Colloids

2ndyear · Sep 22, 2005

Here's my case from last night that I took over:
70 something female, 65 kg, for ex-lap colon resection for Ca. I took over 1.5 hrs into the case. 2 L LR were in already, urine output was marginal 80 cc out when I got there. BP was fine, 120 over 80's. HR was 50's, 60 max. No known history of CHF or any cardiac issues. At 2 hrs total surgery time they were starting to get ready to close. The surg. resident asked me about the patients BP, fluid status and urine output. I had 20 cc of new, light colored urine in the urometer, and more in the tubing since I took over. I stated that we had 2300 cc in, 100 out. He asked for 500 of Hespan, which I didn't give. Note that the surg. attending never said a word about this.

My reasoning was that, while the patient was NPO as well as bowel prepped, sure she was volume depleted. She had urine output that was picking up fine with crystalloids. Hemodynamics were more than adequate. I just didn't see the need for the additional intravascular volume that Hespan would have given me. I could be very wrong on this issue.

We get to the PACU, and he tells the nurse 'Give her 500 of Hespan'. So she got it anyways. No harm for sure, but was this an appropriate use of colloids?
Was I wrong not to give it in the OR? As a new CA-1, if the surgery attending asks for it, I give it. This is the first time a resident has asked this of me, however.

militarymd · Sep 22, 2005

It does't matter. There is no evidence either way to support or not support the use of colloids.

If each of us were required to pay for the therapies that we give to our patients, colloids would be gone from the pharmacy tomorrow.

The proper amount of sodium and water that a patient needs in the perioperative period is not an exact science....and note I say "sodium and water"...and not saline, lr, or whatever mixture that you use because ultimately the neuro-regulatory mechanisms of the body decides where everything goes....intravascular, interstitial, etc.

You just need to be in the ballpark for the patient to do fine....and I do mean ball park....you don't have to hit the bulleyes...not only that....NO ONE (especially a surgery resident) knows exactly how much and what type of fluids a patient needs.

We all talk like we can change "intravascular volume"....we have no control of it....we only have the ability to change total body sodium and water....the neuro-regulatory/inflamatory mechanisms of the body decides where everything goes.

jwk · Sep 22, 2005

2ndyear said:
Here's my case from last night that I took over:
70 something female, 65 kg, for ex-lap colon resection for Ca. I took over 1.5 hrs into the case. 2 L LR were in already, urine output was marginal 80 cc out when I got there. BP was fine, 120 over 80's. HR was 50's, 60 max. No known history of CHF or any cardiac issues. At 2 hrs total surgery time they were starting to get ready to close. The surg. resident asked me about the patients BP, fluid status and urine output. I had 20 cc of new, light colored urine in the urometer, and more in the tubing since I took over. I stated that we had 2300 cc in, 100 out. He asked for 500 of Hespan, which I didn't give. Note that the surg. attending never said a word about this.

My reasoning was that, while the patient was NPO as well as bowel prepped, sure she was volume depleted. She had urine output that was picking up fine with crystalloids. Hemodynamics were more than adequate. I just didn't see the need for the additional intravascular volume that Hespan would have given me. I could be very wrong on this issue.

We get to the PACU, and he tells the nurse 'Give her 500 of Hespan'. So she got it anyways. No harm for sure, but was this an appropriate use of colloids?
Was I wrong not to give it in the OR? As a new CA-1, if the surgery attending asks for it, I give it. This is the first time a resident has asked this of me, however.

Your call was correct. I think she was still dry and you were just starting to catch up, as evidenced by the new urine output.

militarymd · Sep 22, 2005

jwk said:
Your call was correct. I think she was still dry and you were just starting to catch up, as evidenced by the new urine output.

1) urine output MAY or MAY NOT reflect volume status of a patient

2) urine output ABSOLUTELY does not equal renal function

Using urine output as guide to volume status in a hemodynamically stable patient undergoing surgery is not a good idea.

Disse · Sep 22, 2005

militarymd said:
1) urine output MAY or MAY NOT reflect volume status of a patient

2) urine output ABSOLUTELY does not equal renal function

Using urine output as guide to volume status in a hemodynamically stable patient undergoing surgery is not a good idea.

