Curiosity question

[GMed]

Advertisement - Members don't see this ad

I was just curious as to how much NS people give to a patient with CHF who is undergoing septic/hypovolemic shock before you start thinking about overshooting and causing pulmonary edema.

500ml?
1L?

 

[gutonc]

I was just curious as to how much NS people give to a patient with CHF who is undergoing septic/hypovolemic shock before you start thinking about overshooting and causing pulmonary edema.

500ml?
1L?

As much as it takes. You can always get it back.

Honestly, this is kind of a meaningless question. The clinical scenario will dictate what you give and will vary between patients and with any particular patient as well. Are we talking about a previously compensated pt w/ an EF of 35% or a mess in a dress with an EF of 3.5% (yes, I've seen that low). And if they're that sick, you're going to be adding some dobutamine pretty soon.

One man's 250ml is another's 2L. Give fluid, re-assess, lather, rinse, repeat.

 

[RxnMan]

I was just curious as to how much NS people give to a patient with CHF who is undergoing septic/hypovolemic shock before you start thinking about overshooting and causing pulmonary edema.

500ml?
1L?

The answer to your question is dependent on who you ask.

Pulmonologist - keep 'em dry to prevent pulmonary edema and ARDs.
Nephrologist - add as much as you need to prevent AKI.

It is an old question, but like gutonc said, you're not going to let a patient remain hypotensive.

 

[dragonfly99]

For sepsis, you need to go by the CVP (so very likely will need a central line and check CVP's every so often, keep 8-12). If the EF is super crappy like 5 or 10%, you just have to be careful. However, I can't see 500cc being "enough" to treat any kind of sepsis...remember only about 1/3 stays intravascular. If someone is that sick (CHF with systolic dysfunction and sepsis) you're going to need a central line, +/- a Swan, to manage that. Pulm/critical care sometimes frown @Swans because some studies have shown they don't improve outcomes in septic shock, but I think if you have a trauma case or one with hard-to-evaluate CHF or ? of septic versus cardiogenic shock, then the Swan can be useful sometimes.

 

[jdh71]

The answer to your question is dependent on who you ask.

Pulmonologist - keep 'em dry to prevent pulmonary edema and ARDs.
Nephrologist - add as much as you need to prevent AKI.

It is an old question, but like gutonc said, you're not going to let a patient remain hypotensive.

Pulm would never answer this way

 

[ResidentMD]

Pulm would never answer this way

👍

 

[RxnMan]

Pulm would never answer this way

Huh. Maybe Schrier was joking when he said it to me.

 

[ropeadope1983]

Huh. Maybe Schrier was joking when he said it to me.

Dr. Robert W. Schrier? Sure a Nephrologist will say that. Just like surgeons say all IM docs do is think. Just like many people say all Neurologists do is make impressive diagnoses that aren't curable. Just generalizations.

 

[jdh71]

Huh. Maybe Schrier was joking when he said it to me.

Name drop 😀

Cards likes the lungs dry, and I'm sure Schrier was making a bit of a joke, but you will see this battle often in patient's with renal, cardio, and pulm all on board. Cards likes em dry and renal wet. Pulm usually sees the bigger picture because of their critical care training as well.

 

[RxnMan]

Dr. Robert W. Schrier? Sure a Nephrologist will say that. Just like surgeons say all IM docs do is think. Just like many people say all Neurologists do is make impressive diagnoses that aren't curable. Just generalizations.

When the god of AKI and sepsis tells you, the med student, how he thinks the world works, then yeah, you take the god at his word. I'm willing to entertain the idea that he was joking, but don't presume to tell a fellow med student he should have known better when a world-class expert in water homeostasis was telling him how to hydrate a patient.

Name drop 😀...

I generally don't post something unless I've got some sort of leg to stand on.

 

[RTrain]

When the god of AKI and sepsis tells you, the med student, how he thinks the world works, then yeah, you take the god at his word. I'm willing to entertain the idea that he was joking, but don't presume to tell a fellow med student he should have known better when a world-class expert in water homeostasis was telling him how to hydrate a patient.

I generally don't post something unless I've got some sort of leg to stand on.

No need to be defensive. We believe you that your bigwig told you what pulmonologists think, but he was mistaken. 😛

 

[Crazy Diamond]

When the god of AKI and sepsis tells you, the med student, how he thinks the world works, then yeah, you take the god at his word. I'm willing to entertain the idea that he was joking, but don't presume to tell a fellow med student he should have known better when a world-class expert in water homeostasis was telling him how to hydrate a patient.

I generally don't post something unless I've got some sort of leg to stand on.

God--------> student ...religion again didn't realize that Nephro is so theological and pyramidal !

 

[studyguy123]

I have a curiosity question also, unrelated to the OP's post. But what is worse to have, an HDL of 33 or a triglyceride of 509? i know both cause an increased of CHD.

 

[studyguy123]

I have a curiosity question also, unrelated to the OP's post. But what is worse to have, an HDL of 33 (for a guy) or triglycerides of 509. I know both increase risk of CHD.

 

[jdh71]

I have a curiosity question also, unrelated to the OP's post. But what is worse to have, an HDL of 33 (for a guy) or triglycerides of 509. I know both increase risk of CHD.

The 509

 

[Gastrapathy]

God--------> student ...religion again didn't realize that Nephro is so theological and pyramidal !

Did you ever try to study renal physiology? Its easier to just pray to the God of the Tubule, guess, recheck labs p intervention, adjust, repeat.

But, then again, I just stick black tubes in dirty places for a living.

 

[gutonc]

Did you ever try to study renal physiology? Its easier to just pray to the God of the Tubule, guess, recheck labs p intervention, adjust, repeat.

That's my approach too. And if things aren't going in the right direction after 48h (or get a lot worse after 24h), call a Tubule Priest and be done with it.

 

[Finding Chi]

As for the original question...
Those situations totally suck and you deal with them on a case by case basis. Bottom line, you've got to give fluid. No one in their right mind will tell you to keep a septic patient dry.
Central line is a must - check out "Surviving Sepsis" - and really once you start causing the pulmonary edema from the fluids, your next step is pressors. Plus you can monitor the CVP (I have an aversion to Swan's in all but the most convincing situations ever since I saw a patient's Swan get tied in a knot in his RV. Glad I was not the one calling that particular consult to vascular surgery).

As for all the theology...
Ain't no God of medicine. We all say some bullsh*t sometimes. Even the most venerable, published and megalomaniacal among us.