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Thoughts From A Clinician

Warmed IV Fluids: A tepid treatment?

IV Fluids

Recently there has been a lot of discussion around the administration of intravenous fluids for the critical care patient.  It has long been a staple of care for patients in a hypotensive crisis and not many providers have questioned the use of this therapy.  Not only what type of fluids that should be given, but should they be warmed or room temperature?  This is the question that I want to focus on for this article.  Should we be giving warmed intravenous fluids to all of our patients?  Most would agree that in the trauma patient we are constantly fighting the trauma triad of death, part of which includes hypothermia.  In the treatment of the trauma patient we use external warming techniques and, where possible, we administer warmed IV fluids.  But should we give warmed IV fluids?  One primary argument in this debate has been about the temperature at which these fluids should be warmed to. 

Most current evidence surrounds the use of warmed IV fluids in the perioperative and intraoperative periods (1).  In these studies, it has been recommended that the fluid be warmed to at least 37°C.  Warming to this point allows the core body temperature to be kept at the normal range of 36.5-37.5°C (2).  Keeping the patient within this range allows for (as normal as possible) metabolism, the use of glucose, and the ability of the body’s neurologic system to continue working normally.  Not only are we looking at patient survival but being neurologically intact translates to a better quality of life.  Patient survival, based on the body’s ability to function at the cellular level, could be as simple as warming fluids.  Obviously, in the EMS setting we are not working in such a controlled environment as the surgical suite and not all services have fluid warming capabilities.  Even so, can we still utilize these thought processes to increase the chance of survival? 

Let’s look at some points regarding patient rewarming.  In current practice active rewarming is done in the form of peritoneal lavage, extra-corporeal membrane oxygenation, thoracic lavage, etc.  This helps rewarm the core quickly and efficiently.  We cannot perform peritoneal lavage (and others) in the field and this could be a limiting factor in the process of patient rewarming.  In the prehospital setting we do things like turning up the heat in the helicopter or ambulance.  Are we helping by doing these things if we turn around and give patients room temperature saline?  Additionally, the pH of normal saline is around 5.5 on the pH scale (acidotic) (3).  Yes, it does help replace volume, but are we doing the patient any good by lowering the core body temperature with a side of acidosis?  In everyday trauma care we use rewarming of the patient as a means to combat the trauma triad of death (4).  Why not give warm fluids to all patients treated in the prehospital setting?  If we are going to give fluids to any patient, shouldn’t they be warmed? 

Is it feasible to implement prehospital warming of intravenous fluids?  Absolutely!  While many services and agencies already have the means to administer warmed fluids, many of these may not be precise.  However, in the patients who will benefit the most from warmed IV fluids, a constant temperature is not as important as the warmed fluid itself.  While most EMS providers have not taken the Hippocratic Oath to do no harm, we all operate under the pretense of it.  What if we have been doing harm for many years by administering room temperature fluids?  While this author does not believe true harm has been done through this practice, we as a profession have also not been setting our patients up for success and the best outcomes.  Through the routine practice of administering warmed IV fluids to all patients we can improve outcomes and drive best practice throughout emergency medicine.  Thanks for reading.  Be safe out there and remember to always think like a clinician!

Picture from: Image from Outpatient Magazine

References:

  1. https://www.ncbi.nlm.nih.gov/pubmed/26277355
  2. http://www.cochrane.org/CD009891/ANAESTH_warmed-fluids-for-preventing-hypothermia-during-operations
  3. https://www.ncbi.nlm.nih.gov/books/NBK53796/
  4. https://www.ncbi.nlm.nih.gov/pubmed/24249326
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3638298/

Peer Review #1:

Thank you, Klint, for "resuscitating" the topic of warmed fluids.  It is intriguing that this simple therapy has not been well studied and certainly has not been embraced as a standard of care for prehospital providers.  Traumatic hypothermia has been implicated in multiple adverse conditions, including coagulopathy, vasoconstriction and impaired microvascular perfusion, metabolic acidosis, and impaired wound healing with infection.  Although the dangers of traumatic hypothermia are well described, there has been little effort to establish that out-of-hospital fluid warming measures are required as routine therapy.  Thus, the critical care transport and prehospital communities have been reluctant to adopt the use of warmed fluids except as therapy for suspected hypothermia.

It would be interesting to include temperature on the list of variables being explored as part of the optimal approach to fluid resuscitation.  Instead, our focus has been on tonicity, pH, and presence/absence of lactate.  In addition, the out-of-hospital administration of tranexamic acid has overshadowed the use of warmed fluids as "pro-coagulant" therapy.  Until additional interest in formally investigating warmed fluids in the out-of-hospital environment develops, each EMS agency is forced to consider for itself whether ambient temperatures are low enough and/or transport times are long enough to justify routine use of this procedure.
Dr. Dan Davis, MD

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