why is normal saline used with blood transfusions

/F1 13 0 R Patients require evaluation for signs and symptoms of dehydration and fluid overload. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) endobj Glossary: LISS - Blood Bank Guy This is the practice at my hospital, let me know if you have seen different and why. Your blood will be tested before a transfusion to determine whether your blood type is A, B, AB or O and whether your blood is Rh positive or Rh negative. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. While the overuse of 0.45% sodium chloride can cause hyponatremia and cerebral edema, this is due to its hypotonic nature, creating a migration of water molecules into areas of higher sodium concentration. Ideally, the solution helps to maintain or achieve fluid balance in your body. Some nurses never use normal saline to prime the infusion line, as they use blood to prime the line. Blood Products, Crystalloids, and Rapid Infusion: An Experimental Study With Magnesium. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. Its also sometimes called Ringers lactate or sodium lactate solution. First resuscitation of critical burn patients: progresses and problems. The blood typically comes from donors. Epub 2021 Jul 9. Therefore, if an adverse effect does occur, discontinuation of the infusion is strongly suggested. Advertising revenue supports our not-for-profit mission. The glycemic index (GI) is a value used to measure how much a specific food increases your blood sugar levels. >> [4]The dilution of serum bicarbonate through non-buffered crystalloids (e.g., normal saline) may also contribute to acidosis. Without proper management, the consequences of adverse effects increase. Significant deviations from normal concentrations may require tailoring of the electrolyte pattern in these or alternative solutions. This effect usually isnt a concern unless a person gets a large amount of normal saline solution. Unable to load your collection due to an error, Unable to load your delegates due to an error. This site needs JavaScript to work properly. Crystalloids containing potassium (Lactate Ringer's solution, Hartmans solution, etc.) Because of this discrepancy in concentration, these fluids are osmotically active and will cause fluid shifts. These soundsmay indicate pulmonary edema secondary to volume overload. The Y-type blood transfusion tubing may be used with 2 units of blood. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Do not add medications directly to a unit of blood during transfusion. Fluid manufacturers put slightly different components in normal saline compared to lactated Ringers. Patients with congestive heart failure are at anincreasedrisk for detrimental effects of normal saline administration. PMC endstream allnurses is a Nursing Career & Support site for Nurses and Students. In patients receiving hypertonic saline for severe hyponatremia with neurologic sequelae, frequent neurologic checks are necessary to assess clinical improvement. to facilitate the flow of IV medication during surgery. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Transfusions of Packed Red Blood Cells (PRBCs) - Verywell Health Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Whole blood (WB, n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR-5) CaCl2/L solutions for assessment of infusion time, filter weight, and clot formation. There is no physiologic rationale for its use as a resuscitative fluid. 19 0 obj Such monitoring canalso help identify worsening neurologic function as a potential indicator of cerebral edema or central pontine myelinolysis. Within these compartments,sodium plays a significant role in sustaining homeostatic concentrations and the distribution of water. The dose for lactated Ringers depends on the circumstances. Federal government websites often end in .gov or .mil. Blood Transfusion: What is it, Benefits, Risks & Reactions, Time PDF Infusion: IV Start and Blood - Veterans Affairs Some research suggests that lactated Ringers may be preferred over normal saline for replacing lost fluid in trauma patients. Blumberg N, Cholette JM, Pietropaoli AP, Phipps R, Spinelli SL, Eaton MP, Noronha SA, Seghatchian J, Heal JM, Refaai MA. Q: Should blood tubing be primed with or without normal saline before administration of blood products? Trials. /Type /Page [1]However, revised guidelines in 2018 have called into question the efficacy ofEGDT. In this clinical setting, larger bore intravenous cannulas should helpensure the safe administration of high fluid volumes. Administered by the RN Normal Saline is the *only* compatible solution to hang with the blood or blood /Resources 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. While normal saline (0.9% NaCl solution) is the most frequently usedcrystalloid fluid, many other formulations can provide improved clinical outcomes in specific patient populations. Blood bank guidelines should be revised to allow the use of LR in the rapid transfusion of PRBC. Outline interprofessional team strategies for improving outcomes and decreasing adverse effects of normal saline when it is used in critically ill patients. Dextrose Water: This solution contains dextrose, a form of glucose. Red blood cell transfusion is used to replace the blood removed rather than saline solution as discussed above. Crystalloid solutions for intravascular volume replenishment are typically isotonic (eg, 0.9% saline or Ringer's lactate). Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock. n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR . Can J Anaesth. Besides metabolic acidosis, clinical research has shown that high volumes of normal saline can cause hyperchloremia-inducedrenal afferent arteriole constriction, which cancause a decrease in the glomerular filtration rate. 1991 Jul;173(1):9-12. Their primary indication is for emergent replacement of serum solutes, such as in hyponatremia with neurologic symptoms. Water is a necessary ingredient of the body and comprises more than two-thirds of total body weight. You'll be seated or lying down for the procedure, which usually takes one to four hours. Mild complications and rarely severe ones can occur during the transfusion or several days or more after. to restore fluid balance after significant blood loss or burns. Universal blood donor type: Is there such a thing? ), and these patients should, therefore, receive treatment withjudicious useof intravenous fluids.[2]. Another important ion ischloride, which serves as a buffering agentwithin the lungs and tissues. << [2] Normal salinecontains electrolytes (sodium and chloride ions) which dissociate in solution. http://creativecommons.org/licenses/by-nc-nd/4.0/. /GS8 10 0 R American Cancer Society. Instead, the solution will increase the fluid volume in your body. One fact is clear; normal saline should be prescribed, just like all other medications, taking into account individual patient factors, disease processes, and other treatments. If youre very dehydrated, a doctor may order fluids infused at a very fast rate, such as 1,000 milliliters (1 liter). Patients should undergo assessment for signs and symptoms of dehydration and fluid overload. 3 See agency policy for using EID for the administration of blood products. In these patients, fluid overload is a considerable concern; this can lead to life-threatening pulmonary edema and the worsening of diastolic or systolic heart failure, leading to end-organ damage or evendeath. Signs and symptoms of fluid overload can undergo an evaluation with a comprehensive physical exam. In theory, the calcium in Ringer's lactate. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. Use a multi-set administration set if multiple units are to be transfused. Access free multiple choice questions on this topic. Various estimates indicate that between 15% and 45% of patients require transfusions during their intensive care unit (ICU) stay, depending on their length of stay.1,2 The Joint Commission mandates that hospitals have Christine Kessler is a nurse practitioner in the department of endocrinology at Fort Belvoir Community Hospital in Fort Belvoir, Virginia. We use cookies to ensure that we give you the best experience on our website. By continuing to use our website, you are agreeing to our, Copyright 2023 American Association of Critical-Care Nurses. Giving large amounts of pure water directly into a vein would cause your blood cells to become hypotonic, possibly leading to death. Blood products require a dedicated line for infusion, and filtered intravenous tubing. This is a detailed article about almonds and their health benefits. Compared to human serum, saline has a nearly 10% higher Na concentration and 50% higher Cl concentration. ), and these patients should, therefore, receive treatment withjudicious useof intravenous fluids. Here are 14 of the healthiest leafy green vegetables you, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. [5], Acetate buffered crystalloid solutions have been the subject of much debate in the medical literature. Bookshelf Tonicity plays a role but a minor role as upposed to calcium. In comparison to other types of fluids (e.g., hypertonic, hypotonic), there is less of an osmotic effect. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. The SMART and SMART-SURG trials demonstrated a decreasedrate of AKI but not overall survivalamong critically ill patients who received Ringer's lactate, a balanced, lactate-buffered crystalloid over normal saline. stream The fluid requirements of patientsweredetermined to be related to a patient's caloric demand by Drs. It has high levels of sodium and chloride, levels that are higher than the blood. Which type of IV administration set should be used for blood transfusion? http://www.nhlbi.nih.gov/health/health-topics/topics/bt. This includes sodium and potassium. /Lang (en-US) /ProcSet [/PDF /Text /ImageB /ImageC /ImageI] 2022 Apr;36(4):1040-1046. doi: 10.1053/j.jvca.2021.07.006. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. Jung KT, et al. /Type /Group Osmotic pressure is a measurement of the balance of solutes (such as sodium, calcium, and chloride) to solvents (for example, water). x\YoH~7/H},cHb}Ycc/v "U_-B{{c/|&/C{B \Cg/v?_&K }/-~}v5 -y4oy8FW%||.h|]?_{'@/{\ \h This activity describes the indications, action, and contraindications for normal saline as a valuable agent in the use of fluid and electrolyte resuscitation. Duffy RA, Foroozesh MB, Loflin RD, Ie SR, Icard BL, Tegge AN, Nogueira JR, Kuehl DR, Smith DC, Loschner AL. <> Bhaskaran K, Arumugam G, Vinay Kumar PV. Within each 100 mL of 0.45% sodium chloride Injection USP, there is 7.7 mEq of sodium ions and 7.7 mEq of chloride ions. Review appropriate monitoring parameters for normal saline. Acronym for "Low Ionic Strength Saline.". Normal Saline - StatPearls - NCBI Bookshelf This potentially life-saving procedure can help replace blood lost due to surgery or injury. The https:// ensures that you are connecting to the Albert K, van Vlymen J, James P, Parlow J. These solutions were designed to sustain a normal physiologic plasma pH. >> As you load him into the ambulance, your partner tells you he is spiking a 1-liter bag of 0.9% sodium chloride, also known as normal saline (NS). Identify the mechanism of action of crystalloid fluids. An intravenous (IV) line with a needle is inserted into one of your blood vessels. >> Background: Priming Blood Transfusion Tubing: A Critical Review of the Blood /StructTreeRoot 4 0 R Special care is prudent when administering fluids to patients with congestive heart failure or those with significant renal impairment (e.g., CKD-V dialysis-dependent patients). Tonog P, Lakhkar AD. [10]Although additional prospective studies are still needed. In patientswho require a blood transfusion, blood products should utilize aseparate IV setup. 2017 Mar 16;18(1):129. doi: 10.1186/s13063-017-1871-1. /Kids [5 0 R 6 0 R 7 0 R 8 0 R 9 0 R] If the fluid still wont drip, call ______________________________. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Most commercially available crystalloid solutions are isotonic to human plasma. xXKoF#@+;[@6 Eisenhut M. Causes and effects of hyperchloremic acidosis. C. Open the Y-tubing blood administration set for a single unit of blood. A blood transfusion is a routine medical procedure in which donated blood is provided to you through a narrow tube placed within a vein in your arm. Lactated Ringer's Solution: Vs. Saline, Uses, Content - Healthline <> A prospective, randomized, comparison study on effect of perioperative use of chloride liberal intravenous fluids versus chloride restricted intravenous fluids on postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass grafting surgeries. After completing an assessment, the nurse learns that the patient has a . StatPearls. PDF Transfusion Blood Administration - Children's Minnesota Saline Shortage (0.9% NaCl Solution) Background: It is standard practice at many hospitals to follow blood component transfusions with a normal saline (0.9% NaCl) flush. Studies performed on dogs have shown that even small volumes of acetate-containingcrystalloids cansignificantly increase the serum concentration of acetate to 10to 40 times the physiologic level. %PDF-1.5 bone marrow can result in a low red blood cell count - called anaemia. Transfus Apher Sci. In most clinical settings,normal saline isthe choice of fluid for many indications forfluid resuscitation, maintenance, or as a solvent for medication delivery. A blood transfusion provides blood or blood components if you've lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components. Which is the best saline solution for blood transfusion? Patientsshould receive a fluid challenge of 20 mL/kg over the first 30 minutes of treatment. endobj [1]In such a case, providers must utilize other objective findings to evaluate fluid status (e.g., orthostatic, physical examination). 2018 Feb;57(1):127-131. doi: 10.1016/j.transci.2018.02.021. Crystalloid Fluids - StatPearls - NCBI Bookshelf Only solution that can EVER hang with blood is 0.9% normal saline, will need at least a 250ml bag. The Surviving Sepsis Campaign Bundle: 2018 update. The revised guidelines now state that fluid provision should be in a 1-hour bundle by administering 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. Ringer's lactate solution contains calcium ions. >> What are the safety considerations for blood transfusions? Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients. Accessed Feb. 7, 2017. Doctors use IV saline to replenish lost fluids, flush wounds, deliver medications, and sustain patients through surgery, dialysis, and chemotherapy. Which IV fluid is compatible with blood products? Mar 16, 2007 The main reason you cannot utilize LR because the calcium in the LR will bind to the citrate in the blood and cause clumping of the RBCs this is also why you give 1gram of calcium after every 4 transfusions, becuase the citrate that is infused will bind to calcium in the body. If a patient needs blood, there are a few types of . J Neurotrauma. stream StatPearls Publishing, Treasure Island (FL). 