Showing posts with label iv fluids. Show all posts
Showing posts with label iv fluids. Show all posts

Wednesday, September 18, 2019

IV Fluids Types: Do you know your -ish?

Problems with solutions: drowning in the brine of an inadequate knowledge base

More than 50% of residents do not know how much sodium is in 0.9% NaCl. I know you do, though... it's 154mmol/L. Far more than our "normal" of 140mmol/L.
Why do I nag so much with intravenous fluids and what's in them? Truth be told, I did not know my fluid composition as well as I should have even as an intern. I had an ICU attending, a mentor, now someone I'm fortunate to call a colleague, who would pimp the house staff on IV fluids and make us feel ashamed if we didn't know the answer. He was right. My embarrassment was deserved. After all, these are substances that we are mindlessly pouring into our patients. The vast majority of clinicians, I'm not even talking about nurses, I AM REFERRING TO US DOCTORS, do not know what's in these bags that are so easy to click in the EMR and order. We mindlessly just do it. I was embarrassed. I do not want you to feel the same way. I have been teaching fluids now for 4 years. It's one of my passions. I have a talk that is complete and can present at any time of the day. I know it well. But I am always reading and adding to it. The talk is going to be one of the lectures I will be presenting in Hawaii in May of 2020. It will also be presented to the Department of Anesthesia at my hospital on October 20th of this year. I am currently brushing up that talk, adding and subtracting some things, and I ran into this study from 2001 which asked preregistration house officers and senior house officers (I guess that means interns and residents) about the composition of fluids amongst other things. I won't go over the methodology but the training needs to start in medical school. Overall, 11.5% said their training in the matter was poor, 22% stated it was unsatisfactory. I have to agree with this 100%. I received ZERO training in med school regarding IVF. Since it's something so ubiquitous in our daily practice of medicine, it's something we need to do better. A lot better. If you are in medical school or residency, have you been trained in the composition of IV Fluids?

-EJ



Link to the Abstract

Lobo, D.N., Dube, M.G., Neal, K.R., et al., 2001. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin. Nutr., 20(2):125-130.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works. 

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Saturday, September 14, 2019

Normal Saline: A History Lesson for the Inappropriate Name

A little history lesson, my friends, regarding the origins of us calling 0.9% saline solution, aka 0.9% sodium chloride, "normal saline".
We are all disappointed in ourselves. You've been calling it normal saline, I've been calling it normal saline, we just can't stop ourselves! Of course you know I am referring to 0.9% sodium chloride solution used so commonly, and many times inappropriately, in our everyday practice. Why is it not normal? Well, I have covered this many times on my Instagram page and YouTube videos. First of all, the sodium concentration in serum is 140meq/L. The reference range in the labs are usually 135-145meq/L. What's the sodium concentration in "Normal Saline"? 154meq/L. How much chloride is in serum? 98-109meq/L. What about in "normal saline"? 154meq/L because it's equal parts sodium and chloride. We can continue talking about strong ion difference and all the adverse effects of the 0.9% saline but that will take me forever. It's Saturday and I have a birthday party to go to. Where in the world did the associate with "normal" come from? The inspiration for this post came from @anursingnote and her discussion with @med.life.crisis, two RN's who are trying to kick butt and get smarter every day. You go girl(s)!
This article is not free, unfortunately, but they do make a couple key points, all of which show that even though they used the word "normal", it's not in the appropriate way. You're never going to think about a Hamburger now without thinking about 0.9% saline solution. Sorry I ruined that for you.
Here's how all this went down in chronological order:
I credit the authors of this paper for doing much of this heavy lifting, by the way. I can't actually get my hands on many of these papers. I'm going to do my best to briefly summarize.
1888: Hamburger. This Dutch physiologic chemist performed in vitro studies (not in vivo, take a second to let that process) where he found that there was less hemolysis with 0.92% saline than other concentrations.
1888: Dr Churton. "he was ordered transfusion of ‘normal saline’ solution in order to replace the fluid thus lost". That fluid was nothing like the saline we know and are still trying to understand to this day. That particular fluid had 150meq/L of Na and 128meq/L of chloride. It also had some bicarb in it.
1892: Dr Spencer used the term "normal salt solution" but the composition of the fluid was not defined.
There are plenty more goodies in the article which I recommend you try to get your hands on. The article is going to definitely be included in my lecture regarding intravenous fluids that I will be giving to the anesthesia department in my shop next month and on various lectures I have scheduled nationally next year. It's that important. A great job by the authors!
All in all, can we really stop saying "normal saline"? I think it's too embedded in our vernacular and it'll be too challenging to fix. I am always trying to make a conscious effort to stop but it's challenging because I have been hearing it for over a decade now. I'm getting old.
-EJ





Link to Abstract


Citation:
Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr Edinb Scotl. 2008;27:179–188.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works. 

You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work! 

My Amazon Store