Fluid choice for nephrotic syndrome

[VentdependenT]

For a renal bx today the nephrologist asked me what fluid I would run if the kid went hypotensive all of a sudden.

I said, whatever the hell I have hanging. Something isotonicish. A crystalloid.

He said, "ohhhh no....c'mon what is this kids albumin?"

I said, "low."

He said, "see thats why you HAVE to run 5% albumin as the fluid of choice in this situation."

I said, "oh....ok. Pt is ready for you to inject local now."

Where on earth does it say albumin is superior to LR/.9 for resucitation?

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[drccw]

Remember nephrologists come from the land of internal medicine... and it seem nephrotic syndrome and large volume paracentesiseseses are the only reasons to ever give albumin... nonetheless, they also tend to like a lasix albumin combo. ... aka wham bam..

 

[fakin' the funk]

Wouldn't running a crystalloid exacerbate the hypoalbuminemia and edema?

 

[Planktonmd]

For a renal bx today the nephrologist asked me what fluid I would run if the kid went hypotensive all of a sudden.

I said, whatever the hell I have hanging. Something isotonicish. A crystalloid.

He said, "ohhhh no....c'mon what is this kids albumin?"

I said, "low."

He said, "see thats why you HAVE to run 5% albumin as the fluid of choice in this situation."

I said, "oh....ok. Pt is ready for you to inject local now."

Where on earth does it say albumin is superior to LR/.9 for resucitation?

This is a situation where giving albumin might actually be superior to giving cristaloids.
These patients tend to third space very rapidly because of the low albumin and although giving albumin is not going to solve their problem it will allow them to retain intra vascular volume longer.

 

[dhb]

This is a situation where giving albumin might actually be superior to giving cristaloids.
These patients tend to third space very rapidly because of the low albumin and although giving albumin is not going to solve their problem it will allow them to retain intra vascular volume longer.

They third space a lot because of renal avidity for Na+ which drags water along. And albumin has ... 145meq of Na+. I don't disagree with giving it but i don't think it makes a big difference, give a little pressor and save yourself a headache

 

[Planktonmd]

They third space a lot because of renal avidity for Na+ which drags water along. And albumin has ... 145meq of Na+. I don't disagree with giving it but i don't think it makes a big difference, give a little pressor and save yourself a headache

Sodium retention by the kidneys is the principal mechanism for fluid retention and subsequent edema in the nephrotic syndrome but for acute fluid replacement albumin has a better chance of staying intravascular longer and creating a transient oncotic gradient slowing water migration to the interstitial space.
This oncotic gradient although temporary can be helpful in improving hemdynamics.

 

[Tenesma]

dude

if he gets hypotensive during a renal biopsy it is either because they tore the renal vein or because you are vasodilating with your anesthetics - then i would kindly suggest blood... otherwise i would just give the kid a hit of ephedrine or phenylephrine...

generally these kids are hypertensive anyway - so it is a dumb ass question --

i would also not allow a nephrologist to pimp my ass -

and it also isn't cost-effective to have 5% albumin lying around ---

and if he is really that worried why not just use 25% albumin...

whatever...

pimp his ass and ask him to show you any study that shows albumin is superior to normal saline for acute resuscitation....

and by the way point out that the problem with nephrotic syndrome is that they pee out albumin anyway - so how is that going to really be helpful??

i still can't believe you allowed yourself to be pimped... sigh...

 

[Planktonmd]

dude

if he gets hypotensive during a renal biopsy it is either because they tore the renal vein or because you are vasodilating with your anesthetics - then i would kindly suggest blood... otherwise i would just give the kid a hit of ephedrine or phenylephrine...

generally these kids are hypertensive anyway - so it is a dumb ass question --

i would also not allow a nephrologist to pimp my ass -

and it also isn't cost-effective to have 5% albumin lying around ---

and if he is really that worried why not just use 25% albumin...

whatever...

pimp his ass and ask him to show you any study that shows albumin is superior to normal saline for acute resuscitation....

and by the way point out that the problem with nephrotic syndrome is that they pee out albumin anyway - so how is that going to really be helpful??

i still can't believe you allowed yourself to be pimped... sigh...

Good points

 

[jetproppilot]

dude

if he gets hypotensive during a renal biopsy it is either because they tore the renal vein or because you are vasodilating with your anesthetics - then i would kindly suggest blood... otherwise i would just give the kid a hit of ephedrine or phenylephrine...

generally these kids are hypertensive anyway - so it is a dumb ass question --

i would also not allow a nephrologist to pimp my ass -

and it also isn't cost-effective to have 5% albumin lying around ---

and if he is really that worried why not just use 25% albumin...

whatever...

pimp his ass and ask him to show you any study that shows albumin is superior to normal saline for acute resuscitation....

and by the way point out that the problem with nephrotic syndrome is that they pee out albumin anyway - so how is that going to really be helpful??

i still can't believe you allowed yourself to be pimped... sigh...

Hard to argue with that, though.

 

[Idiopathic]

I guess Im finding it hard to imagine the situation where sudden intraoperative hypotension is treated with albumin first.

 

[bubalus]

This is the kind of mental masturbation that frustrated me with internal medicine. I'd suggest, "I like to keep files of significant studies that prove these concepts. Could you please direct me to them?" Or, if you're a little more in-your-face, "Prove it, you internal medicine flea."