6 When to use saline to flush the tubing? Create well-written care plans that meets your patient's health goals. We also use the saline to flush through the blood in the tubing before changing tubings betweeen blood units. Epub 2019 Jun 30. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. /Contents 19 0 R All while, the remainder of the fluid should be saved for examination if contamination is suspected. [6], Unlike acetate buffered solutions, lactated crystalloid fluidshave the potential to induce hyperglycemia. Normal saline is compatible with blood; ringers lactate, dextrose, hyperalimentation and other intravenous solutions with incompatible medications are not compatible with blood and blood products. Blood bank recommendations specify that Ringer's lactate solution (LR) should be avoided while transfusing blood. 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. Access free multiple choice questions on this topic. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) This can be a beneficial effect to avoid fluid overload. Medications that can be administered "IV PUSH" may be administered by stopping the transfusion, clearing the line at the medication injection site with 5 - 10 mL of normal saline, administering the medication, reflushing the line with saline, and restarting the transfusion. Fluid Stewardship During Critical Illness: A Call to Action. O&i;+%p6tMe7Aruu={O=Nt~S;u]/a2>rx/a)ueCD{` Mm1f{ [u3wOo_M}C@o_ o 9okp4bRFGm=O"m9V#tFskc2 http://creativecommons.org/licenses/by-nc-nd/4.0/ National Library of Medicine It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure. "Normal" saline is a hypertonic, acidotic fluid. The site is secure. << The mass-based formula uses what is known asthe "4-2-1" rule: Example: 100 kg patient: 20 kg (40 + 20 mL/hr) + 80 kg (80 mL/hr) = 140 mL/hr, Additional formulas for fluid administration have been developed for specific clinical scenarios (e.g., the Parkland Formula for fluid maintenance in burn patients).[3]. 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. !%#(,$ #'e75'7`dz[ J]TZZZQ ]wh1a|}=>azC^HbGbHkUR~sl|[HXFc2&t7un,u. Am J Surg . While there is still some debate on the exact mechanism of this pH disturbance, the thinking is that the increase in chloride concentration adjusts the substantial ion difference in plasma, resulting in more free water in the intravascular space. Background: Transfusion guidelines advise against coinfusing red blood cells (RBCs) with solutions other than 0.9% saline. >> /Pages 3 0 R LISS is used in blood bank testing to potentiate reactions between antibodies and red blood cells. While saline and lactated Ringers solution have a few similarities, they also have differences. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. [reM}gEI$A4>(>f>~;;OM?ll^we9/nzz~:i1N>x4 Qn#)xcsp8JCeGo6w-7ygNad]>z[BDAg Ringer's lactate. Hence, excessive administration of lactated crystalloids may be of concern in patients with diabetes.[6]. Make sure the medicine bag is higher than your IV line. Fluid overload can cause life-threatening pulmonary edema and the worsening of diastolic or systolic heart failure, leading to end-organ damage or evendeath. . /Length 4456 Hyperchloremia was significantly associated with increased mortality. Science Nursing The physician has ordered one liter of Normal Saline to run at 125ml/hour for a MedSurg patient. The 2018 sepsis guidelines from the Surviving Sepsis Campaign havesuggested the initiation of treatment with crystalloid fluids. These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension. % /GS7 11 0 R Spike the bag of 0.9% normal saline with one of the Y-tubing spikes. 7 What are the safety considerations for blood transfusions? Holliday and Segar in 1957. Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. So far, no good replacement for human blood is available. [2]Since this time,their initial formula has been modified to provide clinicians with guidelines for administering maintenance crystalloid fluids. This study guide will help you focus your time on what's most important. <>/XObject<>/Pattern<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Sodium ions are the main electrolytes of extracellular fluid, integral in the distribution of fluids and other electrolytes. Allergic reactions may occur in people who have corn allergies. Transfusions | Boundless Anatomy and Physiology | | Course Hero 6 When to use IV fluid and blood transfusion? When complications do occur, they're typically mild. 5 0 obj <>>> The dose for lactated Ringer's depends on the circumstances. Its indications include both adult and pediatric populations as sources of hydration and electrolyte disturbances. No significant differences in infusion time or filter weight using WB or PRBC with NS or LR were seen. Mayo Clinic is a not-for-profit organization. What Are the Benefits of Drinking Hot Water? A nurse will monitor you throughout the procedure and take measures of your blood pressure, temperature and heart rate. 