AV fistula revision

[militarymd]

---

Members do not see this ad.

Our vascular surgeon brings a dialysis dependent patient to the OR today for AVF revision.

Patients is INR is 3...on coumadin for AF....INR on the high side, but that is another thread.

Patient does make urine, so sodium balance is NOT the reason for dialysis.

Despite warning from the attending anestheiologist, the surgeon decides it is OK to proceed with the revision after vitamin K administration. (not what I would have done).

Case proceeds with a relatively high blood loss per usual for this surgeon....PACU...patient continues to fill up the drains....and becomes hypotensive and tachycardic.

Attending anesthesiologist gives 500cc of NS and notifies surgeon....surgeon gives anesthesiologist a whole bunch of crap because patient is in "renal failure"....and that FFP was the correct resuscitation fluid...which he then orders.

Everyone's thoughts.

 

[Laryngospasm]

Our vascular surgeon brings a dialysis dependent patient to the OR today for AVF revision.

Patients is INR is 3...on coumadin for AF....INR on the high side, but that is another thread.

Patient does make urine, so sodium balance is NOT the reason for dialysis.

Despite warning from the attending anestheiologist, the surgeon decides it is OK to proceed with the revision after vitamin K administration. (not what I would have done).

Case proceeds with a relatively high blood loss per usual for this surgeon....PACU...patient continues to fill up the drains....and becomes hypotensive and tachycardic.

Attending anesthesiologist gives 500cc of NS and notifies surgeon....surgeon gives anesthesiologist a whole bunch of crap because patient is in "renal failure"....and that FFP was the correct resuscitation fluid...which he then orders.

Everyone's thoughts.

Vitamin K for acute reversal of an INR of 3.0? for a vascular surgery? Did the surgeon order that? I would have insisted on FFP from the start. Pt most likely had other comorbidities, likely cad.I think this is one of those cases where you have to pull out the cancellation card when the surgeon tries to do something stupid.

 

[DreamMachine]

.

 

[DreamMachine]

.

 

[militarymd]

When was the patient last dialyzed(sp?)?

the day before.

 

[DreamMachine]

.

 

[bullard]

Correcting the INR may not have helped. He may have a platelet dysfunction secondary to chronic renal failure. I don't remember the therapy for this. I do remember as a surgical intern on the vascular service having to hold pressure for a very long time at surgical sites (catheters not fistulas) despite INRs in the 1-2 range.

One therapy for uremic platelet dysfunction is ddAVP.

 

[DreamMachine]

.

 

[militarymd]

Military is your point more about what the therapy is or more about the fact the surgeon is an ass? I agree, he sounds like an ass. Surgeons always like to have control over coagulation. He should have requested FFP, instead of yelling at whoever for not giving it. Of course after a certain amount of bleeding the question "is it okay to administer 4 units of FFP?" would be good.

My question/point is about fluid resuscitation in the renal failure patient.

 

[Laryngospasm]

Correcting the INR may not have helped. He may have a platelet dysfunction secondary to chronic renal failure. I don't remember the therapy for this. I do remember as a surgical intern on the vascular service having to hold pressure for a very long time at surgical sites (catheters not fistulas) despite INRs in the 1-2 range.

He may have had platelet dysfunction, but he definitely had an INR of 3.

 

[DreamMachine]

.

 

[Qtip96]

Our vascular surgeon brings a dialysis dependent patient to the OR today for AVF revision...

Patients is INR is 3...on coumadin for AF....INR on the high side, but that is another thread...

Despite warning from the attending anestheiologist, the surgeon decides it is OK to proceed with the revision after vitamin K administration. (not what I would have done)...

Everyone's thoughts.

may i play too?

i think the attending anesthesiologist should have held his/her ground and cancelled the case for many reaasons. 1) it's an ELECTIVE surgery, and a potentially bloody one at that. 2) WHY expose a patient to blood products (i.e. FFP) when you don't have to? 3) holding coumadin and restarting later is far easier than giving vit K and having the INR all over the place after surgery. my 2 cents 😀 .

 

[Laryngospasm]

may i play too?

i think the attending anesthesiologist should have held his/her ground and cancelled the case for many reaasons. 1) it's an ELECTIVE surgery, and a potentially bloody one at that. 2) WHY expose a patient to blood products (i.e. FFP) when you don't have to? 3) holding coumadin and restarting later is far easier than giving vit K and having the INR all over the place after surgery. my 2 cents 😀 .

