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[redy]

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The osmolality of

D5W= 250
D51/2NS = 405
D5NS= 560

I got these from the fluid bags.

Perhaps its a reflection on me / the teaching I got but I was surprised to see that. So often I have seen D51/2 NS or D5NS. All those times pts were given hypertonic stuff which would theoretically shift fluid into extracellular space and probably give them osmotic diuresis too. Should we be doing that? I guess if its done so often its not really of much clinical relevance? And if D5NS has similar osmolarity to 3% saline,why not use D5NS instead in treating patients with raised ICP due to cerebral edema and not worry abt the sodium?

Also the pH of D5 was 4.4. That sounds freakin acidic.

 

[Hernandez]

Also the pH of D5 was 4.4. That sounds freakin acidic.

Did you look at the pH of NS as well?

 

[redy]

Did you look at the pH of NS as well?

Yep. 5.6. I think all this came about after I saw one of your posts about pH of NS being 5 something.

The pH of CaCL is 5.6. I always thought thats why it burns like crazy. I guess thats not why.

 

[bronx43]

The osmolality of

D5W= 250
D51/2NS = 405
D5NS= 560

I got these from the fluid bags.

Perhaps its a reflection on me / the teaching I got but I was surprised to see that. So often I have seen D51/2 NS or D5NS. All those times pts were given hypertonic stuff which would theoretically shift fluid into extracellular space and probably give them osmotic diuresis too. Should we be doing that? I guess if its done so often its not really of much clinical relevance? And if D5NS has similar osmolarity to 3% saline,why not use D5NS instead in treating patients with raised ICP due to cerebral edema and not worry abt the sodium?

Also the pH of D5 was 4.4. That sounds freakin acidic.

Those aren't actually physiologically hypertonic, because the D5 gets metabolized so quickly that you're essentially just giving water with D5W, 1/2NS with D51/2NS, and NS with D5NS.

 

[redy]

Gotcha....there had to be an explanation. Thanks.

Sent from my HTC One using Tapatalk 4

 

[Bostonredsox]

Did you look at the pH of NS as well?

This is why I'm giving more and more LR these days. The hyperchloremic acidosis from large volume NS resuscitation can be significant

 

[jdh71]

This is why I'm giving more and more LR these days. The hyperchloremic acidosis from large volume NS resuscitation can be significant

Show me evidence that it's actually meaningful to endpoints we all care about in an randomized fashion. Believe me the surgeons have tried to prove its poison, it's just not.

 

[core0]

Show me evidence that it's actually meaningful to endpoints we all care about in an randomized fashion. Believe me the surgeons have tried to prove its poison, it's just not.

Depends on if you consider AKI a meaningful endpoint or not.

 

[Bostonredsox]

Show me evidence that it's actually meaningful to endpoints we all care about in an randomized fashion. Believe me the surgeons have tried to prove its poison, it's just not.

Give me a reason not to use it? LR and NS both cost pennies. There is some data that chloride restrictive fluid resuscitation has lead to better outcomes. There is no literature I am aware of showing adverse events with LR unless they are severely hepaticly impaired. So if you have an option that MAY be better for your hyperchloremic acidotic, and it you know it won't hurt them, and it's dirt cheap, why wouldn't you use it?

NS is not poision, I use it constantly. But in a pt who is hypovolemic and needs isotonic fluid, who is already hyperchloremic, I generally use LR. Give me a reason not to.

 

[Hernandez]

Give me a reason not to use it? LR and NS both cost pennies. There is some data that chloride restrictive fluid resuscitation has lead to better outcomes. There is no literature I am aware of showing adverse events with LR unless they are severely hepaticly impaired. So if you have an option that MAY be better for your hyperchloremic acidotic, and it you know it won't hurt them, and it's dirt cheap, why wouldn't you use it?

NS is not poision, I use it constantly. But in a pt who is hypovolemic and needs isotonic fluid, who is already hyperchloremic, I generally use LR. Give me a reason not to.

I've been told it's 5¢ vs 35¢ a bag,,,,,

 

[Bostonredsox]

I've been told it's 5¢ vs 35¢ a bag,,,,,

The fact that both are measured in cents not dollars proves my point. Who the **** cares. It's pennies.

 

[Radonkulous]

That's nearly 1 order of magnitude in cost difference.

 

[jdh71]

Depends on if you consider AKI a meaningful endpoint or not.

I don't. Not per the study I know you are referring.

 

[jdh71]

Give me a reason not to use it? LR and NS both cost pennies. There is some data that chloride restrictive fluid resuscitation has lead to better outcomes. There is no literature I am aware of showing adverse events with LR unless they are severely hepaticly impaired. So if you have an option that MAY be better for your hyperchloremic acidotic, and it you know it won't hurt them, and it's dirt cheap, why wouldn't you use it?

NS is not poision, I use it constantly. But in a pt who is hypovolemic and needs isotonic fluid, who is already hyperchloremic, I generally use LR. Give me a reason not to.

I'm not telling you NOT to do anything. I'm telling you your rationale isn't supported by actual objective data. You are not a bad person for using LR, but if you think it makes you a better person for the reasons you have, well, you should be able to show me the money.

