why normal saline over d5w for blood transfusion

Syn. Do Men Still Wear Button Holes At Weddings? Intravenous Therapy All health care practitioners who administer blood or blood products must complete specific training for safe transfusion practices and be competent in the transfusion administration process. Most IV fluids are isotonic, meaning, they have the same concentration of solutes as blood plasma. There is no physiologic rationale for its use as a resuscitative fluid. This site represents our opinions only. Patients may also have medications, such as potassium chloride, thiamine, and multivitamins, added to IV solutions. Bicarbonate deficit (in mEq) can be estimated. Epub 2013 Nov 14. It's a site that collects all the most frequently asked questions and answers, so you don't have to spend hours on searching anywhere else. This explains the alkalinizing effect of IV bicarbonate. 10 Answers. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Intravascular volume deficiency read more ). These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension. normal saline; NaCl 0.9%. EMCrit is a trademark of Metasin LLC. Water freely travels outside the vasculature, so as little as 10% of isotonic fluid remains in the intravascular space. Choosing a specialty can be a daunting task and we made it easier. Another reason why D5W is often used for hospitalized patients is that it is a sterile solution. A 30 cc/kg bolus of Lactated Ringers might possibly raise the lactate level by ~0.5 mM. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers. Question: Normal Saline (NS) is the solution of choice over D5W when preparing to administer a blood transfusion because A Normal Saline is hypertonic and compatible with all blood products B Normal Saline is the most common primary IV solution Normal Saline is an isotonic solution and prevents cell hemolysis D The dextrose in D5W increases risk This is to tell the Nurseslabs that Im very much grateful for it and always pleased to be part of it simply because, the lab contains all that it takes for Nursing Research with that, I want to say Im happy to see myself here. This unique pharmacology review can be utilized as a spiral-bound notebook or as individual flashcards, making it ideal for mobile study. Note that the development of a pneumothorax in a patient with profound ARDS or asthma may be a catastrophic event. When the patient is stable, if the hemoglobin is < 7 g/dL (70 g/L), in the absence of cardiac or cerebral vascular disease, oxygen-carrying capacity should be restored by infusion of additional blood (or in the future by blood substitutes). However, no blood substitutes have yet proved to increase survival and some have significant adverse effects (eg, hypotension). Don't use hypertonic bicarbonate to treat hyperkalemia (proven not to work). What is the most common complication of TPN? It is also used to replace large sodium losses such as in burn injuries and trauma. This shouldn't be a problem if the patient has adequate IV access. Human albumin is a solution derived from plasma. The PN formulation provides energy, fluid, and various medications via peripheral or central venous access. Lactated Ringers isn't compatible with blood.. Normal saline for injection can cause inflammation or irritation at the injection site. Epub 2015 Jun 29. This study reinforces the unsafe practice of mixing RBCs with certain intravenous solutions. What are the safety considerations for blood transfusions? We use cookies to ensure that we give you the best experience on our website. it's cheap or it's what we're used to using). A transfusion of whole blood or packed red blood cells may be needed to treat acute blood loss or anaemia. . It is often administered to patients with metabolic acidosis. Patients with active coronary or cerebral vascular disease or ongoing hemorrhage require blood when hemoglobin is < 10 g/dL (100 g/L). It has an osmolality of 308 mOsm/L and gives no calories. At this point, there are only two logically coherent strategies which exist, as shown below: Historically, administration of lactate was feared (due to worsening of lactic acidosis). Dismiss. Several years ago, the ICU at Genius General Hospital transitioned from using normal saline to using mostly Lactated Ringers (spoiler alert: it was neither difficult nor dramatic). Lactated Ringers is generally an outstanding choice as it is inexpensive, widely available, and physiologically sound (the choice of lactate as an anion is arguably superior to gluconate/acetate). Patients receiving > 6 units may require replacement of clotting factors with infusion of fresh frozen plasma