There has been a lot of discussion on the ideal intravenous fluid (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs.
This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what's in 1 liter of normal saline. As it turns out, normal saline is not really "normal". Dr. Scott Weingart has a great podcast on "chloride poisoning" using IVFs.
This PV card helps remind me what's in each liter bag of fluids we order. At the bottom half of the card is a brief summary of the JAMA findings.
Feel free to download this card and print on a 4'' x 6'' index card.
@kidney_boy @m_lin @brianjl @pharmertoxguy Great story.It's not what we know/don't know, it's what we don't know that we don't know.
— David Y.T. Chen (@dytcmd) January 4, 2013
Has this JAMA study and ongoing discussions of fluid content changed your approach to ED fluid management?
It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.
Reference
Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012 Oct 17;308(15):1566-72. PubMed PMID: 23073953. .
Results thus far:
The unit of Osmolality is mOsm/kg, or you can rename it to Osmolarity (with a 'r' if you keep mOsm/L).
ReplyDeleteThanks for catching this. Chemist, I am not. I'm glad that there are smarter people out there! Fixed.
DeleteI don't think the Yunos et al sequential study design can establish causation - it is more accurate to state that chloride-rich fluids were associated with acute kidney injury, rather than caused it.
ReplyDeleteChris
Thanks Chris. Great catch. I subconsiously inserted my personal opinion on the issue. Fixed on this page.
DeleteOn an aside, I wonder if this will be how the process of peer-review will go. While journal manuscripts are peer-reviewed BEFORE to decide if they are worthy of publication, blogs will be peer-reviewed AFTER they are "published" and then revised on a dynamic and ongoing basis. Hmm..
I think the latter method of peer review will be better. Instead of a few people commenting before a product is finished, now there will be many people commenting on an ever-improving product. The downside is that nothing that is reviewed in this way will ever be completely "finished." But isn't that the nature of knowledge anyway? It will take a major paradigm shift for the majority to accept this but once they do I think the results will be amazing.
Delete@Jeffmedic - Agreed. The challenge is in defining this process better for (1) "outsiders of FOAM" to build credibility especially in academics and (2) people new to social media for medical education so that they know how to navigate the sea of social media material.
DeleteI've jettisoned NS in favor of P-lyte in all my OR and ICU patients, excepting those with ICP issues and severe hyperkalemia (although quietly, I think it would probably be OK/better to use in many of them, too). I am already seeing, and think we will see more of, a switch to p-lyte in more places. I'll use LR if it's the only alternative, but widen the exclusion criteria to all neuro patients.
ReplyDeleteHow do I know the tide is shifting? A comment from my (very bright) CA-1 resident in the OR a few weeks ago during a kidney transplant: [thinks over surgeon's request for high-volume chloride poisoning] "aren't we just worsening the respiratory demand and hyperkalemia by creating metabolic acidosis?"
Wow, what a great story. Thanks for sharing your practice of exchanging NS for P-lyte now in the OR and ICU. You definitely know when a change is coming when residents/interns start mentioning it as if it's standard practice. Keep up the great work!
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