Intravenous revolution

May 25, 2007

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

We all take intravenous fluids for granted. Patients can get indwelling central venous lines in a hospital, emergency department, outpatient facility, and even at home. A variety of crystalloid, colloid, and nutritional solutions are widely available. IVs can be placed completely under the skin, via a peripheral vein, or tunneled subcutaneously. Because in­travenous fluid and the associated equipment has become a billion-dollar industry, it is hard to believe that this is a relatively recent development. Things have drastically changed during the 42 years I have been practicing surgery.

I was reminded of the intravenous revolution by a letter from a Surgical Rounds reader. He recalled a discussion we had several years ago about the use of young coconut water as an intravenous resuscitation fluid. During a trip to India some years ago, I had learned that the fluid in immature coconuts was sterile and that this solution was commonly used to treat injured soldiers in Asia during the Japanese invasions of World War II.

The reader also provided a copy of a fascinating article, which described the use of intravenous coconut water to resuscitate a dehydrated Solomon Islander unable to eat or drink following a cardiovascular event.* The paper delineates the water’s electrolyte composition and the scientific evidence for its safety. The nonantigenic liquid is rich in glucose, fructose, and essential amino acids, but lacking in protein, vitamins, and cholesterol. Despite co­co­nut water’s widespread availability in Asia and the ease of its use, it is far from an ideal intravenous fluid because it is much closer to intra- rather than extracellular fluid. In addition, the pH is quite acidic, the solution is hypotonic, and it contains high concentrations of potassium, magnesium, and calcium.

In contrast, Ringer’s lactate, which also has a fascinating history, is an excellent resuscitation fluid. This crystalloid was created by Alexis Hartmann, a Washington University pediatrician, and was called Hartmann’s solution for many years. Dr. Hartmann studied neo­natal diarrhea, collected untold volumes of stool from affected infants, and characterized its composition. He used this information to develop a replacement solution. Since neonatal diarrhea is basically a transudate, Dr. Hartmann’s creation closely resembles extracellular fluid.

For many years, Barnes and St. Louis Children’s Hospitals in the Wash­ington University Medical Center prepared and sterilized their own Hartmann’s solution in glass bottles. The preparation was artificially colored a pale purple to make it easy to recognize. Believe it or not, that was the situation during the early years of my residency. This local process ended abruptly one morning when many patients in the operating and recovery rooms developed endotoxemia and became quite sick. We spent hours successfully treating them. By the next day, the hospitals had converted to commercially produced (and uncolored) Ringer’s lactate.

I related this story to Dr. Arthur Palrang, a colleague at the Tulane-run Huey P. Long Hospital in Pineville, Louisiana (where I predominantly worked following Hurricane Katrina). In turn, he told me a similar tale from his residency days, which preceded mine. Charity Hospital in New Orleans used to prepare its own crystalloid solutions for infusion. It became socially acceptable for nurses to mix lemon in refrigerated saline as a summer cooler. One night, while on call, Dr. Palrang was notified that an intravenous infusion had stopped. When he inquired as to whether the line was flushed, he was informed that a pit had occluded the aperture at the hub of the needle. I didn’t want to know if administration of the flavored solution had adverse effects or was simply an early version of hyperalimentation.

I learned a very important lesson during my internship. In l964, nurses were not allowed to put additives in intravenous solutions. Physicians had to add potassium, antibiotics, and medications themselves. Since many of these additions were needed at night, this could be a nightmare. One of my colleagues was unduly tough on the nurses, and they reciprocated by insisting he get out of bed to do the additions. In fact, the floors arranged a coordinated schedule so that he was needed on 5200 (one of the nursing stations) at 1: 00 am, 10200 (another nursing station) at 1:45 am, 7200 at 2:30 am, 11200 at 3:30 am, etc. The nurses had responded to his meanness by making certain that as soon as he fell asleep, he was aroused to return again to a nursing station and squirt a syringe of liquid into an intravenous bottle. I treated the nurses much better, and as a result, I was never called to mix intravenous solutions at night. The nurses simply bent the rules a bit and did the additions on my behalf.

The intravenous revolution has had a salutory effect on surgical residency life. Gone are the days of sharpening reusable needles, conducting twice-daily sticks for rapid intravenous infusions, or requiring prolonged hospitalizations for long-term antibiotic infusion. These have been replaced with angiocaths, hep-locks, central lines, Quentin catheters, and portacaths. Thank your liquid stars.

Reference

*Campbell-Falck D, Thomas T, Falck TM, et al. The intravenous use of coconut water. Am J Emerg Med. 2000;18(1): 108-111.