or cryoprecipitate and platelet transfusion (see also Blood Products Blood Products Whole blood can provide improved oxygen-carrying capacity, volume expansion, and replacement of clotting factors and was previously recommended for rapid massive blood loss. There is no physiologic rationale for its use as a resuscitative fluid. Isotonic IV fluids have a total osmolality close to that of the ECF and do not cause red blood cells to shrink or swell. Lactated Ringers contains 1.5 mM of calcium. They are available in either saline or glucose solutions. The procedure is simple: fluids are restricted to normal saline and serum sodium levels, and it . . Other investigational methods such as measurement of sublingual tissue carbon dioxide or near-infrared spectroscopy to measure tissue oxygenation through the skin may also be considered. In patients with severe hypovolemia or hypovolemic . What are the complications of parenteral nutrition? Lactated Ringers is only ~25 cents more expensive per liter, and the cost difference of Plasmalyte/Normosol isn't much greater. Several RCTs have shown that hypertonic bicarbonate does, Available data shows that isotonic bicarbonate. Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values. It is used to increase the circulating volume and restore protein levels in conditions such as burns, pancreatitis, and plasma loss through trauma. It can also be used in fluid losses due to burns, fistula drainage, and trauma. Lactated Ringers Solution (also known as Ringers Lactate or Hartmann solution) is a crystalloid isotonic IV fluid designed to be the near-physiological solution of balanced electrolytes. It could even function as an osmotic diuretic agent. After blood loss is controlled, hemoglobin is used to guide the need for further transfusion. This study guide will help you focus your time on what's most important. How many gtt/min will the patient receive?, The patient is to receive 3000ml of D5W at 125 ml/hr. NS, as well as similar fluids like Lactated Ringers (LR), are crystalloids, and therefore consist of an. (4) In animal models, normal saline causes significant harm compared to balanced crystalloid (e.g. No statistical differences were identified between groups for other measured variables. Conclusion: In vitro characteristics of RBCs coinfused with 0.9% saline or D10W were not adversely impacted. Standard, large (eg, 14- to 16-gauge) peripheral IV catheters are adequate for most fluid resuscitation. White blood cells White Blood Cells help fight infection, bacteria and other substances that enter the body. These factors provide a safety margin of about 9 times the resting oxygen requirement. Dextrose 10% in Water (D10W) is an hypertonic IV solution used in the treatment of ketosis of starvation and provides calories (380 kcal/L), free water, and no electrolytes. Background: Careers. Bookshelf Also, normal saline has a higher chloride content. 1 Why is normal saline used for blood transfusions? TPN requires a chronic IV access for the solution to run through, and the most common complication is infection of this catheter. Blood substitutes are oxygen-carrying fluids that can be hemoglobin-based or perfluorocarbons. to facilitate the flow of IV medication during surgery. The link you have selected will take you to a third-party website. This effect causes cells to shrink and may disrupt their function. 1-917-426-3524, By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. 2022 - 2023 Times Mojo - All Rights Reserved However, it's dubious whether we really need any additional trials: There is zero physiologic rationale for using saline in most patients. These solutions are derived from starch and are used to increase intravascular fluid but can interfere with normal coagulation. This has been shown in a variety of studies, most recently the SALT-ED RCT. Why is normal saline the only solution used for blood transfusions(PRBC's)? Enter a Melbet promo code and get a generous bonus, An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. These differences simply aren't relevant in the context of a patient's hospital bill which will range in the thousands of dollars. The nature and severity of abdominal injuries vary read more , extremity compartment syndrome). This isn't possible, because. Mosbys Pharmacology Memory NoteCards: Visual, Mnemonic, and Memory Aids for NursesThe 6th edition of Mosbys Pharmacology Memory NoteCards: Visual, Mnemonic, & Memory Aids for Nurses incorporates illustrations and humor to make studying easier and more enjoyable. Paediatric administration Blood administration sets containing an integral 170-200 micron filter should