militarymd

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When blood is lost....the dogma that is taught....and continue to be perpetuated is that you replace it 3 to 1 with isotonic crystallloid....


I hear it a lot....I smile each time I hear it and watch it done....

Does anyone know where this originated?

I suspect I know, but I'm not for sure....this applies to big name chairmen that I have asked this question to.
 
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VolatileAgent

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If you want to split hairs.....none of them.

that's exactly the point. we are physicians too, you know. our knowledge doesn't stop with what-you-believe-you-are-the-only-one-to-realize is the obvious. the devil is in the details.

yes, this mantra is repeated often early in people's training. it is based on the oncotic gradient difference between most commonly used rescuscitative fluids... 1:1 for colloids and 3:1 for crystalloids. i don't think that it's meant to be a strict rule to follow so much as pearl for people to remember that there are different gross effects concerning what happens to those fluids once they are put in the bloodstream. but, after all, it's not as simple as that, is it? are you surprised that you aren't the only one who knows that?

at some point, we all learn that there is a huge controversy in this particular topic, resuscitation. there is data that shows that giving colloid can worsen peripheral edema after injury. conversely, there is other data that shows that giving crystalloid, namely LR, activates the immune system and can worsen peripheral edema as well. there is even data that shows that people are horrible at estimating actual blood loss. the point is, there is always a better, more detailed, sometimes even more controversial and confusing story when you put a finer point on things. this is the difference between the lesson, the pearl, and what we do in actual practice, which the vast majority of us are, despite your belief, capable of understanding.

so, what's the point of worrying about the origin of this "mantra" and chuckling when you hear it? is it just another way you prop your own ego up and prove to yourself how superior you think you are to everyone else? that we actually follow pearls by rote and never think twice about it?

what's the point of this thread?
 

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It was started because of intravascular redistribution to interstitium as I understand it.

For ye youngsters:
60%body weight = Total Body Water
66% of that is in ye cells
33% of that be extracellular then
of that 33%, 3/4ths is in ye old interstitial space, and 1/4th be in what ye refer to as the old intravascular space.

soz for yer crystalloids, which redistribute within 20-30min or so from what I have read, roughly 75% will go into the interstitium and 25% will stay in ye circulation.

Thats why it got started...me thinks.
 

fakin' the funk

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It was started because of intravascular redistribution to interstitium as I understand it.

For ye youngsters:
60%body weight = Total Body Water
66% of that is in ye cells
33% of that be extracellular then
of that 33%, 3/4ths is in ye old interstitial space, and 1/4th be in what ye refer to as the old intravascular space.

soz for yer crystalloids, which redistribute within 20-30min or so from what I have read, roughly 75% will go into the interstitium and 25% will stay in ye circulation.

Thats why it got started...me thinks.

"Ye old interstitial space" got me a much-needed chuckle :thumbup:
 

militarymd

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When you do the math....according to the diagrams that everyone looks at...it doesn't come out to 3 to 1....

more like 4 to 1....

When pressed...no one seems to know the origin...

I think...I know the origin.....

Why does it matter?

Everything matters in medicine.......therapy in medicine is based on these things....patient population...and the intervention....and then the desired effect.

So....where the 3 to 1 comes from...is important...because it allows you to identify the key components to what you need to know when you practice medicine...

1) patient population
2) intervention
3) desired effect...

Once you know the history...then you know how the intervention is applicable to your practice...

Sooo...once again...does anyone know? I think I know, but I'm not sure....

Volatile knows everything...so please stay out of this thread...leave this to those of us who are still learning everyday...

oh...btw...has your group asked you how I know you yet?
 

VolatileAgent

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Why does it matter?

Everything matters in medicine.......therapy in medicine is based on these things....patient population...and the intervention....and then the desired effect.

so, professor, just how much of our daily practice is evidence-based? come one, toss out a number. just an average. do you even have a clue how little it actually is?

Sooo...once again...does anyone know? I think I know, but I'm not sure....

come on! do his homework for him! help mil be able to beat his chest!

