of only 19% in its radius; and when the radius is doubled, resistance is reduced to 6% of its previous value. This is why organ blood flow is so effectively regulated by small changes in the caliber of the arterioles and why variations in arteriolar diameter have such a pronounced effect on systemic arterial pressure.<\/p>\n
How it works: <\/strong> Poiseulle’s law states that the flow rate Q is also dependant upon fluid viscosity \u03b7, pipe length L and the pressure difference between the ends P by but all these factors are kept constant for this demo so that the effect of radius is clear. The apparatus consists of two 12 liter Plexiglass tanks, one to be emptied through a single 6mm bore capillary tube and the other through sixteen 3mm bore tubes. All tubes are 60cm in length. For direct comparison, all tubes need to be opened to the tanks simultaneously and this is achieved using a valve consisting of a long steel rod with 17 holes drilled through it, corresponding to the 17 tubes (figure<\/em> 1b). The rod runs the length of the tanks and has a handle that rotates it to align the holes in the rod with those in the tank. figure<\/em> 1a. Poiseulles’s apparatus, and 1b. detail of valve.<\/p>\n<\/span>Elmhurst Equipment<\/span><\/h3>\ntimings of 100 cc of NS <\/strong> saline lock 3:09<\/strong> ext+cap 1:31<\/strong> ext \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a01:15<\/strong><\/p>\n<\/span>Saline Locks Slow Everything Down<\/span><\/h2>\n(PMID 23659827)<\/p>\n
<\/p>\n
<\/span>EMJ Study on In Vivo Fluid Flow Rates<\/span><\/h3>\n<\/p>\n
<\/p>\n
In situations where rapid fluid resuscitation is needed fluid delivery by a peripheral cannula of size 18G or greater is preferableto infusion by central line. If a central line is the onlyobtainable access then the addition of a pressure bag makesa greater difference to rate of flow than it would witha peripheral cannula.An over the needle FEP large-bore cannula inserted into a largevein is likely to give a greater flow rate than a Seldinger typepolyurethane catheter and would be preferable if all otherfactors are equal.A needle-free intravenous access connector should not be usedwhen rapid fluid resuscitation is required as it slows the rate offlow by up to 40% with peripheral cannulae. (Emerg Med J 2011;28:201)<\/p>\n
<\/span>Perioperative<\/span><\/h2>\nanesth 2008;109(4):736=last page<\/p>\n
1. extracellular deficit after usual fast is low<\/p>\n
2. Use crystal only for insensible and urine output. Insensible=0.5 ml\/kg\/hr or 1 ml\/kg\/hr in open abdominal<\/p>\n
3. primarily fluid-consuming third space does not exist<\/p>\n
4. replace circulatory plasma loss with iso-oncotic colloid<\/p>\n
Choice of colloid:<\/h4>\n
agents differ by half-life, mw, colloid oncotic pressure, side effects, and cost; albumin small molecule at 69,000 daltons (d); Hespan\u0097much larger (450,000 d) than albumin; has anticoagulant effect (lowers factor VIII and von Willebrand\u0092s factor); dosage limited to 20 mL\/kg per day; however, since large- mw molecules persist in circulation, speaker recommends 20-mL\/kg total dose; most studies conclude Hespan increases risk of bleeding in risk-prone surgical procedures; Hextend similar to Hespan, but in balanced salt solution rather than normal saline; several studies suggest lower risk for coagulopathy with Hextend; trial that randomized patients to receive Hextend or standard hetastarch solution found both equally efficacious in treating hypovolemia; patients received >1.5 L on average; almost two fifths of patients received >20 mL\/kg; coagulopathy found only in hetastarch group; trend toward lower bleeding, red blood cell, and platelet transfusions among Hextend patients; new medium-weight starches\u0097under study; not associated with coagulopathy, even in large doses; they may reduce permeability of blood vessels by plugging holes; animal studies suggest they also decrease inflammation, neutrophil activation, ischemia-reperfusion injury, and improve microcirculatory flow; hypertonic saline\u0097 greater than or equal to 3% saline solution given primarily in prehospital phase to draw water out of cells and interstitium; each mL given causes 3-mL increase in circulating blood volume; decreases extravascular fluid, cerebral edema, and intracranial pressure; may improve myocardial contractility, microcirculatory flow, and decrease inflammation; one meta-analysis showed it was not effective alone, but somewhat beneficial in combination with dextran<\/p>\n
<\/p>\n