always be used. A ratio of 1 unit of plasma for each 1 unit of red blood cells and each 1 unit of platelets is currently recommended (1 Fluids references Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion (eg, due to diarrhea or heatstroke). Very good illustration. When the white blood cell count becomes too low, it is called They are contraindicated in patients with hemorrhagic shock. It contains 130 mEq/L of sodium, 4 mEq/L of potassium, 3 mEq/L of calcium, and 109 mEq/L of chloride. saline, physiological. (3) Volume load of isotonic bicarbonate may directly dilute out potassium, thereby decreasing the potassium concentration. However, fluid therapy is an extremely common intervention. See eyewash; irrigation; isotonic solution. Extracorporeal CO2 removal: Putting the cart ahead of the horse? This can be life-threatening. Its a crystalloid fluid (easily passes through the cell membrane) and is generally isotonic. The child is given a 20 ml/kg bolus of 0.9% saline over 10-20 minutes. Quality of red blood cells washed using an automated cell processor with and without irradiation. An additional component, white cells, is often removed from donated blood before transfusion. Overly rapid infusion of any type of fluid may precipitate pulmonary edema Pulmonary Edema Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding. Intravenous bicarbonate contains both bicarbonate and dissolved CO2. 8600 Rockville Pike PMC Q: Should blood tubing be primed with or without normal saline before administration of blood products? Normal saline solution (0.9% NaCl) or NSS, is a crystalloid isotonic IV fluid that contains water, sodium (154 mEq/L), and chloride (154 mEq/L). They are available in two types: low-molecular-weight dextrans (LMWD) and high-molecular-weight dextrans (HMWD). . The optimal rate of alkalinization is unknown, and likely varies depending on the individual patient scenario. Berman, A., Snyder, S. J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., & Stanley, D. (2018). Please confirm that you are a health care professional. However, colloid solutions offer no major advantage over crystalloid solutions, hydroxyethyl starch increases risk of renal injury, and albumin has been associated with poorer outcomes in patients with traumatic brain injury. government site. well-done very easy and has a lot of very important data for nurses, every nurse should read this , thanks a lot to the site and the nice people who are updating and maintain up to date. Although the bag of fluid will be hypertonic, glucose doesn't function as an effective osmole (since it readily enters cells). Hinkle, J. L., & Cheever, K. H. (2017). The following are the general nursing interventions and considerations when administering colloid IV solutions: This is where you can download the cheat sheets for intravenous solutions for free! 4 Intravenous immunoglobulin (IVIG) is only compatible with D5W. Occasionally, intubated patients who are encountered who are extremely difficult to ventilate (typically due to status asthmaticus or severe ARDS). Bethesda, MD 20894, Web Policies The safest approach to these patients may be to administer exogenous bicarbonate, with a goal of increasing the bicarbonate level to ~30-35 mEq/L, This will generally amount to shifting patients from a state of mild metabolic. Unfortunately, current guidelines mandate that only normal saline be administered with blood products because of the danger of creating emboli. We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. Normal saline is the isotonic solution of choice for expanding the extracellular fluid (ECF) volume because it does not enter the intracellular fluid (ICF). It is the choice for first-line fluid resuscitation for certain patients. There are many potential problems related to saline. Prophylaxis against hepatorenal syndrome after large volume paracentesis. A higher hematocrit does not improve outcome and, by causing increased blood viscosity, may impair perfusion of capillary beds. An elevated arterial blood lactate level may reflect hypoperfusion and/or continued sympathetic drive from endogenous catecholamine production; however, lactate levels do not decline for several hours after successful resuscitation. Lactated Ringers isn't compatible with some drugs (e.g. There is no high-quality evidence on this topic. Our recommended nursing pharmacology resources and books: Disclosure:Included below are affiliate links from Amazon at no additional cost from you. Additionally, use of a balanced fluid may avoid the need for IV bicarbonate and/or dialysis which would, I will give two liters of saline and then switch