Volatile knows everything...so please stay out of this thread...leave this to those of us who are still learning everyday...

an admission that you don't know something?!?!? everyone! mark this thread. this has got to be a first! i take that back. you didn't know what a journal impact factor was. of course. makes sense.

oh...btw...has your group asked you how I know you yet?

ahhh.... NOW i know who you are! yes, they were wondering why such a jackass was asking after me. so, you know our business model then. shouldn't surprise you that we're expanding, and will continue to expand. i'm sure you'll be working for me someday in the not too distant future. but, don't worry, i won't be to tough on you, sweetie. after i break you in, that is.
 

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When blood is lost....the dogma that is taught....and continue to be perpetuated is that you replace it 3 to 1 with isotonic crystallloid....


I hear it a lot....I smile each time I hear it and watch it done....

Does anyone know where this originated?

I suspect I know, but I'm not for sure....this applies to big name chairmen that I have asked this question to.

I had this question assigned to me by an attending - short answer is that I couldn't find out for sure. The closest I could find is an old edition of Miller from the early 80s in which he cited surgical critical care articles from the 70s where they bled animals and found that it required crystalloid replacement 3:1 to achieve whatever variables they were looking for. I couldn't read the original articles though since our medical library doesn't carry anything prior to 1988.
 
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militarymd

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I had this question assigned to me by an attending - short answer is that I couldn't find out for sure. The closest I could find is an old edition of Miller from the early 80s in which he cited surgical critical care articles from the 70s where they bled animals and found that it required crystalloid replacement 3:1 to achieve whatever variables they were looking for. I couldn't read the original articles though since our medical library doesn't carry anything prior to 1988.

Shires?

I think that's what I had tracked down also....

anyone else.?
 

militarymd

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Another thread becomes a pissing match. Good job, gentlemen.


Don't blame me.....I didn't start any pissing matches here .......however, old people tend to leak urine...so maybe that's why he feels the need to piss everywhere for no reason...

Or it could be his obesity that causes him to leak urine ...all that fat is making his prostate even bigger....I don't know....I haven't figured him out yet.

I'm pretty sure baldness doesn't cause incontinence, but I may be wrong.
 

mocdoc

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that's exactly the point. we are physicians too, you know. our knowledge doesn't stop with what-you-believe-you-are-the-only-one-to-realize is the obvious. the devil is in the details.

yes, this mantra is repeated often early in people's training. it is based on the oncotic gradient difference between most commonly used rescuscitative fluids... 1:1 for colloids and 3:1 for crystalloids. i don't think that it's meant to be a strict rule to follow so much as pearl for people to remember that there are different gross effects concerning what happens to those fluids once they are put in the bloodstream. but, after all, it's not as simple as that, is it? are you surprised that you aren't the only one who knows that?

at some point, we all learn that there is a huge controversy in this particular topic, resuscitation. there is data that shows that giving colloid can worsen peripheral edema after injury. conversely, there is other data that shows that giving crystalloid, namely LR, activates the immune system and can worsen peripheral edema as well. there is even data that shows that people are horrible at estimating actual blood loss. the point is, there is always a better, more detailed, sometimes even more controversial and confusing story when you put a finer point on things. this is the difference between the lesson, the pearl, and what we do in actual practice, which the vast majority of us are, despite your belief, capable of understanding.

so, what's the point of worrying about the origin of this "mantra" and chuckling when you hear it? is it just another way you prop your own ego up and prove to yourself how superior you think you are to everyone else? that we actually follow pearls by rote and never think twice about it?

what's the point of this thread?

Regardless of the point of this thread it is a good alternative to the CRNAs spewing b.s. and the "I only scored 249 on step I, do I have a chance at this program" type of threads.

I appreciate something being posted that is at least quasi educational.
 

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I'd say it came out of the good state of Texas-- Vietnam era. Dallas and/or San Antonio. Lots of GSWs on young kids and not much blood to give em. Regards, ---Zippy
 

SexPanther

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Seriously, I don't think milMD was doing anything other than trying to get us thinking and talking about topics related to the practice of anesthesiology.

Like someone else said, it is a nice change from all of the CRNA crap. This is the kind of thread that I, as a student and soon to be intern, enjoy reading.

Please stop with the hijack posts.
 

fakin' the funk

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soz for yer crystalloids, which redistribute within 20-30min or so from what I have read, roughly 75% will go into the interstitium and 25% will stay in ye circulation.

I know I'm probably behind on the semantics here, but if we're talking 100mL of blood loss, you're gonna give 400mL of crystalloid, so that 25% of it goes to intravascular volume, right...

