300 cc of 0.9% saline vs 300 cc of coca cola

[militarymd]

To many 300 cc of 0.9% saline versus 300 cc of some dextrose containing solution is the same "volume".....

Nothing can be further from the truth.

Although "volume" is a term that many use.....what it means in a patient is murky?

For any volume of any type of fluid given, the effect of total intravascular volume is unknown and VERY difficult to measure....see the 3 to 1 thread.

However, the following is clear...certain patients do not tolerate sodium loads well.

-Cirrhotics
-congestive heart failure SYNDROMES....(and i mean the syndrome not just a patient with low EF)
-dialysis patients where the only avenue of sodium loss is via dialysis.

All of the above patients...as part of their routine medical care are placed on sodium restricted diets....usually less than 2 grams in 24 hours...and many of those patients still require furosemide to assist in off loading the 2 grams of sodium that they take in to prevent sodium overload syndromes.....ie pulmonary edema...and edema in other parts of their bodies.

sooo...in a patient with any of the above disorders....a mere 300 CC of 0.9% saline over a few hours (actually about 1 gram of sodium) WILL Cause pulmonary edema and other signs and symptoms of sodium overload states...

Whereas 300cc of sodium free fluid....is really just like drinking water.

And notice ...no talk of "volume" ...because in the care of these patients....Our concepts of "volume" ie...bleeding patient....is really non-applicable....and cause nephrologists and cardiologists to smile.

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[nutmegs]

can we get a preemptive lock on this thread?

sorry, any shred of interesting clinical discussion goes out the window in 2 posts with your personalitieS.

 

[proman]

To truly compare:
0.9% saline has 154 mEq or 3.54 gm/L sodium, osmolality of about 308 mOsm/L and obviously no dextrose, pH 7.4

Coca-cola has 3 mEq/L of sodium, osmolality of 470-500 mOsm/L (sources vary), and is basically a D10W solution, pH 2.4

Anyway, I thought the main effect of crystalloids was to increase the interstitial volume (instead of plasma volume). At least that's what Marino states.

 

[powermd]

How do you feel about volume loading in renal transplant cases? Typically at Columbia we load in about 2L of NS or LR over the course of a renal transplant to help perfuse the new kidney. Often our kidneys have spent significant time in transit and don't function well initially. Is this volume loading strategy reasonable? I haven't seen any dialysis dependant patient go into pulmonary edema yet with 1.3-3L of volume during the case, but I haven't done THAT many.

What do you use to replace blood loss in ESRD patients undergoing non-renal transplant surgery? NS/LR 3:1?

I haven't had any attending recommend D5W during any case except for type 1 diabetics who are on insulin drips. Would you use this for maintenance fluid repletion intraoperatively in ESRD patients +/- crystalloid for blood loss?

 

[militarymd]

How do you feel about volume loading in renal transplant cases? Typically at Columbia we load in about 2L of NS or LR over the course of a renal transplant to help perfuse the new kidney. Often our kidneys have spent significant time in transit and don't function well initially. Is this volume loading strategy reasonable? I haven't seen any dialysis dependant patient go into pulmonary edema yet with 1.3-3L of volume during the case, but I haven't done THAT many.

What do you use to replace blood loss in ESRD patients undergoing non-renal transplant surgery? NS/LR 3:1?

I haven't had any attending recommend D5W during any case except for type 1 diabetics who are on insulin drips. Would you use this for maintenance fluid repletion intraoperatively in ESRD patients +/- crystalloid for blood loss?

Patients ability to handle sodium varies...Many do fine with 3x/week dialysis while eating a normal diet...meaning their total body sodium can change 4 to 10 grams at a time without any ill effect.....those are the patients who do fine with "volume loading"....and "volume loading" clearly has salutatory effects on the nephrons....

I guess I should be more clear...I'm referring to those patients who develop pulmonary edema when they don't pay attention to their diet......an extra hot dog equalling worsening shortness of breath....

Surgery and anesthesia appears to have cause a sodium deficit ....hence we always use isotonic crystalloids in the OR.....however, this sodium requirement quickly reverses itself when you stop surgery and anesthesia.....reason why surgeons, intensivists, cardiologists, and others frequently complain about the gas guy giving too much "fluids".

 

[militarymd]

To truly compare:
0.9% saline has 154 mEq or 3.54 gm/L sodium, osmolality of about 308 mOsm/L and obviously no dextrose, pH 7.4

Coca-cola has 3 mEq/L of sodium, osmolality of 470-500 mOsm/L (sources vary), and is basically a D10W solution, pH 2.4

Anyway, I thought the main effect of crystalloids was to increase the interstitial volume (instead of plasma volume). At least that's what Marino states.

yes

 

[TIVA]

I like to use 5% Albumin to replace blood loss on a 1:1 basis for most patients including ESRD patients up to a predetermined lower acceptable Hb level. After that, it's PRBC's.

I think the 3:1 crystalloid resuscitation just lends itself to too much tissue edema.

Besides, when patients are losing blood, they're not bleeding out crystalloid, they're bleeding out colloid (and cells).

 

[lobelsteve]

300 cc?

10 ounces?

Unless the patient is significantly compromised to the point of having a Swan-Ganz inserted, how much of a difference can 10 oz of any fluid (H20, NSS, Coke, Beer) really make?

Let me point out that I only practice pain medicine and do not frequent the ICU. So the above is actually a question (sarcasm not intended). I can see 10 oz of Everclear or 10 oz of Mag Citrate having a big effect, but whether its Gatorade, water, or Yeungling- what's the difference?

 

[militarymd]

It's not the volume of water that matters.....it is the grams of sodium that gets you.

 

[VolatileAgent]

To many 300 cc of 0.9% saline versus 300 cc of some dextrose containing solution is the same "volume".....

are you just trying to piss me off?

my only reference to the can of coca-cola in the other post was in regards to the amount of fluid, not the actual content of the fluid. i'm sorry if that irrevocably confused you.

300ml ("cc" is no longer an acceptable abbreviation in medical charting... you should know that) of any IV fluid - alone - will never tip a surgical patient into CHF, even if they're already on the brink of CHF. there are many physiologic reasons for this, all of which you should know, that are directly related to the procedure. and, for the latter stipulation, i would assume that the patient did not actually present in CHF before they were taken to the OR, otherwise noy's colleague would've identified the problem and treated it. i will also assume that they did not give 3% saline or the like, as well.

you are doing nothing more than attempting to change the playing field in order to try to save face. i will not comment further on this lame thread.

 

[militarymd]

As I have said before....the 1 gm of sodium will cause "volume overload" syndromes.

Sodium DOES NOT put one into...or cause "congestive heart failure".

Patients who have congestive heart failure syndromes do not tolerate sodium indtake or loads very well.....and hence...as part of their treatment....are sodium restricted and also given drugs which enhance sodium loss (furosemide)..

anyone who has spent time taking care of cardiac patients (outside of the OR...as physicians do) knows this.

Patients who have congestive heart failure are not told to "don't drink too much water" or Coca-Cola for that matter.....

Many junior physicians do get confused because water restriction is used on patients with SIADH....which many CHF patients have as part of their inappropriate compensatory changes....