Well put, you cant use a revised AVF for several weeks anyway so what the heck is the big hurry? Was the surgeon going on a 3 week vacation? Oh wait, they dont get that much vacation. 😛

 

[DreamMachine]

.

 

[militarymd]

may i play too?

i think the attending anesthesiologist should have held his/her ground and cancelled the case for many reaasons. 1) it's an ELECTIVE surgery, and a potentially bloody one at that. 2) WHY expose a patient to blood products (i.e. FFP) when you don't have to? 3) holding coumadin and restarting later is far easier than giving vit K and having the INR all over the place after surgery. my 2 cents 😀 .

I would agree with you....

The attending anesthesiologist is new...one of my recruits...actually one of my former residents.......only 4 years out of Board Certification, but experienced in vascular surgery..

Problem....he doesn't know the surgeon.

Normally, an AVF revision is an essentially bloodless surgery that frequently is done under local.

Our vasuclar guy....tends to phleblotomize more than necessary....and sutures tend not to get tied as tight as necessary.

So, new guy gets suckered into doing the case...but that's fine...perioperative coagulopathies are not difficult to manage.

Problem is that the surgeon disagrees with management of hypovolemia.

I don't know what the cause of the bleeding was....medical or surgical...but hypovolemic patients require resuscitation reqardless of renal function...that's my point...

Surgeon's point was that because the patient had renal failure, you shouldn't give fluids in boluses.

 

[Qtip96]

Surgeon's point was that because the patient had renal failure, you shouldn't give fluids in boluses.

this surgeon sounds like a prick 😛 .

 

[Laryngospasm]

I would agree with you....

The attending anesthesiologist is new...one of my recruits...actually one of my former residents.......only 4 years out of Board Certification, but experienced in vascular surgery..

Problem....he doesn't know the surgeon.

Normally, an AVF revision is an essentially bloodless surgery that frequently is done under local.

Our vasuclar guy....tends to phleblotomize more than necessary....and sutures tend not to get tied as tight as necessary.

So, new guy gets suckered into doing the case...but that's fine...perioperative coagulopathies are not difficult to manage.

Problem is that the surgeon disagrees with management of hypovolemia.

I don't know what the cause of the bleeding was....medical or surgical...but hypovolemic patients require resuscitation reqardless of renal function...that's my point...

Surgeon's point was that because the patient had renal failure, you shouldn't give fluids in boluses.

How much blood did the patient lose, how big were they? Most likely 500c of fluid would not be a problem for a dialysis pt (unless the patient was 25KG)who had been NPO for surgery, AND lost a significant amount of blood volume. You would still have room to give some FFP and not put the patient into volume overload. Dx-the surgeon is a D___.

 

[militarymd]

He's actually OK....it's just that his understanding of physiology is not the same as the rest of us....and being a surgeon...sometimes it is hard to change his mind.

 

[DreamMachine]

.

 

[Qtip96]

He's actually OK....it's just that his understanding of physiology is not the same as the rest of us....and being a surgeon...sometimes it is hard to change his mind.

yes, we always seem to vouch for people who appear to be nice people. but in a physician, we have to value clinical judgment. i try to make my decisions based upon what i would have done for myself or my family. no way in hell is going forward with this elective procedure acceptable if it was my mom/dad on the slab, when waiting a few days would dramatically decrease risk, odds of complications, and exposure to blood products. not to mention all the extra phebotomies to get the INR within target range after the surgery.

 

[militarymd]

yes, we always seem to vouch for people who appear to be nice people. but in a physician, we have to value clinical judgment. i try to make my decisions based upon what i would have done for myself or my family. no way in hell is going forward with this elective procedure acceptable if it was my mom/dad on the slab, when waiting a few days would dramatically decrease risk, odds of complications, and exposure to blood products. not to mention all the extra phebotomies to get the INR within target range after the surgery.

When I say he is OK....I'm saying he's not an a-hole....I would not let him touch me with a 5 mile pole.

 

[toughlife]

I would agree with you....

The attending anesthesiologist is new...one of my recruits...actually one of my former residents.......only 4 years out of Board Certification, but experienced in vascular surgery..

