Fluid and Volume Management
1:1:1
MTP Ratio
PRBCs to FFP to platelets in massive transfusion
4
Transfusion Reactions
Febrile allergic hemolytic TRALI
2
Fluid Types
Crystalloid (LR Plasmalyte NS) vs colloid (albumin)
Crystalloids and Colloids
not all fluids are created equalBalanced crystalloids (LR, Plasmalyte) preferred for large-volume resuscitation
Normal saline 0.9% has 154 mEq/L chloride (supraphysiologic)
Albumin 5% for volume expansion, 25% for oncotic pull
Colloids stay intravascular longer but cost more
Avoid starches (hydroxyethyl starch) due to renal injury risk
Normal saline in large volumes causes hyperchloremic metabolic acidosis. Use balanced crystalloids.
Massive Transfusion and Reactions
MTP activates when hemorrhage exceeds replacement capacity
Ratio of 1 unit PRBCs to 1 unit FFP to 1 unit platelets
Febrile nonhemolytic reaction is the most common (slow rate, antipyretics)
Allergic reaction presents with urticaria and pruritus (antihistamines)
Acute hemolytic reaction is ABO incompatibility (STOP transfusion immediately)
TRALI presents as acute respiratory distress within 6 hours of transfusion
Key Values to Memorize
MTP = 1:1:1 ratio
NS Cl 154 mEq/L
TRALI within 6 hours
PLR +10% = responsive
LR over NS for volume
Stop for hemolytic rxn
fluid management and transfusion reactions are CCRN staples
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Practice CCRN QuestionsExam Traps
Normal saline causes hyperchloremic acidosis
Large volumes of 0.9% NS deliver a supraphysiologic chloride load that causes hyperchloremic non-anion gap metabolic acidosis. Balanced crystalloids (lactated Ringer, Plasmalyte) have a more physiologic electrolyte profile and are preferred for large-volume resuscitation.
MTP ratio is 1 to 1 to 1
Massive transfusion protocol delivers PRBCs, FFP, and platelets in a 1:1:1 ratio. This mimics whole blood and prevents the dilutional coagulopathy that occurs when you only give packed red cells. The exam expects you to know this ratio.
TRALI vs TACO distinction
TRALI (transfusion-related acute lung injury) is noncardiogenic pulmonary edema occurring within 6 hours of transfusion. TACO (transfusion-associated circulatory overload) is cardiogenic pulmonary edema from volume overload. TRALI has normal BNP and no JVD. TACO has elevated BNP and JVD.
Passive leg raise for fluid responsiveness
A passive leg raise (PLR) test transiently increases preload without giving fluid. If cardiac output or pulse pressure increases by 10% or more, the patient is likely fluid responsive. This is safer and more reliable than a fluid bolus challenge.
TRALI vs TACO
TRALI = noncardiogenic, normal BNP, within 6 hours. TACO = cardiogenic, elevated BNP, volume overload. Treatment is different.
Balanced Over Saline
LR or Plasmalyte over NS for large-volume resuscitation. NS in large volumes = hyperchloremic metabolic acidosis.
Think of IV fluids like plumbing supplies. Normal saline is like using pipe cleaner that works but leaves a corrosive residue (chloride) if you use too much. Balanced crystalloids are the gentler, pH-matched solution that does the same job without the damage.
MTP is the emergency supply truck. When the pipes are hemorrhaging, you need red cells (oxygen carriers), plasma (clotting factors), and platelets (clot builders) all at once in equal proportion. Sending only red cells without the clotting components creates new problems.
Before ordering more supplies, test if the pipes actually need more volume. The passive leg raise is like temporarily opening a valve to see if pressure improves. If it does, more fluid will help. If not, the problem is not volume.
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