Colloids Acacia and albumin: in World War I, combat casualties resuscitated with acacia gum colloid until plasma introduced; in 1940s, \u0093no-salt theory\u0094 in vogue; during World War II, albumin separated from plasma and became popular resuscitative fluid; German military used colloid named Periston (povidone; osmotically active, high molecular-weight derivative of vinyl; found to accumulate in spleen and reticuloendothelial system [RES] of animals) Hetastarch (eg, Hespan, Hextend): \u0093just a saline solution with a little bit of cornstarch added to it\u0094; United States military Tactical Combat Casualty Care (TCCC) specifies 1 L of Hespan for fluid resuscitation; speaker\u0092s institution (large naval hospital) stocks only Hextend Gelatins\/Haemaccel (polygeline): only colloid available to speaker in Australia; unavailable in United States since 1978 because of high incidence of hypersensitivity reactions to gelatin Blood substitute prospects (intravascular O2 carriers) Perflurochemical (PFC) technology: Oxygent (perflubron) one example; pure PFCs not miscible with water; carry significantly more O2 than H2 O Hemoglobin-based O2 carriers: Oxyglobin (hemoglobin glutamer-200) approved by Food and Drug Administration (FDA) in 1998 for veterinary use; not approved for use in humans<\/p>\n
<\/p>\n
Use albumin in SBP (Sort P, Navasa M, Arroyo V, et al: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341:403\u0096409)<\/p>\n
<\/span>Colloids vs. Crystalloids<\/span><\/h2>\n <\/p>\n
tonicity is effective osmolality–normal is 275-295 mOsm\/kg. Normal tonicity is 270-290 mOsm\/kg<\/p>\n
Ringers can cause marked decrease in osm<\/p>\n
This was enough to raise ICP in healthy volunteers [88]<\/p>\n
Albumin 4% is also low osm compared to normal (260 mOsm\/kg); thismay explain increased mortality in SAFE [89]<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
From Resus.me<\/strong><\/p>\n Independent\u00a0of underlying disease, CVP and GEDVI increased more after colloid than saline loading (P = 0.018), so that CI increased by about 2% after saline and 12% after colloid loading (P = 0.029).<\/p>\n Their results agree with the traditional (pre-SAFE) idea of ratios of crystalloid:colloid, since the difference in cardiac output increase multiplied by the difference in volume infused was three for colloids versus saline.<\/p>\n Take home message? Even though an outcome benefit has not yet been conclusively demonstrated, colloids such as albumin increase pre-load and cardiac index more effectively than equivalent volumes of crystalloid in hypovolaemic critically ill patients.<\/p>\n Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia<\/strong> Intensive Care Med. 2010 Apr;36(4):697-701<\/a><\/p>\n <\/p>\n <\/p>\n The relation between the flow in a long narrow tube, the viscosity of the fluid, and the radius of the tube is expressed mathematically in the Poiseuille\u0096Hagen formula: where <\/p>\n Since flow is equal to pressure difference divided by resistance (R), Since flow varies directly and resistance inversely with the fourth power of the radius, blood flow and resistance in vivo are markedly affected by small changes in the caliber of the vessels. Thus, for example, flow through a vessel is doubled by an increase of only 19% in its radius; and when the radius is doubled, resistance is reduced to 6% of its previous value. This is why organ blood flow is so effectively regulated by small changes in the caliber of the arterioles and why variations in arteriolar diameter have such a pronounced effect on systemic arterial pressure.<\/p>\n How it works: <\/strong> Poiseulle’s law states that the flow rate Q is also dependant upon fluid viscosity \u03b7, pipe length L and the pressure difference between the ends P by timings of 100 cc of NS <\/strong> saline lock 3:09<\/strong> ext+cap 1:31<\/strong> ext \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a01:15<\/strong><\/p>\n (PMID 23659827)<\/p>\n <\/p>\n <\/p>\n In situations where rapid fluid resuscitation is needed fluid delivery by a peripheral cannula of size 18G or greater is preferableto infusion by central line. If a central line is the onlyobtainable access then the addition of a pressure bag makesa greater difference to rate of flow than it would witha peripheral cannula.An over the needle FEP large-bore cannula inserted into a largevein is likely to give a greater flow rate than a Seldinger typepolyurethane catheter and would be preferable if all otherfactors are equal.A needle-free intravenous access connector should not be usedwhen rapid fluid resuscitation is required as it slows the rate offlow by up to 40% with peripheral cannulae. (Emerg Med J 2011;28:201)<\/p>\n anesth 2008;109(4):736=last page<\/p>\n 1. extracellular deficit after usual