to a balanced fluid.. Experimental and clinical evidence indicates that internal hemorrhage (eg, due to visceral or vascular laceration or crush) may be worsened by resuscitation to normal or supranormal MAP. Because CVP may be unreliable in assessing volume status or left ventricular function, pulmonary artery catheterization Pulmonary Artery Catheter (PAC) Monitoring Some monitoring of critical care patients depends on direct observation and physical examination and is intermittent, with the frequency depending on the patients illness. Clipboard, Search History, and several other advanced features are temporarily unavailable. Clumping and hemolysis are seen when ADSOL-stored RBCs or saline-washed RBCs are mixed with D5W. Pharmacy. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Safety considerations: 1 No medications may be added to blood units or through IV tubing. If your hospital. Hypertonic saline is not recommended for resuscitation because the evidence suggests there is no difference in outcome when compared to isotonic fluids. The most common way to categorize IV fluids is based on their tonicity: IV solutions can also be classified based on their purpose: Crystalloid IV solutions contain small molecules that flow easily across semipermeable membranes. Why You Should Pursue a Career in Oncology Nursing. The doctor said NS at 70 ml/hr which is better for the different situations 0.9 or 0.45 or could I have recommended D5W? Exogenous bicarbonate has long been used by nephrologists in efforts to improve pH and avoid dialysis. And to wash the eye following a chemical burn. Which type of IV administration set should be used for blood transfusion? It is called normal saline solution because the percentage of sodium chloride dissolved in the solution is similar to the usual concentration of sodium and chloride in the intravascular space. Intravascular volume deficiency is acutely compensated for by vasoconstriction, followed over hours by migration of fluid from the extravascular compartment to the intravascular compartment, maintaining circulating volume at the expense of total body water. Differentiate isotonic, hypertonic, and hypotonic IV solutions and the nursing interventions and management for each. In theory, the calcium in Ringer's lactate. Pulmonary Artery Catheter (PAC) Monitoring, Acute Hypoxemic Respiratory Failure (AHRF, ARDS), Recognizing complications of abdominal trauma, End Point and Monitoring of Fluid Resuscitation, Dehydration and Fluid Therapy in Children, Advocate Glucose SOS, BD Glucose, Dex4 Glucose, Glutol , Glutose 15 , Glutose 45 , Glutose 5. Isotonic dextrose (D5W) may be used instead of saline, but dextrose in the solution may contribute to hyperglycaemia and may also affect blood sugar determinations in blood samples drawn from the arterial line . . How come lactated ringers or Normosol-R cannot be use with packed red cells. Such fluids do not alter the osmolality of the vascular compartment. It is used to store and rinse soft contact lenses, to irrigate the eye, etc. Thank you so much for this website,this has helped me alot in my nursing career . Crit Care Nurse 1 June 2013; 33 (3): 8084. This website has become a lifesaver! Which is the best saline solution for blood transfusion? It should not be used for fluid resuscitation because hyperglycemia can result. What IV solution should be used with a blood transfusion why? Effects of intravenous delivery systems on infused red blood cells. Our members represent more than 60 professional nursing specialties. Don't miss opportunities to fix your patient's pH abnormalities using pH-guided resuscitation (especially for patients with uremic metabolic acidosis). However, because read more are required. Other complications of massive transfusion Complications of Transfusion The most common complications of transfusion are Febrile nonhemolytic reactions Chill-rigor reactions The most serious complications, which have very high mortality rates, are Acute hemolytic read more are discussed elsewhere. Platelets and cryoprecipitate should NOT be warmed. If a patient comes to us two hours after dying you cant bring them back to life. After the patient is volume resuscitated, this opportunity will be lost (because large volumes of fluid can no longer be given without causing volume overload). This has been shown in a variety of studies, most recently the SALT-ED RCT. Higher concentrations of dextrose (i.e., D50W) are strong hypertonic solutions and must be administered into central veins so that they can be diluted by rapid blood flow. Brunner-Suddarth. There are many reasons for this, but one salient one is as follows: eventually you will wind up giving liters of saline to a hyperkalemic and acidotic patient, thereby pushing them off a pH cliff. Lactate may function as a metabolic fuel for the heart, so if anything, lactate could be a good thing. