Normal (Abnormal) Saline vs. Ringer’s Lactate

The choice of crystalloid fluid for volume resuscitation is debated often. With rising concern about the effect of hyperchloremic metabolic acidosis associated with normal saline, clinicians more commonly are opting for balanced crystalloids, such as lactated Ringer’s solution or Plasma-Lyte. 

What’s the “Best” Site for Central Line Placement?

Using the subclavian site for central venous catheterization reduced infections and DVT to a minimum, but tripled the risk of pneumothorax compared to the internal jugular (IJ) position. Using the femoral position eliminated pneumothorax risk, and was comparable to the IJ in infection risk, but significantly increased DVT risk.

 

Does adrenaline need a central line?

iv-adrenalineIt has been dogmatically believed that prolonged infusion of any vasopressor mandates placement of a central line.  However, available evidence doesn’t support this. Diluted solutions of epinephrine and norephrine are safe for infusion via a well funcioning 18-20G IV proximal to the wrist.

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Size does matter

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If you want to get big water into your patient, observe the following recommendations:

  1. Gauge is king. Choose the fattest tube you can stick into the patient.
  2. When it comes to catheter length, it’s not the size… it’s how you use it. Shorter catheter lengths mean less resistance.
  3. Consider plugging your drip set directly into the catheter hub instead of using a needle-free adapter or saline lock. The aforementioned study reports significant loss of flow through these types of connectors.
  4. Optimize the pressure difference between the bag and the vein. Place the bag high above the patient and use a compression sleeve, if indicated.

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I’m just drunk NOT vitamin deficient so stop with the ‘bananas’

Most of our intoxicated patients are not vitamin deficient, and don’t need supplementation. The real kicker is that  we almost never really try to find out if the patient might be a chronic abuser and potentially at risk. We just hang the bag. Remember, everything we do in medicine has a potential downside. And if the patient really doesn’t need a banana bag in the first place, there is no benefit to balance that risk. The next time you ask for that little yellow bag, think again!

Air bubbles in your patients IV line?

Air embolism from IV tubing: In most cases, it will require at least 50 mL of air to result in significant risk to life, however, there are case studies in which 20 mLs or less of air rapidly infused into the patients circulation has resulted in a fatal air embolism.