Problem....he doesn't know the surgeon.

Normally, an AVF revision is an essentially bloodless surgery that frequently is done under local.

Our vasuclar guy....tends to phleblotomize more than necessary....and sutures tend not to get tied as tight as necessary.

So, new guy gets suckered into doing the case...but that's fine...perioperative coagulopathies are not difficult to manage.

Problem is that the surgeon disagrees with management of hypovolemia.

I don't know what the cause of the bleeding was....medical or surgical...but hypovolemic patients require resuscitation reqardless of renal function...that's my point...

Surgeon's point was that because the patient had renal failure, you shouldn't give fluids in boluses.

Yeah but doesn't he remember that the point of dialysis is to also remove excess fluid? Besides if the patient was a dialysis pt, I surmise he/she was getting dialized 3x/wk, so whatever fluid overload the pt had would be removed the next day (provided the surgery was on an off day). All this is assuming the patient had a HD catheter in place since the AV fistula could not be used.

 

[Noyac]

Wow Mil, Do you feel like the Oral Examiner that can't get the examinee to answer the question? This type of answering will get you a repeat trip to the Orals. You guys didn't understand what Mil was getting at. The case whether right or wrong was done (frequently you will find this on the orals) and now we are trying to deal with the post-op issue of hypotension and blood loss in a dialysis pt that MAKES urine. 🙁



Resuscitate the pt and deal with the renal failure later.

 

[Qtip96]

Wow Mil, Do you feel like the Oral Examiner that can't get the examinee to answer the question? This type of answering will get you a repeat trip to the Orals. You guys didn't understand what Mil was getting at. The case whether right or wrong was done (frequently you will find this on the orals) and now we are trying to deal with the post-op issue of hypotension and blood loss in a dialysis pt that MAKES urine. 🙁

Resuscitate the pt and deal with the renal failure later.

sorry, i must be dense. i didn't really understand the direction of Mil's quesiton. it did not even occur to me that withholding resuscitation in a symptomaticallly hypovolemic patient was even an option, HD dependent or not, irrespective of oliguria/anuria.

in any case, Noyac, get off your high horse. he literally asked for us to "give us his thoughts." and we did. when Mil stated, "my question/point is about fluid resuscitation in the renal failure patient", my initial throughts were "what about it?", but did not voice it for fear of sounding obvious (or sounding obviously stupid 😉 ).

 

[DreamMachine]

.

 

[militarymd]

If thats what the boards are like, I might fail 6 times like that cat that mil works with.

that's funny

 

[militarymd]

sorry, i must be dense. i didn't really understand the direction of Mil's quesiton. it did not even occur to me that withholding resuscitation in a symptomaticallly hypovolemic patient was even an option, HD dependent or not, irrespective of oliguria/anuria.

in any case, Noyac, get off your high horse. he literally asked for us to "give us his thoughts." and we did. when Mil stated, "my question/point is about fluid resuscitation in the renal failure patient", my initial throughts were "what about it?", but did not voice it for fear of sounding obvious (or sounding obviously stupid 😉 ).

Not everyone would have the good sense to think that......for example, I can't stand the automatic hanging of NS vs LR in someone who receives dialysis.

What about that topic?

Do you guys use LR or NS in HD patients?

 

[Qtip96]

Not everyone would have the good sense to think that......for example, I can't stand the automatic hanging of NS vs LR in someone who receives dialysis.

What about that topic?

Do you guys use LR or NS in HD patients?

ugh... the age old crystalloid question. now i put my foot in my mouth. i'm going to sound "obviously stupid".

i'd have to say if the fluid resuscitation is a small volume (i.e. < 1 liter), it probably doesn't matter. if asked formally, i would favor LR for larger volumes because of dilutional metabolic acidosis with NS. most people with medicine backgroud (like me) would stick to NS and use bicarb when needed, but in a HD patient that would result in more sodium load.

 

[Qtip96]

If thats what the boards are like, I might fail 6 times like that cat that mil works with.

thank god we don't have orals in cards. i'd probably get a bad attack of the stutters, like that dude in a "Fish Called Wanda"...

"ka KA... ka KA... ka KA" [now singing] "ka KA... ka KA..."