Wouldn't this be called "4:1" fluid replacement?
 

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I think the point is - most of us would use the clinical indices rather than some stupid rule.

The origin came when measurement of the ECF showed that it's about 25% intravascular and 75% ISF, so your isotonic normal saline distributes freely through out that, so only 25% of the volume is intravascular. So therefore for every litre of blood lost, you need 4L of saline to replace the volume.

Only 50% of colloid remains intravascular (even though it's supposed to stay entirely intravascular) it doesn't - so you need half as much.

There has been one study dones in Australia (the SAFE trail) to show that Albumen is equally safe as saline so in that sense safety is probably not an issue.

If we're needing that much saline though you'd probably be going for Oneg...
 

militarymd

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no....the question was where did that formula come from.....historically.
 

militarymd

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I think the point is - most of us would use the clinical indices rather than some stupid rule.

The origin came when measurement of the ECF showed that it's about 25% intravascular and 75% ISF, so your isotonic normal saline distributes freely through out that, so only 25% of the volume is intravascular. So therefore for every litre of blood lost, you need 4L of saline to replace the volume.

Only 50% of colloid remains intravascular (even though it's supposed to stay entirely intravascular) it doesn't - so you need half as much.

There has been one study dones in Australia (the SAFE trail) to show that Albumen is equally safe as saline so in that sense safety is probably not an issue.

If we're needing that much saline though you'd probably be going for Oneg...

In the SAFE trial where they used 4% albumin vs NS....the ration was about 1 to 1.5
 
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Sorry... will try and find out.

Hypothetical...
"This person is bleeding out... need some saline STAT!"
"But we've given him a litre... it hasn't done anything"
"Keep going.. how much now?"
"4L now boss"
"Okay, scoop up the blood from the drapes and tell me how much he's lost"
"Errrm okay... hmm... about 1L?"
"Good - for every litre of blood lost we'll give 4L of saline... for now and for ever more amen"
 

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It is strictly an empiric observation. It began in the resuscitation of shock pts from what I remember.

this brings another topic to mind. Where did the transfusion rules come from with the trigger being a Hct of 30. I know, blood viscosity and optimum O2 delivery but why do we use it for all (not all of us do). Thread now highjacked.
 

militarymd

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So, I've asked many folks...including well published people....trauma surgeons...other critical care folks..etc....and no one seems to know the historic origins of this dogmatic number.

So I'm reading some historical stuff for a talk I was preparing, and I run across some dog studies that George (first name?) Shires (spelling) published in the late 60's early 70's.

Any surgeon, please chime in....Shires is known for his work on hemorrhagic shock.......

Anyways, he has a dog hemorrhagic shock model where he had a reproducible 50% mortality.

He would drain half the blood volume from these dogs.....leave the dogs in hypovolemic shock for a certain period of time....and return the shed blood to the dogs.....despite the returned blood, the "first hit" caused multi organ dysfunction...and led to a 50% mortality.

So he used this model to study which resuscitative regimen would increase survival back to near 100%....he used multiple fluids...colloids, blood, varying tonicity of crystalloids...and varying volume.

The regimen that had the most impact on survival was isotonic crystalloid at 3 X the shed blood volume....adding blood to 3 x crystallloid did not improve survival anymore.

When I read that.....a lightbulb went off , and I think I found the source of the 3 to 1 forumula........the 3X volume had nothing to do with the kinetics of how much stayed intracellular and how much leaked out.....

the 3 x volume is just what was observed to improved survival....

So I think this is where it comes from....any other thoughts?
 

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I'm pretty sure baldness doesn't cause incontinence, but I may be wrong.

Oh crap...I need to go ahead and stock up on depends :oops:

Whilst at Emory, Dr Carl Hug(you should know or have heard of him) taught me about that Shires guy with the dog study and it being the origination of 3:1 dogma(pardon the pun). But he indicated that more recent evidence has suggested 4:1 might be more adequate.