 

[fakin' the funk]

and by the way point out that the problem with nephrotic syndrome is that they pee out albumin anyway - so how is that going to really be helpful??

as mentioned above, a common treatment for symptomatic relief of nephrotic syndrome exacerbations is 25% albumin, then IV furosemide.

 

[militarymd]

Remember nephrologists come from the land of internal medicine... and it seem nephrotic syndrome and large volume paracentesiseseses are the only reasons to ever give albumin... nonetheless, they also tend to like a lasix albumin combo. ... aka wham bam..

was debunked in the late 90's by the Barcelona group....might have changed again in the early 21'st century...I have not been keeping up with the end stage liver disease literature.

 

[Tenesma]

fakin the funk

actually fluid and protein restriction is the most common treatment and diuresis is more of an extreme... and I definitely wouldn't diurese a patient right before or during a renal bx...

and you have to remember that the albumin and lasix trick will only last about 6 hours - then what? they will likely need steroid therapy and all those other cool internal medicine tools of the trade...

 

[TIVA]

i would also not allow a nephrologist to pimp my ass - ...

i still can't believe you allowed yourself to be pimped... sigh...

You can say that if you're an Attending. But if you're the resident or fellow, I don't think you can refuse to be pimped. What exactly do you do or say ... "aww gee fellas (in a whiny nasal tone), stop pimping me."

Or maybe you can just whisper to your colleagues for a couple of seconds and then announce in a grave and solemn tone, "Counsel advises me not to answer that question."

 

[VentdependenT]

Its not like the guy was ripping on my mom. I'm not going to tell the nephrologist to STFU man.

 

[Tenesma]

dude

it doesn't matter if you are an attending or a fellow or a resident - don't let yourself get pimped.

When somebody asks a question like that I just respond:
"Are you asking me because you don't know the answer or because you are planning on telling me what your view is?"

"If you don't know the answer then this is what I would recommend"

"If you do know the answer then share your fund of knowledge - and I will let you know if I agree or disagree"

and if they are being whiny about it then I would just say: The only person that can pimp me is either my attending or my chairperson...

Don't let them bait you into a question that they know you are going to answer wrong... it is a setup... and it is also a powerplay because they then look like the smart dick in the room and make you look helpless and powerless ...

 

[TIVA]

dude

it doesn't matter if you are an attending or a fellow or a resident - don't let yourself get pimped.

When somebody asks a question like that I just respond:
"Are you asking me because you don't know the answer or because you are planning on telling me what your view is?"

"If you don't know the answer then this is what I would recommend"

"If you do know the answer then share your fund of knowledge - and I will let you know if I agree or disagree"

and if they are being whiny about it then I would just say: The only person that can pimp me is either my attending or my chairperson...

Don't let them bait you into a question that they know you are going to answer wrong... it is a setup... and it is also a powerplay because they then look like the smart dick in the room and make you look helpless and powerless ...

Hmmm ... sounds good now, but not in real life. There's too much arrogance in it. And arrogance is a bad thing because it prevents you from learning. In order to learn, you have to have humility. And the job of residents and fellows is to 1. deliver the best patient care they can, and 2. to learn. Save the comebacks and quick quips for when you actually can walk the walk.

 

[coprolalia]

Its not like the guy was ripping on my mom.

That's what you got that new 'gat' for...

-copro

 

[Tenesma]

well i guess i walk the walk... i agree that the role of a resident, fellow and even attending is to learn as much as possible...

but being pimped by a different profession isn't going to do it - especially when that other specialty has no understanding of what we do --- even surgeons who spend more time with us than they do with their spouses, don't really understand what we do...

so again, if a nephrologist wants to teach then so be it - but guys and gals, don't set yourself up to be pimped...

by the way, i have had a nephrotic kid crump on me, and i can tell you from personal experience albumin/blood/saline don't matter when those kidneys are crap and dump everything right back out...

 

[toughlife]

For a renal bx today the nephrologist asked me what fluid I would run if the kid went hypotensive all of a sudden.

I said, whatever the hell I have hanging. Something isotonicish. A crystalloid.

He said, "ohhhh no....c'mon what is this kids albumin?"

I said, "low."

He said, "see thats why you HAVE to run 5% albumin as the fluid of choice in this situation."

I said, "oh....ok. Pt is ready for you to inject local now."

Where on earth does it say albumin is superior to LR/.9 for resucitation?

The "if he went hypotensive all of the sudden" part of the question jumped out at me.

If that was the case, then pressors followed by determination of the precipitating event as in "what vessel did you just hit" would have been my answer.

 

[Idiopathic]

dude

it doesn't matter if you are an attending or a fellow or a resident - don't let yourself get pimped.

When somebody asks a question like that I just respond:
"Are you asking me because you don't know the answer or because you are planning on telling me what your view is?"

"If you don't know the answer then this is what I would recommend"

"If you do know the answer then share your fund of knowledge - and I will let you know if I agree or disagree"

and if they are being whiny about it then I would just say: The only person that can pimp me is either my attending or my chairperson...

Don't let them bait you into a question that they know you are going to answer wrong... it is a setup... and it is also a powerplay because they then look like the smart dick in the room and make you look helpless and powerless ...

Im surry, but its a pretty well understood rule that residents dont openly question attendings. I dont care if you are right (you usually are) but that s**t will get you hurt.

 

[Tenesma]

dude

the neprhologist isn't your attending --- he is somebody else's attending...

just remember that your behavior and confidence in the OR becomes a self-fulfilling prophecy... of course, if you are wrong or unsure of yourself it can become a very dangerous behavior