 

[towrope]

Okay, this was my case so let me say a couple of things. First, when I noticed the patients INR to be 3.4 in the preop area I obviously was concerned. My first thought was that the surgeon must not know because otherwise the patient would not be scheduled for surgery that morning. On further questioning though the patient told me that her INR 2 days ago was 5.5 and that the surgeon told her to hold her coumadin for 2 days...very suspicious since 2 days is not long enough for such a high INR. I think patients hold coumadin for at least 3 days...and that's for a therapeutic INR of 2-3. My initial impressions of this surgeon's medical judgements based on prior experience was not favorable so I was not surprised. I called him to let him know....thinking surely he will cancel and wait a few days...afterall, the fistula works. He told me to give her Vit K and he would be available to do the case in an hour or so. Now I don't give a lot of Vit K, but my recollection was that a minimum it takes 4-6 hours to start working and probably a little longer. Well, not feeling the greatest level of confidence yet in this hospital since I just started I was not going to butt heads with our sole vascular surgeon. So things went okay in the OR...not a whole lot of blood loss, but more than one would expect...maybe 300 cc of blood. In the PACU she quickly filled up the 60 cc JP bulb 4 times over 45 minutes....BP 98/38, HR 64...I told the nurse to bolus with 500 cc NS and if the JP filled up again to get stat H and H and PT/PTT/INR. After the bolus...10 minutes later... the surgeon scolds me like a school child for giving so much fluid to a patient with renal failure. My mouth on the ground I am thinking this guy is a real a-hole and an idiot. I told him that she was bleeding and hypotensive so I gave her a small fluid bolus and intended to check coags and give FFP if the oozing continued...his response....500 cc is way too much. He would have given 250....he insisted that 250 ml was the thing to do not 500....anyway...this is getting too long....the point is that when a patient is hypotensive and I think the source is blood loss I am going to give some fluid irrespective of their renal funtion. Furthermore, would anyone think that 500 was way too much and that 250 was the only appropriate amount.

 

[Qtip96]

So things went okay in the OR...not a whole lot of blood loss, but more than one would expect...maybe 300 cc of blood. In the PACU she quickly filled up the 60 cc JP bulb 4 times over 45 minutes....BP 98/38, HR 64...I told the nurse to bolus with 500 cc NS and if the JP filled up again to get stat H and H and PT/PTT/INR... Furthermore, would anyone think that 500 was way too much and that 250 was the only appropriate amount.

for someone hypotensive from hypovolemia, i would agree 250cc is homeopathic and generally pissing in the wind. that being said, this degree of hypotension from 360cc blood loss seems a little unusual, as well as the relative bradycardia. on first pass, sounds somwhat vagalish, eh?

 

[dhb]

his response....500 cc is way too much. He would have given 250....he insisted that 250 ml was the thing to do not 500...

that's B$ even if the hole 250 would go strait to her lungs it wouldn't have a significant effect especially considering the loss of 540cc

is that surgeon a relative of your now famous anesthesiologist Mr 👎 x6?

btw if tha patient has a fistula you can HD him or even CVVH if needed (fill him up!!)

 

[Qtip96]

that's B$ even if the hole 250 would go strait to her lungs it wouldn't have a significant effect especially considering the loss of 540cc

is that surgeon a relative of your now famous anesthesiologist Mr 👎 x6?

oops, i should check my math... i'll shut up now. 😳

 

[towrope]

for someone hypotensive from hypovolemia, i would agree 250cc is homeopathic and generally pissing in the wind. that being said, this degree of hypotension from 360cc blood loss seems a little unusual, as well as the relative bradycardia. on first pass, sounds somwhat vagalish, eh?

The heart rate response to hypovolemia is not always reliable, especially in older patients and patients on beta blockers. A 500-600 cc blood loss (OR plus PACU) acutely in a recently dialyzed person can certainly result in some relative hypotension as evidenced in this patient.

 

[Noyac]

sorry, i must be dense. i didn't really understand the direction of Mil's quesiton. it did not even occur to me that withholding resuscitation in a symptomaticallly hypovolemic patient was even an option, HD dependent or not, irrespective of oliguria/anuria.

in any case, Noyac, get off your high horse. he literally asked for us to "give us his thoughts." and we did. when Mil stated, "my question/point is about fluid resuscitation in the renal failure patient", my initial throughts were "what about it?", but did not voice it for fear of sounding obvious (or sounding obviously stupid 😉 ).

