Showing posts with label resuscitation. Show all posts
Showing posts with label resuscitation. Show all posts

Tuesday, November 12, 2019

Lactate is an Alarm, not a Treatment.

I need to eat my words on this one, because now there's data to show that there's a benefit to rechecking lactate levels in septic patients, but not for the reasons why one would think.

During my rounds over the course of the weekend, I recall telling several nurses that there's no data to suggest that trending lactates changes outcomes. This study, which came out last night, tells me I was wrong in saying that. A close examination of the data will show that it has nothing to do with the lactate itself, but rather the fact that the clinicians are prompted to "do something" in response to a number that makes us uncomfortable.

Okay, so the lactic acid is elevated. You're going to do one or two or all three of the following:
a. start vasopressors
b. start antibiotics
c. give more fluids

That's the kicker, we don't know which of those interventions, or combination of which, are what decreased mortality. Maybe it just means that someone gave these patients more attention. It certainly just wasn't the "checking the lactate" part. Lactate is just an alarm of sorts, we still need to be clinicians. I will suggest, though, that earlier initiation of antibiotics plays the most important role in decreasing mortality as there's already data suggesting that earlier antibiotics leads to improved outcomes. I personally start vasopressors pretty early and will share data in the upcoming weeks as to why I do that in my practice. Giving more fluids is only useful if the patients is fluid responsive, you know, if you can prove that giving that fluid will increase the cardiac index/output or increase the stroke volume. Giving fluids just to make the blood pressure go up arbitrarily is just plain dumb. It's 2019. We're better than that.

Ultimately, early lactate measurement did not improve outcomes, nurses relaying the information to the doctors, ARNP's, or PA's did.

-EJ



Link to FULL FREE PDF

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

Thursday, October 17, 2019

Fluid Resuscitation of Trauma Patients: 0.9%NaCl (saline) or Plasma-lyte?

I am not a trauma surgeon. I am not a trauma physician. I do not take care of trauma patients in my current practice. I did several rotations in the trauma intensive care unit during my fellowship training but by know means am I going to pretend to have the knowledge that my colleagues who do that every day have. The study I am going to be discussing today is a pilot study.

The authors were concerned about the metabolic acidosis that occurs from the elevated chloride concentrations in 0.9% NaCl which is 154mmol/L. Remember, reference values in the lab for chloride levels are between 98 and 109mmol/L. Also, there is data suggesting that an increase in chloride levels by just 5mmol/L could have deleterious effects on our patients. This hyperchloremic metabolic acidosis is not something new, we've known about its effects on the kidneys for decades now. I guess we've just been ignoring it.

I am a fan of whole blood to resuscitate trauma patients, but I my knowledge on the matter is weak. At the time being, patients receive a significant amount of crystalloids for resuscitation. The authors chose to use NS and plasma-lyte due to the fact that lactated ringers is contraindicated with blood products as it allows the blood to coagulate as it goes in due to the calciums effect on citrate.

Surgeons are trained, from my experience, to focus on base excess. When a patient you're taking care of them is sick, and you're giving them a call to give them the heads up of what's going on, one of the first questions you need to be prepared to answer is "what is the base deficit"? Plasma-lyte is a balanced salt solution that I have reviewed numerous times on instagram, my website, and youtube. Plenty of resources out there from me explaining this fluid. This focus on base excess is why they made this

They ended up with 46 patients enrolled in the study.

Plasma-lyte corrected the base deficit faster than 0.9% NaCl. Primary outcome achieved. Patients reached and remained in their normal acid-base physiology longer.

They also found that 0.9% NaCl leads to hyperchloremic metabolic acidosis, decreased serum bicarb levels, and worse base deficit.

Patients also had increased urine output with plasma-lyte compared to saline solution. There is some concern about whether gluconate causes some sort of increased urine production but this is not specified in this paper.

Some institutions worry about the added cost of plasma-lyte, which is approximately $1 on top of the cost of NS or LR depending on the institution and their contract. This study showed that providing plasma-lyte kept serum magnesium levels closer to normal (p=0.007). If you are a bean counter, you could potentially save some money by using plasma-lyte due to less cost of magnesium replacement. I may be stretching a bit but at least I am admitting that I'm stretching. The patients needed about 4gm of Mg in the NS group and no replacement in the PL group. I take back the part of me stretching. The authors state that the difference at their institution of cost between NS and PL is $0.76. 2gm of magnesium is $5.19. That means that PL may end up saving money and additional testing.

All in all, this is a pilot study. I have not personally seen the actual study. If you all have, feel free to correct me. This is not a full free article, unfortunately.

-EJ








Link to Abstract

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



Monday, September 30, 2019

Cordis vs MAC Introducer: What is the difference between the two?

This is a topic better handled by Surgeons than myself but I haven't seen anyone do it. Here I go! @buckparker, you're invited to chime in at this party, bud. @physiciandoodles inspired me to create this post.

Quick! This patient needs to be resuscitated with blood STAT! Call for the massive transfusion protocol and grab me a Cordis STAT! Do you know what this means? Do you know what it means if they asked for an introducer? For many years I was confused myself. I mean, aren't they both just large bore central lines for the purpose of infusion blood quickly or floating a central line? Well yes, they are. But depending on what institution you work at, you may get a funny look on your face if you ask for it by the non-standard name. Non-standard for that institution, of course. I will make this clear, though, as I posted this earlier in the life of my instagram page. You can get A LOT done in a massive bleed with two solid 16 gauge peripheral IVs. Many times you do not need to puny central line. But there are times when patients mean business and they needs all and a catheter of this type is necessary. Okay, let's get started.