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. Therefore, the clinician and nursing staff must perform monitoring and reassessment of the patient and coordinate the reporting of abnormal findings. Reddy S, Weinberg L, Young P. Crystalloid fluid therapy. Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial. These fluids approximate concentrations of various solutes found in plasma anddo not exert an osmotic effect in vivo. Normal saline versus Normosol-R in sepsis resuscitation: A retrospective cohort study. Patients at high risk of developing fluid overload shouldreceive frequent re-evaluation, especially patients with known cardiopulmonary diseases. Common practices utilize the formulas created by Drs. Chang R, Holcomb JB. /F4 17 0 R Both adults and children can receive lactated Ringers solution. [11][9] [Level 2], Established guidelines for crystalloid fluidunder various clinicalconditions are not yet extant. Is lactated Ringers compatible with blood products? Patientswho are fluid-overloaded should not receive crystalloid fluids. You might develop a bruise around the needle site, but this should go away in a few days. This potentially life-saving procedure can help replace blood lost due to surgery or injury. Blood transfusions are usually done in a hospital, an outpatient clinic or a doctor's office. A blood transfusion also can help if an illness prevents your body from making blood or some of your blood's components correctly. /Type /Catalog By definition, it is an aqueous solution of electrolytes and other hydrophilic molecules. Patients with elevated lactate and creatinine concentration are signs that they may not be receiving an adequate amount of volume. FOIA Learn about 10 possible benefits of drinking hot water, Packed with nutrients but low in calories, leafy greens are crucial to a wholesome diet. Rapid correction of hyponatremiamay cause central pontine myelinolysis, a devastating neurologic condition. Prime the line with saline and attach to IV pump before you even pick up the blood from blood bank. Surg Gynecol Obstet. [1], An isotonic concentration of sodium chloride is best suited for the parenteral replacement of chloride losses that exceed or equal the sodium loss. Disclaimer. The treatment of hemolysis includes the administration of normal saline after the transfusion is stopped and all the tubing is changed to . allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 Compatibility of packed erythrocytes and Ringer's lactate solution. Overall, this decreases the number of bicarbonate ions available for buffering. to facilitate the flow of IV medication during surgery, to restore fluid balance after significant blood loss or burns. Crystalloid and Colloid Compositions and Their Impact. We use cookies to ensure that we give you the best experience on our website. It is vital for the clinician to monitor these patients carefully and administer the minimum required volume to maintain volume homeostasis. Only normal saline should be used to prime the intravenous line, with no other solutions or medications used. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. rBn= Normal saline has a higher concentration of chloride ions (154 mmol/L)than in human serum (98to 106 mmol/L). INTRAVENOUS SOLUTIONS Of the various intravenous solutions, only isotonic saline (0.9%) is recommended for use with blood components. The main reason you cannot utilize LR because the calcium in the LR will bind to the citrate in the blood and cause clumping of the RBCs this is also why you give 1gram of calcium after every 4 transfusions, becuase the citrate that is infused will bind to calcium in the body. << So how long can you go without water before the effects of dehydration kick in? Due to normal saline's well-known side effects, there have been concerns regarding its use in critically ill patients. r0MCP+fg~FsFrxV9mzB Qrh{"Y99I##Z9zUx*}4iAZf+tkRB/KawI"lmFUQQQ'0kUZJbB-Aje&IN?BQZi:S{O3"yQR*V)2lQNjOlV>=ZAL>z#ON9 /F2 12 0 R And to wash the eye following a chemical burn. Chapter 30 Blood transfusions.docx - Chapter 30 Blood Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluids should be administered, preferably via large-bore peripheral lines (18-gauge or larger) or through central access, which may also be used to deliver blood products if required. Saline solution: A bag of saline. { N7:&`J>9-9%\M* g:{7_r" Under normal testing conditions, red blood cells have a negative surface charge, and sodium ions (Na +) in saline solutions aggregate around the red cell surface. Within each 100 mL of 0.9% sodium chloride Injection USP, there is 15.4 mEq of sodium ions and 15.4 mEq of chloride ions. Fleischhacker E, Trentzsch H, Kuppinger D, Piltz S, Beyer F, Meigel F, Kammerer T, Rehm M, Hartl WH. 4 Intravenous immunoglobulin (IVIG) is only compatible with D5W. Christine Kessler; Priming Blood Transfusion Tubing: A Critical Review of the Blood Transfusion Process. Specializes in ICU. If you have to have an IV, you may see that your IV bag reads lactated Ringers. This is a time-tested option for fluid replacement that doctors commonly prescribe. Why is normal saline used for blood transfusions?