Yeah, Huh, that answer will get you another trip to the boards as well. I am not attacking anyone here. Some of you guys are too sensitive. I was trying to get to th question at hand. Geaz!

 

[TIVA]

Towrope,

The answer to your question is no, a 500 cc bolus is not unreasonable in your patient.

The fact of the matter is, that when it comes to crystalloids, by the time you have finished infusing one liter of normal saline or LR, there is a whopping 300 cc's remaining intravascularly while the other 700 cc's is floating around in the interstitium. That's how they came upon the 3:1 rule for fluid resuscitation in the face of blood loss.

If it had been me, I would have used 5% Albumin (another thread) to cope with the blood loss and replaced 1 cc of albumin for each cc of blood loss. Albumin has a half-life of 8-10 days and all of it stays intravascular. That way noboby gets worried about overly aggressive resuscitation in a "renal failure" patients. Besides, less crystalloid equates to less tissue edema and in my view, less post-op complications (also another thread). And then I would have checked CBC and coags and corrected them accordingly. So once, Hb starts to fall below 10, I would have started PRBC's and FFP to correct the coags.

And finally, I would have told the surgeon about the newly discovered factor in the coagulation cascade called "Two-O- Proline."

At the end of the day, were you careless in giving 500 cc's? Absolutely not. In fact, I think you could have safely given 1000 cc's of crystalloid in a patient who had dialysis just the day prior and is normally expected to take on at least 2 to 2.5 liters of fluid excess between dialysis sessions.

The key is to resuscitate your patient. Don't be worried about pulmonary edema. If you have to put a patient into pulm edema in order to resuscitate them, do it. Because then all you have to do is intubate them, put them on the vent, stabilize their hemodynamics, correct their coags, and then start drying them out (all via auto diuresis, lasix, dialysis) in the ICU. Voila.

And when the surgeon comes rounding on his AV Fistula patient in the ICU for the next two days, he'll remember to heed your advice regarding elevated INR's ... unless he's dumb.

TIVA

 

[towrope]

Towrope,

The answer to your question is no, a 500 cc bolus is not unreasonable in your patient.

The fact of the matter is, that when it comes to crystalloids, by the time you have finished infusing one liter of normal saline or LR, there is a whopping 300 cc's remaining intravascularly while the other 700 cc's is floating around in the interstitium. That's how they came upon the 3:1 rule for fluid resuscitation in the face of blood loss.

If it had been me, I would have used 5% Albumin (another thread) to cope with the blood loss and replaced 1 cc of albumin for each cc of blood loss. Albumin has a half-life of 8-10 days and all of it stays intravascular. That way noboby gets worried about overly aggressive resuscitation in a "renal failure" patients. Besides, less crystalloid equates to less tissue edema and in my view, less post-op complications (also another thread). And then I would have checked CBC and coags and corrected them accordingly. So once, Hb starts to fall below 10, I would have started PRBC's and FFP to correct the coags.

And finally, I would have told the surgeon about the newly discovered factor in the coagulation cascade called "Two-O- Proline."

At the end of the day, were you careless in giving 500 cc's? Absolutely not. In fact, I think you could have safely given 1000 cc's of crystalloid in a patient who had dialysis just the day prior and is normally expected to take on at least 2 to 2.5 liters of fluid excess between dialysis sessions.

The key is to resuscitate your patient. Don't be worried about pulmonary edema. If you have to put a patient into pulm edema in order to resuscitate them, do it. Because then all you have to do is intubate them, put them on the vent, stabilize their hemodynamics, correct their coags, and then start drying them out (all via auto diuresis, lasix, dialysis) in the ICU. Voila.

And when the surgeon comes rounding on his AV Fistula patient in the ICU for the next two days, he'll remember to heed your advice regarding elevated INR's ... unless he's dumb.