First of all, the MAC introducer. This is a proprietary product from Arrow/Teleflex. MAC is a trademarked name that stands for multi-lumen catheter. You may say to yourself, well Eddy, a triple lumen catheter should be a MAC line too! You're not wrong, but we can't make this already challenging job easier on ourselves, right? MAC introducers can come with anywhere from one to three lumens. You could float a swan through many of them, but not all. It is essentially like a "Cordis" but it could have another line. The MAC also has the dilator in the catheter as my colleague Zahid, @zvhvd, pointed out.




A "Cordis" is also an introducer, but the word Cordis is the brand name of the product. A Cordis is the same introducer, but only has one side port. You can also float a swan through this puppy. 





There are other manufacturers who make similar products that I am not going to cover here for the sake of time. Your friendly neighborhood ICU should have one of these introducers in stock. Familiarize yourself with where it is because the day you need it, the patient NEEDS it.

- EJ

Photo credits for Arrow/Teleflex Products

Photo credits for Cordis Products

Copyright gods: If the photos posted upset you, let me know and I will take them off. Just trying to teach here.

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

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. 

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

Wednesday, August 14, 2019

Prediction of fluid responsiveness: an update



Link to Article

Link to PDF

If your way of determining whether a patient is fluid responsive or not is to see if the blood pressure went up after giving a bolus, you are doing it WRONG! You need to stop, take a deep breath, and reassess your way of thinking about fluid responsiveness. This (FREE!) article dives into why fluids should not be provided arbitrarily go make us feel good inside and make us feel like we at least "did something" in response to that low mean arterial pressure. No, I do not use SBP and DBP off of the BP cuff in my practice. More on that at another time. This article also goes briefly into why we should not be checking CVP (duh). Bottom line is that we can't accurately predict fluid responsiveness without an arterial line and some sort of device to predict stroke volume, stroke volume variation, cardiac index/output. You could have some really good echo nunchuck skills as well. This study also emphasizes why looking at IVC variations is not the best test. Ultimately, we all need to get better at this, myself included. I feel that this article is particularly important for nurses as you all are the ones who relay the BP concerns to the clinicians essentially ordering the fluids. These three authors are legends of critical care. A real treat that Annals of Intensive Care published this for free.
This article is going to be part of the bibliography for the talk I will be giving in Portland, OR in August of 2020.

-EJ

Sunday, August 4, 2019

Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis



Link to Abstract

I honestly wonder how much data is enough data to change some minds. This is why I am counting on you all, people who are trying to keep up with this flurry of data to the best of your ability, to go through medical school, residency, possibly fellowship with a healthy respect for 0.9% saline solution. It may seem like it's hopeless from time to time to change decades worth of practice. Heck, my first IVF resuscitation video is almost 2.5 years old and has almost 39000 views! Hopefully the studies which will be published within the upcoming 2 years will hit the nail on the head. You can see the data from the slides, using saline versus balanced salt solutions increased mortality in the critically ill, increased acute kidney injury, and kept the patients on the ventilator for a longer period of time. To those harping about the increased costs of one fluid versus the next, consider the cost of one ventilator day. Consider the risks involved with each day on the vent. Consider the financial strain from working up every-single-case of AKI. This stuff adds up, colleagues. Anyway. A hat tip to the authors! 

- EJ



Abstract Copied/Pasted from the article above. 
Background: The optimal resuscitative fluid remains controversial. 
Objective: To assess the association between crystalloid fluid and outcomes in critically ill adults. Methods: Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, and Cochrane Central Register for Controlled Trials were searched from inception through July 2019. Cohort studies and randomized trials of critically ill adults provided predominantly nonperioperative fluid resuscitation with balanced crystalloids or 0.9% sodium chloride (saline) were included. 
Results: Thirteen studies (n = 30 950) were included. 
Balanced crystalloids demonstrated lower hospital or 28-/30-day mortality (risk ratio [RR] = 0.86; 95% CI = 0.75-0.99; I2 = 82%) overall, in observational studies (RR = 0.64; 95% CI = 0.41-0.99; I2 = 63%), and approached significance in randomized trials (RR = 0.94; 95% CI = 0.88-1.02; I2 = 0%). 
New acute kidney injury occurred less frequently with balanced crystalloids (RR = 0.91; 95% CI = 0.85-0.98; I2 = 0%), though progression to renal replacement therapy was similar (RR = 0.91; 95% CI = 0.79-1.04; I2 = 38%). 
In the sepsis cohort, odds of hospital or 28-/30-day mortality were similar, but the odds of major adverse kidney events occurring in the first 30 days were less with balanced crystalloids than saline (OR = 0.78; 95% CI = 0.66-0.91; I2 = 42%). 
Conclusion and Relevance: Resuscitation with balanced crystalloids demonstrated lower hospital or 28-/30-day mortality compared with saline in critically ill adults but not specifically those with sepsis. Balanced crystalloids should be provided preferentially to saline in most critically ill adult patients.

Friday, March 29, 2019