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Comparison of maximal infusion rate of FMS 2000 fluid warmer on various catheters and fluids

Authors:
  • Inje University Haeundae Paik Hospital, South Korea, Busan

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Objective To compare the maximal infusion rate of FMS 2000 fluid warmer on various intravenous catheters and fluids. Methods This study was performed on 4th February 2011 in operation room, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea. 0.9% sodium chloride (NS), Ringer's lactate (RL), and 6% hydroxylethyl starch 130/0.4 (HES) were applied to FMS 2000 fluid warmer. After FMS 2000 was equipped with one kind of fluid, 16 types of catheter including double lumen catheter were connected to the end of line. We accelerated infusion rate to 750ml/min under 300mmHg of pressure limit. Maximal infusion rate under 300mmHg was measured three times. Maximum value of maximal infusion rate was compared. Results 7-, 8.5F rapid infusion catheter (RIC) resulted in rate of 750ml/min in NS, RL and HES group. Other catheters did not exceed 750ml/min. Maximal infusion rate of NS and RL was faster than HES in all kinds of catheter except RIC. There was no statistically significant difference between NS and RL. Conclusion Maximal infusion rate of HES is slower than NS and RL in ordinary sized venous catheter using FMS 2000. NS and RL had no difference in maximal infusion rate. (Rawal Med J 2011;36:262-266).
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Rawal Medical Journal
An official publication of Pakistan Medical Association Rawalpindi Islamabad branch
Established 1975
Volume 36 Number 4 October - December 2011
Original Article
Comparison of maximal infusion rate of FMS 2000 fluid warmer on
various catheters and fluids
Yong Han Kim, Young Gyun Choi, Sira Bang, Sang Eun Lee, Jae Hong Park, Sang Yoon
Jeon, Jung Dae Shin, Ki Hoon Kim, Jin Soo Kim
Departments of Anesthesiology and Surgery, Haeundae Paik Hospital, Inje University, Busan,
Republic of Korea
ABSTRACT
Objective
To compare the maximal infusion rate of FMS 2000 fluid warmer on various intravenous
catheters and fluids.
Methods
This study was performed on 4th February 2011 in operation room, Haeundae Paik Hospital,
Inje University, Busan, Republic of Korea. 0.9% sodium chloride (NS), Ringer’s lactate (RL),
and 6% hydroxylethyl starch 130/0.4 (HES) were applied to FMS 2000 fluid warmer. After
FMS 2000 was equipped with one kind of fluid, 16 types of catheter including double lumen
catheter were connected to the end of line. We accelerated infusion rate to 750ml/min under
300mmHg of pressure limit. Maximal infusion rate under 300mmHg was measured three
times. Maximum value of maximal infusion rate was compared.
Results
7-, 8.5F rapid infusion catheter (RIC) resulted in rate of 750ml/min in NS, RL and HES group.
Other catheters did not exceed 750ml/min. Maximal infusion rate of NS and RL was faster
than HES in all kinds of catheter except RIC. There was no statistically significant difference
between NS and RL.
Conclusion
Maximal infusion rate of HES is slower than NS and RL in ordinary sized venous catheter
using FMS 2000. NS and RL had no difference in maximal infusion rate. (Rawal Med J
2011;36:262-266).
Key words
Fluid warmer, hydroxylethyl starch, intravenous infusion.
INTRODUCTION
More than 100,000 persons died as the result of an unintentional injury in United States.1
Hemorrhage and shock is the major cause of death in trauma patients.2 Rapid fluid and blood
product infusion is very crucial to increase cardiac output and blood pressure, thus maintains
circulation and tissue perfusion. Several methods like high gravity infusion, manual squeeze,
and pressure bag compression have been used to increase of infusion rate, but these methods
are limited in terms of both velocity and convenience.3 Hypothermia occurs in approximately
60% of patients with trauma or those who were surgically treated.4 It potentiates dilutional
coagulopathy and systemic acidosis, shivering and vasoconstriction in response to cold
increases demand and additional metabolic effort that may predispose the patient to
myocardial ischemia leading to death.5
Not only rapid infusion but also heating is important. Rapid infusion and fluid warming
devices such as the Rapid Infusion System (Haemonetics Corp., Braintee, MA, USA), the
Level 1, Hotline (Level 1 Technologies, Inc., Rockland, MA, USA) and FMS 2000 fluid
warmer (Belmont Instrument Corp., Billerica, MA, USA) are suitable for this purpose. Large
bore intravenous (IV) catheter is recommended for rapid infusion, but this may be difficult in
some child and small adults.6 The purpose of this study was to compare maximal infusion
rate of FMS 2000 in various sized catheters and fluids in vitro.