TIVA

I have learned my lesson the hard way with this surgeon. A week ago I did a fem-pop with him and the patient was bleeding post-op...stat coags in the PACU and and H and H revealed a low hct and a PTT greater than 120....so I ordered blood and called the surgeon to tell him that we were transfusing and suggested we give some protamine to reverse the residual heparin effect from the OR...something normally done in the OR but which he told us not to do...so in the PACU he comes and orders FFP in addition to the blood....very very bizarre. The patient needed some protamine and a trip back to the OR which I suggested from the very beginning. He then placed the patient on "renal dose dopamine"....yes, you heard me...those very words came out of his mouth and I then realized just how stubborn he was. And guess what happened....the patient developed and SVT with a heart rate of almost 200 with rate related ischemia 20 minutes after leaving the PACU. One of the ICU nurses called me and said she was crashing...I suggested he first stop the dopamine and he jumped all over me and became very irritated. My conclusion...this guy is not only an arrogant surgeon, but he has bad judgement...a deadly combination.

 

[meddog1]

What bothers me is the HR of 64 with a low BP. Sure the PT is probably an old vasculopath with crappy sympathetic compensation but I start thinking about cardiac pathology in my DDX in these populations when I see those vitals post-op. Anything look funky in this PT that way poster?

 

[meddog1]

The other question on the DDX is if the Vitamin K may have been infused too rapidly. Certainly though, as everyone has stated, expanding the vascular space was the correct measure. You already indicated that the Pt made urine, so with an EBL of 0.5-1.0 L, who can fault you for a little IVF? I sure don't. 😉

 

[towrope]

No evidence of myocardial ischemia on the monitor...the patient was completely asymptomatic. The Vit K had gone in 4 hours ago....Bottom line is this...the patient looked and felt fine, but NIBP was a little low...not really low...the bleeding was not catastrophic and was slowing. The point is this....the surgeon and I should have had a friendly conversation about the utility of Vit K in this setting and he should have agreed that exposing this patient to FFP and expending a limited resource for an elective case was not worthwhile. Hence we should come back to fight another day. Lesson number 1....his patients aren't always prepared for surgery and neither is he. Second, in a patient with renal failure a small amount of NS is not going to harm the patient provide they are not currently volume overloaded....but then again this surgeon is a nimrod and explaining this to him is futile.

 

[Qtip96]

Yeah, Huh, that answer will get you another trip to the boards as well. I am not attacking anyone here. Some of you guys are too sensitive. I was trying to get to th question at hand. Geaz!

dude, sorry. my bad. 😳

 

[Annette]

Next time the surgeon takes you to task for giving 500 cc of anything to an HD patient, hand him one of those small cans of shasta, and let him have at it! Like the other posters have said, the patient needed resus. The fluid choice should be what is currently most convient -LR or NS. Both have the draw back of either too much NA or K for large volumes- but that is what HD is for. You would do the kidneys much more harm if you had not resus. the patient. Obviously, the patient still has some renal function, and that should be protected. Dropping the MAP below 90 will do more damage that having to UF the patient.

Vit K sucks. It should be an almost last resort, unless you won't be anticoagulating the patient afterwards. Delaying the surgery would have been the best option, followed distantly by FFP for an elective surgery.

 

[Noyac]

Towrope,

And then I would have checked CBC and coags and corrected them accordingly. So once, Hb starts to fall below 10, I would have started PRBC's and FFP to correct the coags.

You want to transfuse this pt for a Hb of <10? 😕 How much below 10 do want to transfuse for?

Most of these dialysis pts live at a Hb of 10. If it falls below that so what? They have a higher 2,3 DPG and will release O2 more effectively to the tissue. I'd let them fall probably 20% or more b/4 transfusing unless something else began to occur like ischemia or continued large blood loss.

 

[TIVA]

You want to transfuse this pt for a Hb of <10? 😕 How much below 10 do want to transfuse for?

Most of these dialysis pts live at a Hb of 10. If it falls below that so what? They have a higher 2,3 DPG and will release O2 more effectively to the tissue. I'd let them fall probably 20% or more b/4 transfusing unless something else began to occur like ischemia or continued large blood loss.

Fair enough question, Noyac.

The optimal Hb concentration for maximizing oxygen delivery and minimizing blood viscosity is 10.

So, if our patient has CAD (which he may or may not have), the ideal Hb is 10. And if our patient does not have CAD, then certainly you can afford to let the Hb drift down further before causing myocardial ischemia.

However, when having to resuscitate a patient, aim for a Hb of 10 not just to maximize your oxygen delivery/blood viscosity ratio, but because in an actively bleeding patient, by the time you start to transfuse at a Hb of 10, the real Hb is probably even less, maybe 9 or 8.