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure. Why is saline solution used for blood loss? This serves the dual purpose of administering to the patient any residual blood left in the administration set (up to 40 mL), and it flushes the line for later use. A clear and engaging writing style simplifies complex concepts, making even the most challenging pharmacology content enjoyable. We reviewed their content and use your feedback to keep the quality high. Before What happens to red blood cells in saline solution? Get to know the different types of intravenous solutions or IV fluids in this guide and cheat sheet. ( 29485926) Interestingly, the SALT-ED trial showed benefit from balanced crystalloid, despite most patients' receiving relatively little fluid. "Normal" saline is a hypertonic, acidotic fluid. This seems to be a myth. http://www.pathology.med.umich.edu/bloodbank/manual/bbch_6/index.html. Ringers solution is another isotonic IV solution that has content similar to Lactated Ringers Solution but does not contain lactate. It should not be used for heart failure, pulmonary edema, and renal impairment, or conditions that cause sodium retention as it may risk fluid volume overload. I NEED AN ANSWER A PATIENT IS RECEIVING 50ML/HR OF 5%DETROSE VIA IVF DUE TOA DX OF DEHYDRATIONAND A UTI. Isotonic bicarbonate is generally formulated by adding 150 mEq of sodium bicarbonate to a liter of D5W (above). The transition from normal saline to balanced crystalloids (Step I, above) is focused largely on the avoidance of. HMWD used for patients with hypovolemia and hypotension. Does dextrose increase risk of infection with blood transfusion? Unauthorized use of these marks is strictly prohibited. Indications are the same for Lactated Ringers but without the contraindications related to lactate. Explanation When preparing to provide a blood transfusion, normal saline is preferred over D2W since only isotonic saline (0.9%) from the range of intravenous solutions is advised for use with blood components. Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. to restore fluid balance after significant blood loss or burns. Conclusion: Furthermore, Plasmalyte doesn't contain calcium, so it's compatible with a wider variety of drugs. Create well-written care plans that meets your patient's health goals. Patients with intravascular volume depletion without shock can receive infusion at a controlled rate, typically 500 mL/hour. Very rarely, acute metabolic alkalosis may be seen. There are many potential problems related to saline. Kozier and Erbs Fundamentals of Nursing [4th Australian edition]. A liter of D5W provides fewer than 200 kcal and contains 50g of glucose. Red blood cell transfusion has a low risk of directly transmitting infection, but in critically ill patients, it seems to cause a slightly higher rate of hospital-acquired infection. This serves the dual purpose of administering to the patient any residual blood left in the administration set (up to 40 mL), and it flushes the line for later use. Normal saline When leveraged over the high number of patients receiving fluid, even small differences in efficacy can be important (e.g. The use of exogenous bicarbonate to balance out severe respiratory acidosis is a longstanding practice in critical care (e.g. Tonicity plays a role but a minor role as upposed to calcium. Christine Kessler; Priming Blood Transfusion Tubing: A Critical Review of the Blood Transfusion Process. Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. The most common types of solutions include normal saline (NS) and D5W. Transfusion. Hypovolemic shock is considered present when severe hypovolemia results in organ dysfunction as the result of inadequate tissue perfusion. Caution needs to be exercised with repeated ampules, as eventually this may cause hypernatremia. Hello Mj, yes, of course, youre free to download them. Why is normal saline used for blood transfusions? There are many potential problems related to saline. Differences between various balanced crystalloids are minor and probably of minimal clinical significance. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock. If bicarbonate is administered more slowly, then transient pCO2 elevations are smaller. These reactions can occur when your ABO or Rh blood type and that of the transfused blood do not match. The trusted provider of medical information since 1899, Last review/revision Jun 2022 | Modified Sep 2022. D5 in one-half normal saline is hypertonic, and would be an acceptable IV solution for this patient. Do a google search and you'll likely come up with your information. 