MATERIALS AND METHODS
This study was performed on 4th February 2011 in operation room, Haeundae Paik Hospital,
Inje University, Busan, Republic of Korea. 0.9% Sodium Chloride solution (NS) (JW
Pharmaceutical Corp, Seoul, South Korea), Ringers Lactate solution (RL) (JW
Pharmaceutical Corp, Seoul, South Korea) and 6% Hydroxyethyl Starch 130/0.4 (HES)
(Voluven®, Fresenius Kabi Deutschland GmbH, Bad Homburg vor der Höhe, Germany) were
used in the study. Model 2516 universal 3-Spike disposable set (Belmont Inst., Billerica, MA,
USA) for FMS 2000 was equipped with NS (Fig. 1). After disposable set was primed with
fluid, intravenous catheter was connected to outlet of disposable set. One examiner kept the
fluid line straight and maintained 20cm below FMS 2000. The other examiner accelerated
infusion rate to 750ml/min under pressure limit of 300mmHg.
Fig 1. FMS 2000 is equipped with 3-spike disposable set and fluid.
Eight types of peripheral catheter (24-, 22-, 20-, 20-, 18-, 16G catheters [Becton Dickson
(BD), Gumi, South Korea], 7-, 8.5French (F) catheters [Arrow International, Reading, PA,
USA]) and eight types of central catheter (2.5-, 3-, 4-, 5-, 7F single lumen and 4-, 5-, 7F
double lumen [Becton Dickinson, Singapore]) were used.
Table 1. Description of intravenous catheter for peripheral vein.
Catheter
OD(mm)
Length(mm)
Flow rate(ml/min)
Color
BD angiocath PlusTM 24G 0.75"
0.7
19
25
yellow
BD angiocath PlusTM 22G 1.00"
0.9
25
35
blue
BD angiocath PlusTM 20G 1.16"
1.1
30
60
pink
BD angiocath PlusTM 20G 1.88"
1.1
48
55
pink
BD angiocath PlusTM 18G 1.16"
1.3
30
105
green
BD angiocath PlusTM 16G 1.77"
1.7
45
170
gray
Arrow RIC® 7F
2.333§
50.8
*
orange
Arrow RIC® 8.5F
2.833§
63.5
*
blue
BD=Becton Dickinson, RIC®=Rapid infusion catheter, OD=Outer diameter, TM=Trade mark, G=Gauge,
F=French, §=Inner diameter, *=Unobtainable
Manufacturers data was represented in Table 1 and 2. Numeric data of table 1 and 2 was
collected from product catalogue. Three of central catheters were double lumen type, thus
proximal and distal ports were tested respectively. Each catheter was tested three times using
new product. RL and HES were used with new disposable set of FMS 2000. All of these
fluids and catheters were available in trauma center and department of anesthesiology. Tests
were performed at room temperature of 23°C.
Table 2. Description of intravenous catheter for central vein.
OD(mm)
Lumen
Flow rate
(ml/min)
Color
0.90
single
10
blue
1.10
single
16
pink
1.45
single
36
green
1.75
single
71
gray
2.40
single
190
gold
1.45
double
proximal 22G
8
white
distal 20G
20
brown
1.75
double
proximal 20G
6
white
distal 18G
29
brown
2.40
double
proximal 18G
24
white
distal 16G
74
brown
BD=Becton Dickinson, OD=Outer diameter, G=Gauge, F=French
Data was collected at a steady state. Statistical analysis was carried out using SAS 9.1.3
software (SAS, Inc., Cary, NC, USA). Paired t-test was used for maximal infusion rate in
intergroup comparison. Multiple regression analysis was used in BD peripheral catheter
group. A value of p<0.05 was considered statistically significant.
RESULTS
Mean values of maximal infusion rate are summarized in table 3. Velocity of NS group was
statistically significantly faster than in HES group (p< .001). RL group showed faster than
HES group as well (p< .001). It was found that between NS and RL group has no significant
difference (p=0.324). Rapid infusion catheter (RIC) represented maximum rate at 750ml/min
in NS, RL and HES group.
Table 3. Mean value of maximal infusion rate of FMS 2000.
Catheter
NS group
RL group
HES group
Product
catalogue
§
BD angiocath PlusTM 24G 0.75"
80
76.67
56.67
25
BD angiocath PlusTM 22G 1.00"
110
111.67
86.67
35
BD angiocath PlusTM 20G 1.16"
176.67
173.33
150
60
BD angiocath PlusTM 20G 1.88"
160
160
126.67
55
BD angiocath PlusTM 18G 1.16"
273.33
275
238.33
105
BD angiocath PlusTM 16G 1.77"
503.33
498.33
441.67
170
Arrow RIC® 7F
750
750
750
*
Arrow RIC® 8.5F
750
750
750
*
BD CareflowTM 2.5Fr 100mm
45
43.33
23.33
10
BD CareflowTM 3Fr 150mm
63.33
60
33.33
16
BD CareflowTM 4Fr 200mm
108.33
113.33
70
36
BD CareflowTM 5Fr 150mm
190
195
146.67
71
BD CareflowTM 7Fr 150mm
490
498.33
446.67
190
BD CareflowTM 4Fr 60mm
proximal 22G
33.33
33.33
10
8
distal 20G
63.33
63.33
36.67
20
BD CareflowTM 5Fr 150mm
proximal 20G
36.67
40
10
6
distal 18G
115
118.33
80
29
BD CareflowTM 7Fr 150mm
proximal 18G
86.67
90
56.67
24
distal 16G
203.33
203.33
150
74
NS=Normal saline, RL=Ringer's lactated solution, HES=Hydroxyethy starch, unit=ml/min, *=Unobtainable,
§=Gravity infusion
Multiple regression analysis was significant (p< .001) with high coefficient of determination
(r2=0.955). Maximum infusion rate (ml/min) =263.365+489.833OD(mm)2.272
Length (mm). Two variables in this formula, OD and length were significant (p< .001 and
p=0.047, respectively).