And the ONLY indication for PRBC's is symptomatic anemia. Thus, if a patient is anemic and hypotensive, he needs blood. For some people, they become symptomatic at a Hb of 9.5, for others, they become symptomatic at a Hb of 5.5. Judge accordingly.

Moreover, PRBC's are an excellent colloid and will help replenish the intravascular volume. Don't get me wrong ... blood is by no means benign. It is quite possibly the filthiest fluid on the face of the earth ... which is why we take great care in making the decision to transfuse. But if you wait until a Hb of less than "x", it becomes more difficult to rescuscitate because then you have to deal with all the after effects of shock, low perfusion status, lactic acidosis, coagulopathy, etc, and it's best to stay on top of the resuscitation than to get behind, if just to make your life a little easier.

 

[Noyac]

Fair enough question, Noyac.

The optimal Hb concentration for maximizing oxygen delivery and minimizing blood viscosity is 10.

So, if our patient has CAD (which he may or may not have), the ideal Hb is 10. And if our patient does not have CAD, then certainly you can afford to let the Hb drift down further before causing myocardial ischemia.

However, when having to resuscitate a patient, aim for a Hb of 10 not just to maximize your oxygen delivery/blood viscosity ratio, but because in an actively bleeding patient, by the time you start to transfuse at a Hb of 10, the real Hb is probably even less, maybe 9 or 8.

And the ONLY indication for PRBC's is symptomatic anemia. Thus, if a patient is anemic and hypotensive, he needs blood. For some people, they become symptomatic at a Hb of 9.5, for others, they become symptomatic at a Hb of 5.5. Judge accordingly.

Moreover, PRBC's are an excellent colloid and will help replenish the intravascular volume. Don't get me wrong ... blood is by no means benign. It is quite possibly the filthiest fluid on the face of the earth ... which is why we take great care in making the decision to transfuse. But if you wait until a Hb of less than "x", it becomes more difficult to rescuscitate because then you have to deal with all the after effects of shock, low perfusion status, lactic acidosis, coagulopathy, etc, and it's best to stay on top of the resuscitation than to get behind, if just to make your life a little easier.

Yes, your statements are correct for most pts. And I know you understand what I was getting at which was that dialysis pts are chronically anemic and it is difficult to pick a number at which you will transfuse all dialysis pts. Especailly since they can tolerate anemia.

Here's sort of a trick question:
What's wrong with a lab value of, Hb 7, Hct 24?

 

[dhb]

Especailly since they can tolerate anemia.

Renal patients once started on dialysis have a much higher rate of cardio-vascular events... so if many tolerate a relative anemia i'm not sure if they do well if their crit falls any lower acutely...?

 

[dhb]

Here's sort of a trick question:
What's wrong with a lab value of, Hb 7, Hct 24?

If you compare to normal values of 15 for Hb and 45 for Hct the Hb is less than half while the Hct has not dropped as much...
Hct is influenced by RBC size; Hb 7, Hct 24 --> macrocytosis?

 

[IN2B8R]

Do you guys use LR or NS in HD patients?[/QUOTE]

I think the answer hinges on how much volume you intend on giving. Realizing, ofcourse, that LR does have K, the wizer choice is avoiding fluids that are going to drastically elevate the serum K level.

 

[The_Sensei]

Do you guys use LR or NS in HD patients?

I think the answer hinges on how much volume you intend on giving. Realizing, ofcourse, that LR does have K, the wizer choice is avoiding fluids that are going to drastically elevate the serum K level.

Yeah......I don't think the 4 meq/L of K in LR is going to "drastically" elevate the serum K level. 🙄

 

[VentdependenT]

Use fluids as needed.

Dialyze em afterwards if needed. Keep em intubated if they can't maintian a decent/baseline vitals sat on < 40% fio2. Too bad. Gotta be done.

Sucks but oh well.

If fluid loss is yer problem give fluids. Sure you could give neo/pressor o' choice to keep MAP/end organ perfusion up but now you're constricting dry vessels. I know we always think in terms of pressure cause it keeps flow up but so does volume. So I would ballpark volume and if patient was still havin trouble use pressors.

But then again what the hell do I know.