fast is low<\/p>\n 2. Use crystal only for insensible and urine output. Insensible=0.5 ml\/kg\/hr or 1 ml\/kg\/hr in open abdominal<\/p>\n 3. primarily fluid-consuming third space does not exist<\/p>\n 4. replace circulatory plasma loss with iso-oncotic colloid<\/p>\n agents differ by half-life, mw, colloid oncotic pressure, side effects, and cost; albumin small molecule at 69,000 daltons (d); Hespan\u0097much larger (450,000 d) than albumin; has anticoagulant effect (lowers factor VIII and von Willebrand\u0092s factor); dosage limited to 20 mL\/kg per day; however, since large- mw molecules persist in circulation, speaker recommends 20-mL\/kg total dose; most studies conclude Hespan increases risk of bleeding in risk-prone surgical procedures; Hextend similar to Hespan, but in balanced salt solution rather than normal saline; several studies suggest lower risk for coagulopathy with Hextend; trial that randomized patients to receive Hextend or standard hetastarch solution found both equally efficacious in treating hypovolemia; patients received >1.5 L on average; almost two fifths of patients received >20 mL\/kg; coagulopathy found only in hetastarch group; trend toward lower bleeding, red blood cell, and platelet transfusions among Hextend patients; new medium-weight starches\u0097under study; not associated with coagulopathy, even in large doses; they may reduce permeability of blood vessels by plugging holes; animal studies suggest they also decrease inflammation, neutrophil activation, ischemia-reperfusion injury, and improve microcirculatory flow; hypertonic saline\u0097 greater than or equal to 3% saline solution given primarily in prehospital phase to draw water out of cells and interstitium; each mL given causes 3-mL increase in circulating blood volume; decreases extravascular fluid, cerebral edema, and intracranial pressure; may improve myocardial contractility, microcirculatory flow, and decrease inflammation; one meta-analysis showed it was not effective alone, but somewhat beneficial in combination with dextran<\/p>\n <\/p>\n Colloids Acacia and albumin: in World War I, combat casualties resuscitated with acacia gum colloid until plasma introduced; in 1940s, \u0093no-salt theory\u0094 in vogue; during World War II, albumin separated from plasma and became popular resuscitative fluid; German military used colloid named Periston (povidone; osmotically active, high molecular-weight derivative of vinyl; found to accumulate in spleen and reticuloendothelial system [RES] of animals) Hetastarch (eg, Hespan, Hextend): \u0093just a saline solution with a little bit of cornstarch added to it\u0094; United States military Tactical Combat Casualty Care (TCCC) specifies 1 L of Hespan for fluid resuscitation; speaker\u0092s institution (large naval hospital) stocks only Hextend Gelatins\/Haemaccel (polygeline): only colloid available to speaker in Australia; unavailable in United States since 1978 because of high incidence of hypersensitivity reactions to gelatin Blood substitute prospects (intravascular O2 carriers) Perflurochemical (PFC) technology: Oxygent (perflubron) one example; pure PFCs not miscible with water; carry significantly more O2 than H2 O Hemoglobin-based O2 carriers: Oxyglobin (hemoglobin glutamer-200) approved by Food and Drug Administration (FDA) in 1998 for veterinary use; not approved for use in humans<\/p>\n <\/p>\n Use albumin in SBP (Sort P, Navasa M, Arroyo V, et al: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341:403\u0096409)<\/p>\n <\/p>\n<\/a><\/a><\/a><\/p>\n\u00a0 or <\/p>\n<\/p>\n but all these factors are kept constant for this demo so that the effect of radius is clear. The apparatus consists of two 12 liter Plexiglass tanks, one to be emptied through a single 6mm bore capillary tube and the other through sixteen 3mm bore tubes. All tubes are 60cm in length. For direct comparison, all tubes need to be opened to the tanks simultaneously and this is achieved using a valve consisting of a long steel rod with 17 holes drilled through it, corresponding to the 17 tubes (figure<\/em> 1b). The rod runs the length of the tanks and has a handle that rotates it to align the holes in the rod with those in the tank. figure<\/em> 1a. Poiseulles’s apparatus, and 1b. detail of valve.<\/p>\n<\/span>Elmhurst Equipment<\/span><\/h3>\n
<\/span>Saline Locks Slow Everything Down<\/span><\/h2>\n
<\/span>EMJ Study on In Vivo Fluid Flow Rates<\/span><\/h3>\n
<\/p>\n<\/span>Perioperative<\/span><\/h2>\n
Choice of colloid:<\/h4>\n
<\/span>Colloids vs. Crystalloids<\/span><\/h2>\n
![\"\"](\"\/wp-content\/images\/part6\/colloid%20acid%20base_small.png\")
<\/a><\/p>\n