Similarly there are a multitude of other variables that influence urine output, laparascopy, positioning, obstruction, blah blah blah. I haven't done a literature search on this overall but I would guess that since intraoperative urine output has no bearing on renal function post-AAA repair then I would not sweat an ASA-1 healthy patient who has 20 cc of clear yellow fluid in the foley bag.

UOP is simply a number....like all the rest of the numbers. I like to think its the "sum" of all those numbers that are more important rather than any number by themselves.

militarymd · Sep 22, 2005

Disse said:
that since intraoperative urine output has no bearing on renal function post-AAA repair then I would not sweat an ASA-1 healthy patient who has 20 cc of clear yellow fluid in the foley bag.

UOP is simply a number....like all the rest of the numbers. I like to think its the "sum" of all those numbers that are more important rather than any number by themselves.

thanks for posting that...I forgot to mention that in my post

supahfresh · Sep 22, 2005

2ndyear said:
Here's my case from last night that I took over:
70 something female, 65 kg, for ex-lap colon resection for Ca. I took over 1.5 hrs into the case. 2 L LR were in already, urine output was marginal 80 cc out when I got there. BP was fine, 120 over 80's. HR was 50's, 60 max. No known history of CHF or any cardiac issues. At 2 hrs total surgery time they were starting to get ready to close. The surg. resident asked me about the patients BP, fluid status and urine output. I had 20 cc of new, light colored urine in the urometer, and more in the tubing since I took over. I stated that we had 2300 cc in, 100 out. He asked for 500 of Hespan, which I didn't give. Note that the surg. attending never said a word about this.

My reasoning was that, while the patient was NPO as well as bowel prepped, sure she was volume depleted. She had urine output that was picking up fine with crystalloids. Hemodynamics were more than adequate. I just didn't see the need for the additional intravascular volume that Hespan would have given me. I could be very wrong on this issue.

We get to the PACU, and he tells the nurse 'Give her 500 of Hespan'. So she got it anyways. No harm for sure, but was this an appropriate use of colloids?
Was I wrong not to give it in the OR? As a new CA-1, if the surgery attending asks for it, I give it. This is the first time a resident has asked this of me, however.

i hate taken over a case as a CA-1. you look like a doush if something is not there in the setup....like today, no nerve stimulator.

Noyac · Sep 22, 2005

As you know there are no great answers to the crystalloid vs.colloid debate even after many attempts to study it. But there are some things that may help you make a decision when faced with the question.
Colloid expensive - crystalloid cheap
colloid 1 in 20,000 chance of allergic rxn
colloid inhibits platelets, von Willenbrand factor and factor VIIIc (granted not usually in the doses we give < 1L) (and LMW-HES does not change platelet aggregation)
Now colloid can help DVT prevention while some studies claim that crystalloid can increase coaggulation leading to DVT.
The use of HES is cautioned in renal dysfunction because of the potential to form cast in kidney tubules leading to obstruction.
A recent RCT demonstrated that intraoperative resuscitation with colloid reduces post-op nausea and vomiting and improves the quality of post-op recovery when compared with crystalloid resuscitation in GI surgery.

These are just a few things to think about with respect to colloids. Ultimately, I think you were probably more right in the case or less wrong.

jetproppilot · Sep 22, 2005

militarymd said:
1) urine output MAY or MAY NOT reflect volume status of a patient

2) urine output ABSOLUTELY does not equal renal function

Using urine output as guide to volume status in a hemodynamically stable patient undergoing surgery is not a good idea.

I concur, but I'd rather see urine than not see urine in an ELAP, and if I dont see urine for an 30 min to an hour, I'm gonna find out why and fix it.

jetproppilot · Sep 22, 2005

militarymd said:
urine output ABSOLUTELY does not equal renal function

I agree, BUT, usually a peeing kidney is a happy kidney. Usually. Not always....i.e. only about 30% of ATN patients are oliguric or anuric, which means 70% ARE NOT oliguric or anuric.

zippy2u · Sep 23, 2005

Oh hell, just give that pt. lasix 10mgs IV about 30 minutes before case is over to keep that lil' surgery resident happy. It'll all be good ----Zippy

Colloids

2ndyear

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militarymd

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jwk

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militarymd

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Disse

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militarymd

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supahfresh

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Noyac

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jetproppilot

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jetproppilot

Turboprop Driver

zippy2u

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