DISCUSSION
Infusion rate using FMS 2000 was higher as compared with IV catheter manufacturers flow
rate using gravity infusion in NS, RL and HES (Table 3). The steady flow rate of fluid
through circular tube is proportional to the fourth power of the radius, as described in
Poiseuilles law:
where Q = rate of flow, r = tube radius, = pressure gradient, L = length of tubing, =
dynamic fluid viscosity. This equation is completed on the assumption that the flow is lamina
and the density is constant. Poiseuilles law is not exactly suitable in this experiment because
the flow is turbulent under pressure of FMS 2000. But we were able to recognize what
component is important in hydromechanics.7
If the caliber of catheter is identical, the flow is more speedy in shorter catheter.8 In this study,
long 20G catheter showed flow of 160 ml/min, and short 20G catheter had rate of 176.67
ml/min in NS group. If the length is identical, the flow is faster in larger caliber. 1.16 inch
(30mm) of 20G catheter showed flow of 176.67 ml/min, and 1.16 inch of 18G catheter had
rate of 273.33 ml/min in NS group. Gravity infusion by two 20G IVs is faster than a single
18G IV of identical length in healthy volunteers.9 It was thought that HES has higher
viscosity than NS and RL that results in slow infusion rate. NS has similar to RL in aspect of
viscosity. Outer diameter and length were designated as variables in multiple regression
analysis. Inner diameter is more appropriate than outer diameter in this formula. We made a
contact with BD Korea to get the exact data of inner diameter, but was not provided saying
that it was confidential information in the company. We quoted outer diameter and length
from the product instructions.
Murat et al. investigated mean value of right internal jugular vein diameter of 135 Turkish
children under 15 years and categorized 0-12 months (5.195mm), 1-2 years (6.6mm), 2-6
years (7.508mm), over 6 years (7.609mm).10 Warkentine et al. studied right femoral vein of
84 American children under 9 years and classified 0-2 month (4.9mm), 1 year (5.6mm), 3
year (6.4mm), 5 year (7.4mm), 7 year (8.2mm) and 9 year (10.6mm) category.11 Proper size
of IV catheter has to be placed according to age and vein.
Commercial rapid infusion devices can result in rapid infusion, heating, elimination of air
bubbles, record of volume administered and mixing of infusion of fluid and blood product.
FMS 2000 infuses blood or fluid warmed to physiologic temperature via electromagnetic
induction at rates from 2.5-750ml/min. Hypovolemic trauma patients resuscitated with the
rapid infusion system needed fewer fluid/blood products and had less hypothermia.12 One
unit of refrigerated blood or 1 L of crystalloid solution administered at room temperature
each decreases mean body temperature approximately 0.25°C. Ventricular arrhythmia may
occur below 30°C of body temperature.13 There is no heating property at 2.5 and 5 ml/min in
FMS 2000. Rapid infusion more than 100ml/min minimizes heat loss.14 The length of venous
line from warmer determines the exposure to the atmosphere. Short IV fluid line is suitable
for heat preservation.15
Unstable trauma patients get more attention for their injuries and accurate IV access is
unnoticed.16 The mean leakage pressure for thick- and thin-walled atraumatically cannulated
veins in vitro was 1433 and 838 mmHg, respectively (p<.001).17 Unrecognized extravasation
of IV infusion leads to ischemic injury in the limb. An increase in tissue pressure within a
muscular compartment to the point that tissue perfusion is interrupted can cause the
compartment syndrome.18 FMS 2000 can prevent IV induced hematoma by slowing infusion
rate when restriction of flow is detected. Venous air embolism, in case of massive inflow,
may be rapidly fatal.19 A considerable air can enter the circulation with external pressure
300mmHg (average, 49.3ml/sec; range, 43-61ml/sec).20 FMS 2000 performance to detect air
is remarkable in condition of providing packed red cell infusion at physiologic temperature.21
We wanted to conduct this experiment using packed red cell as the fluid, but it was difficult
of obtain outdated blood supply.
CONCLUSION
Fluid administration using rapid infusion device like FMS 2000 is essential and convenient
for hypovolemic traumatic patient. Maximal infusion rate is determined by what kind of fluid
and catheter. The viscosity of fluid and the caliber and length of catheter are factors of
determination.
ACKNOWLEDGEMENTS
This work was supported by Grant from Inje University, 2010.
Correspondence: Yong Han Kim. Email: adonis94@naver.com
Received: August 10, 2011 Accepted: September 13, 2011
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