To play the devil's advocate, there is a paper by the trauma guy out of Houston at Ben Taub(Ken ?) showing that crystalloid replacement is actually deleterious and should not be part of the resuscitation algorithm. I could locate that article IF someone really wanted it

Gotta go, there's a yellow puddle forming underneath my chair...
 

militarymd

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Oh crap...I need to go ahead and stock up on depends :oops:

Whilst at Emory, Dr Carl Hug(you should know or have heard of him) taught me about that Shires guy with the dog study and it being the origination of 3:1 dogma(pardon the pun). But he indicated that more recent evidence has suggested 4:1 might be more adequate.

To play the devil's advocate, there is a paper by the trauma guy out of Houston at Ben Taub(Ken ?) showing that crystalloid replacement is actually deleterious and should not be part of the resuscitation algorithm. I could locate that article IF someone really wanted it

Gotta go, there's a yellow puddle forming underneath my chair...

Where did he get the 4:1 number from?

In the setting of hemorrhagic shock ...with subsequent 50% mortality...3:1 gets you back to almost 100% survival.....

In the SAFE trial....comparing a colloid (4% albumin) vs NS...they found that 1.5 :1 was enough to for NS to expand intravascular volume as effectively when measuring their clinical endpoints.

Ben Taub was where Bickell was...one of their claims to fame is the hypotensvie resuscitation in penetrating injuries....is that what you're referring to...or something else?
 
C

CremeSickle

There were 2 studies at Ben Taub


Ken Mattox is probably one of the premiere trauma surgeons currently and he is the champion of Permission hypotension (debunking the 3:1 rule entirely).

You can find Kens editorial on permissive hypotension HERE

All the references are the hx of the 3:1 rule (which did origionate from Shires) is HERE
 

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Gentlemen,

Thank you for restoring my faith in our anesthesiology forum.

Kudos to the op for starting a discussion that's interesting, informative, and useful.
 

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there's was a talk at a recent Harvard Anesthesia update where a couple interesting points were brought up:

-Shire cannulated the dogs's vessels, bled them, then clamped the cannula shut

-in real life, soft clots form that limit hemmorhage...when we give lots of crystalloid, we increase intravascular volume->increase BP -> increase pressure on those soft clots, blow them out, and can cause more hemmorhage

-there's data supporting an ideal endpoint for hemmorhage resuscitation that keeps this in mind (don't know that off the top off my head)

another unrelated point is that some are now advocating the idea of "scoop and run", meaning the first responders do less resuscitation than currnt standards, they grab the pt and get'm to the OR/ED ASAP
 

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there's was a talk at a recent Harvard Anesthesia update where a couple interesting points were brought up:

-Shire cannulated the dogs's vessels, bled them, then clamped the cannula shut

-in real life, soft clots form that limit hemmorhage...when we give lots of crystalloid, we increase intravascular volume->increase BP -> increase pressure on those soft clots, blow them out, and can cause more hemmorhage

-there's data supporting an ideal endpoint for hemmorhage resuscitation that keeps this in mind (don't know that off the top off my head)

another unrelated point is that some are now advocating the idea of "scoop and run", meaning the first responders do less resuscitation than currnt standards, they grab the pt and get'm to the OR/ED ASAP
We call it "treat em with gas" We're taught the italics in the military pre-hospital care. More specifically, we're taught to keep their blood pressure at ~100 when the patient is in hypovolemic shock. Pushing it more is just wasting fluid that we could use on someone else. Take it for what it's worth though, not much, I'm no expert.
 

militarymd

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The discussion has now moved into 2 distinct and separate topics:

1) what I started......how much to give for blood lost....

2) what others have brought up.....the timing of how much to give....



settle difference....but different topics.
 

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Finally - a thread not about programs and CRNAs etc. I'm also not too sure about the origins of the 3:1 rule - somewhere in the primordial swamp of anaesthesiology one supposes.

Surely the issue is that one should tailor the fluid replacement to the patient on the table. Your obese COPD patient having a Whipple is a totally different kettle of fish from the young motorcycle vs sidewalk victim. The right fluid at the right time is probably how we should be doing it.

The other point is that that 3:1 crystalloid rule was prior to our realisation of the negative effects of many crystalloids - esp (Ab)normal saline which used to be given to anyone with a vein to accept it. I know if i give 4 L of L/R or another crystalloid to a patient who has lost 1L of blood then I'm going to have to "please explain" to one of the bossmen.

Perhaps it is time to banish Dogma to the dogbox? Sorry, couldn't resist:smuggrin:
 
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