The properties of an improvised piston pump for the rapid delivery of intravenous fluids

A pressure-resistant peripherally inserted central catheter is as useful as a central venous catheter for rapid fluid infusion: an in vitro study

Background

Although peripherally inserted central catheters (PICCs) have been widely used, they have not been frequently used in anesthesia practice. The central venous pressure measured via PICCs are reportedly as accurate as that measured via central venous catheters (CVCs), but the findings concerning rapid infusion are unclear. This study examined whether or not pressure-resistant PICCs could be used for rapid fluid infusion. 

Methods

The in-line pressure was measured in similar-sized double-lumen catheters—4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (20 and 13 cm)—at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion.

Results

The pressure-resistant PICCs obtained a high flow rate similar to that of CVCs, but the in-line pressures increased in proportion to the flow rate and catheter length. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC.

Conclusion

Pressure-resistant PICCs can be used for rapid fluid infusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01738-x.

When Minutes Matter: Rapid Infusion in Emergency Care

Purpose of Review

This review provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. Emergency department providers who manage critically ill patients with undifferentiated shock will benefit from the insights of early pioneers and an overview of newer techniques which can be used to optimize resuscitation in the first minutes of care.

Recent Findings

Rapid infusion of fluids and blood products can be a life-saving intervention in the management of circulatory and hemorrhagic shock. Recent controversy over the role of fluid resuscitation in sepsis and trauma management has obscured the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies demonstrates that rapid and early resuscitation improves patient outcomes.

Summary

Current practice standards, guidelines, and available literature support the rapid reversal of shock as a key priority in the treatment of hypotension from traumatic and non-traumatic conditions. An improved understanding of the physiologic rationale of rapid infusion and the timing, volume, and methods of fluid delivery will help clinicians improve care for critically ill patients presenting with shock.

Clinical Case

A 23-year-old male presents to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. On arrival at the scene, first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. Bag-valve-mask (BVM) ventilation was initiated, and a semi-rigid cervical collar was placed prior to transport to your ED for stabilization while awaiting air transport to the nearest trauma center. You are the attending emergency medicine physician at a community ED staffed by two attending physicians, two physicians assistants, and six nurses covering 22 beds. On ED arrival, the patient has no spontaneous respiratory effort, and vital signs are as follows: pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation 85% while receiving BVM ventilation with 100% oxygen. He is bleeding profusely through a gauze dressing applied to the exposed dura. The prehospital team was unable to establish intravenous access. What are the management priorities for this patient in shock, and how should his hypotension best be addressed?

Comparison of effectiveness of the piston-pump method versus the pressure-infusor method for rapid infusion of crystalloids: A bench study

Background and Aims

The piston-pump method is a simple method for rapid administration of fluids but some problems are unsolved. We compared the effectiveness of using the piston-pump method with that of the pressure-infusor method.

Methods

Twelve anaesthetists were classified randomly into the piston-pump and pressure-infusor groups. They were asked to infuse 500 ml of saline three times successively through a 16-G intravenous cannula as rapidly as possible using a pump with a 50-ml syringe or a pressure-infusor at 300 mmHg. The time taken for infusion and the maximum or minimum pressure in the infusion circuit and substitute vessel were measured. Bacterial culture of the saline infused sterilely was performed to estimate bacterial contamination.

Results

The pressure-infusor group led to faster infusion of 500 ml of saline (233 ± 19 s) than the piston-pump group (301 ± 48 s) (P < 0.01). The infusion time at the third attempt (316 ± 43 s) was significantly longer than that at the first attempt (285 ± 53 s) only in the piston-pump group (P < 0.05). The maximum pressure (mmHg) in the circuit was 131 ± 9 and > 200 (P < 0.01) and in the substitute vessel was 5 ± 1 and 17 ± 7 (P < 0.01) in the pressure-infusor and piston-pump groups, respectively. A pressure of <-200 mmHg occurred at all infusion attempts in the piston-pump group. Bacterial contamination was not observed in either group.

Conclusion

If fluids must be administered rapidly, the pressure-infusor method is more efficient than the piston-pump method because the latter is less effective in infusing fluids rapidly and associated with excessive positive and negative pressure in the infusion circuit.

Efficacy of Rapid Fluid Administration Using Various Setups and Devices

OBJECTIVES

In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model.

METHODS

Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe.

RESULTS

The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid.

CONCLUSIONS

When considering factors that affect fluid administration, Poiseuille's law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.

In-line pressure within a HOTLINE® Fluid Warmer, under various flow conditions

Roller pump infusion devices are widely used for rapid infusion, and may be combined with separate warming devices. There may be instances however, where the pressures generated by the roller pump may not be compatible with the warming device. We assessed a commonly used roller pump in combination with a HOTLINE® Fluid Warmer, and found that it could generate pressures exceeding the HOTLINE® manufacturers specifications. This was of concern because the HOTLINE® manufacturer guideline states that not for use with pressure devices generating over 300 mmHg. Pressure greater than 300 mmHg may compromise the integrity of the HOTLINE® Fluid Warming Set. The aim of this study was to compare in-line pressure within a HOTLINE® Fluid Warmer at different infusion rates of a roller pump using various sizes of intravenous cannulae. The rapid infusion system comprised a 500 mL-normal saline bag, roller pump type infusion device, HOTLINE® Fluid Warmer (blood and fluid warmer system), and six different sizes of intravenous cannulae. In-line pressure was measured proximal to the HOTLINE® (pre-warmer) and proximal to the cannula (post-warmer), at flow rate of 50-160 mL/min. The in-line pressures increased significantly with increasing flow rate. The pre-warmer pressures exceeded 300 mmHg when the flow rate was ≥120 mL/min with 20-gauge, 48 mm length cannula, 130 with 20-gauge, 25 mm cannula, and 160 mL/min with 18-gauge, 48 mm cannula. However, they were <300 mmHg at any flow rates with 18-gauge, 30 mm cannula and 16-gauge cannulae. The post-warmer pressures exceeded 300 mmHg at the flow rate of 140 mL/min with 20-gauge, 48 mm cannula, and 160 mL/min with 20-gauge, 25 mm cannula, while they were <300 mmHg at any flow rates with 18 and 16-gauge cannulae. The in-line pressure within a HOTLINE® could exceed 300 mmHg, depending on the flow rate and size and length of cannula. It is important to pay attention to the size and length of cannulae and flow rate to keep the maximum in-line pressure<300 mmHg when a roller pump type infusion device is used.