 

[group_theory]

NS is not poision, I use it constantly. But in a pt who is hypovolemic and needs isotonic fluid, who is already hyperchloremic, I generally use LR. Give me a reason not to.

For someone who is already hyperchloremic from aggressive volume resuscitation from NS, yeah, it makes sense to switch to another fluids (although no great evidence that it affects mortality).

Just keep in mind that LR is more hypertonic than 1/2NSS - 273 mOsm/L versus 154 mOsm/L respectively. Plus LR will have more chloride than 1/2NSS - 109 mEq/L versus 77 mEq/L. And a liter of LR will have 4 meq of potassium - not a lot, but something to consider if your patient is already in ARF, anuric, with elevated serum potassium (e.g. rhabdo)

 

[Hamhock]

I've been told it's 5¢ vs 35¢ a bag,,,,,

At my current hospital system, the LR is about 2 pennies cheaper per bag than the NS; and both cost less than a dime.

HH

Oh, please look up the pH of LR too.

 

[Bostonredsox]

For someone who is already hyperchloremic from aggressive volume resuscitation from NS, yeah, it makes sense to switch to another fluids (although no great evidence that it affects mortality).

Just keep in mind that LR is more hypertonic than 1/2NSS - 273 mOsm/L versus 154 mOsm/L respectively. Plus LR will have more chloride than 1/2NSS - 109 mEq/L versus 77 mEq/L. And a liter of LR will have 4 meq of potassium - not a lot, but something to consider if your patient is already in ARF, anuric, with elevated serum potassium (e.g. rhabdo)

Agree on monitoring the k, it can add up in pts with ARF.

And the ph is around 7.3-7.5 if I remember correctly.

 

[Hamhock]

And the ph is around 7.3-7.5 if I remember correctly.

K+ with NS or LR matters little.

BSox: are you saying that the pH of LR is 7.3-7.5?

Although there is a "gray area" that is political in many ways, I would say that most people agree LR is closer to 5.8-6.0.

(big arguement, I know)

However, there is little debate that both NS and LR are very acidotic and should not be used in the crashing, acidotic patient (with Hgb acceptable).

Let's cut to the bones: What are people using for the hyperchloremic,acidotic resus?

HH

 

[Bostonredsox]

K+ with NS or LR matters little.

BSox: are you saying that the pH of LR is 7.3-7.5?

Although there is a "gray area" that is political in many ways, I would say that most people agree LR is closer to 5.8-6.0.

(big arguement, I know)

However, there is little debate that both NS and LR are very acidotic and should not be used in the crashing, acidotic patient (with Hgb acceptable).

Let's cut to the bones: What are people using for the hyperchloremic,acidotic resus?

HH

Sorry was typo I meant 6.3-6.5, been drinking during his colossally horrible sox game.

And I looked it up its 6.5

 

[jdh71]

K+ with NS or LR matters little.

BSox: are you saying that the pH of LR is 7.3-7.5?

Although there is a "gray area" that is political in many ways, I would say that most people agree LR is closer to 5.8-6.0.

(big arguement, I know)

However, there is little debate that both NS and LR are very acidotic and should not be used in the crashing, acidotic patient (with Hgb acceptable).

Let's cut to the bones: What are people using for the hyperchloremic,acidotic resus?

HH

Already obnoxiously hyperchloremic? LR. But if they are really that fooked up they are almost certainly alreasy hooked up to a peripheral kidney which is taking care of much of that. So it becomes a bit of an exercise in academic masturbation.

 

[Stitch]

Anyone using plasmalyte (pH 7.4)? Our cardiac guys have switched to it in order to avoid the hyperchloremic acidosis in post op hearts. I don't think there's any evidence, but I imagine plasmalyte isn't cheap.

 

[jdh71]

Anyone using plasmalyte (pH 7.4)? Our cardiac guys have switched to it in order to avoid the hyperchloremic acidosis in post op hearts. I don't think there's any evidence, but I imagine plasmalyte isn't cheap.

I'll use if it ever gets cheap.

Gomers don't get fancy treatments, they get the basics.

 

[ORL10]

I'll use if it ever gets cheap.

Gomers don't get fancy treatments, they get the basics.

Ouch, but agree. How often are you using albumin?

 

[jdh71]

Ouch, but agree. How often are you using albumin?

Depends in the attending. 😉

But I'd say often enough if we think it makes some kind of sense

 

[jdh71]

I guess I should clarify a bit just in case anyone was confused, I don't give gomers "worse" treatment because they are gomers, but rather the pharmacy won't let me treat gomers with plasmalyte unless I have some kind of reason they will agree with.

 

[MSmentor018]

this is a good topic, something that has plagued the sicu vs micu for years. has anyone seen this, I've never calculated a SID. it looks interesting, thoughts?
http://emcrit.org/wp-content/uploads/acid_base_sheet_2-2011.pdf

yep, with the pharmacist it's all about taking care of the insurance, i meant patient

 

[jdh71]

Find me a single time that knowing the SID actually changes the management from what you were going to do with traditional acid-base anyway and I'll get interested in SID again