3 See agency policy for using EID for the administration of blood products. Some patients may need diuretic therapy to assist in fluid excretion. A: Christine Kessler, RN, MN, CNS, ANP, BC-ADM, replies: Many hospital transfusion protocols and related nursing practices have been based more on tradition and assumptions than on scientific evidence. Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged read more , acute respiratory distress syndrome Acute Hypoxemic Respiratory Failure (AHRF, ARDS) Acute hypoxemic respiratory failure is defined as severe hypoxemia (PaO2 (See also Overview of Mechanical Ventilation.) Don't bolus hypertonic bicarbonate for a patient in cardiac arrest (unless you suspect a toxicologic etiology). Is lactated Ringers compatible with blood products? Colloid solutions are generally not used. This is the perfect supplement to class materials, offering solid preparation for NCLEX as well as a handy refresher for experienced nurses. If physicians and nurses in your unit are used to giving saline and a patient crashes, they're going to give saline. anyways this is a big help <3 thank you so much. Do NOT hang longer than 4 hours. Other monitoring read more may be considered for diagnosis or for more precise titration of fluid therapy if there is no cardiovascular improvement after initial therapy. A pool-and-split design was used to allow conditions to be tested on each pool within 2 hours of irradiation. When combined with red cells, other frequently used . IV Fluids and Solutions Guide & Cheat Sheet, Lactated Ringers 5% Dextrose in Water (D5LRS), Nursing Considerations for Isotonic IV Solutions, Nursing Considerations for Hypotonic IV Solutions, Nursing Considerations for Hypertonic IV Fluids, Nursing Considerations for Colloid IV Solutions, Pharmacology Made Incredibly Easy (Incredibly Easy! In vitro characteristics of RBCs coinfused with 0.9% saline or D10W were not adversely impacted. The transfusable components that can be derived from donated blood are red cells, platelets, plasma, cryoprecipitated AHF (cryo), and granulocytes. "Normal" saline is a hypertonic, acidotic fluid. These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension. and transmitted securely. Blood Transfusion / methods* c. Normal saline is an isotonic solution and prevents cell hemolysis. They contain no electrolytes and are used to treat shock related to vascular volume loss (e.g., burns, hemorrhage, trauma, or surgery). 2. In most cases, gradual alkalization (e.g. Platelets and cryoprecipitate should NOT be warmed. Paediatric blood administration sets are appropriate for small volume transfusions. There are many potential problems related to saline. An official website of the United States government. JAMA 313(5):471-482, 2015. doi:10.1001/jama.2015.12, 2. IV fluid therapy is an efficient and effective way of supplying fluids directly into the intravascular fluid compartment, in replacing electrolyte losses, and in administering medications and blood products. D5W is initially an isotonic solution and provides free water when dextrose is metabolized (making it a hypotonic solution), expanding the ECF and the ICF. The gtt factor is 60. Medical-surgical nursing. Hypotonic IV fluids are usually used to provide free water for excretion of body wastes, treat cellular dehydration, and replace the cellular fluid. Just as we wouldn't give the patient any antibiotic we shouldn't give any fluid the fluid should be selected to maximize benefit. PMID: 2493255 . Exogenous bicarbonate administration is a physiologically logically and reasonably well-accepted treatment for NAGMA. Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. The following are the general nursing interventions and considerations when administering hypertonic IV solutions: Colloids contain large molecules that do not pass through semipermeable membranes. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree read more for discussion of mild dehydration. MeSH It is called normal saline solution because the percentage of sodium chloride dissolved in the solution is similar to the usual concentration of sodium and chloride in the intravascular space. 2017 Jan;44(1):30-38. doi: 10.1159/000449039. But really, if you think about how much it affects the blood volume, it takes 3L of D5W to have the same effect as 1L of saline on the intravascular volume.

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