Erroneous Academia Dogma Thats Quoted Every Day In Academia

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jetproppilot

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SOOOOOOOOO........WHAT IS IT?????

FLUID REPLACEMENT

Reading the responses in the Jet's Academia B.S. thread rekindled a conversation I remember from my intern year with a cardiology fellow during my cards rotation.

He commented on how anesthesiologists needlessly FLOODED patients during surgery with IVF, and he didnt understand it.

I remembered this conversation when I was a resident...and since I was taught to replace NPO loss, insensible loss, 3:1 for blood loss......I concluded when I was a resident that the cardiology fellow was uneducated.

Eleven years into private practice, I now conclude that cardiology fellow was correct.

I think on alotta cases we use way too much IV fluids.

Don't misintrepret, though.....

cuz even on dialysis patients, history-of-CHF patients, etc.....there are times where you have to...in order to maintain perfusion... flood them intraoperatively, and deal with the sequelae in the ICU...

but I think our resident education on empiric fluid administration leaves too many patients overloaded.

Doesnt matter on ASA 1-2 patients......I had some kinda GI bug at work today so had a CRNA start an IV on me.....Zofran, Decadron, and 3 liters later I felt like a new man....


but pump 3 liters IVF in the wrong patient on the wrong case because "the book" says you should.......I think is wrong.

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You are right on the spot!

Isn't it funny that when we get taught something the first time...whether it is right or wrong, it becomes imprinted somehow, and it will take YEARS of experience and YEARs of data and a LOT of relearning before we UNLEARN what should never have been taught????
 
You are right on the spot!

Isn't it funny that when we get taught something the first time...whether it is right or wrong, it becomes imprinted somehow, and it will take YEARS of experience and YEARs of data and a LOT of relearning before we UNLEARN what should never have been taught????

Absolutely.

I had to unlearn
my resident education.

Thats f u kk ed up.

Hopefully the resident studs on this forum will intellectually challenge themselves, and their attendings, on this subject.

Cuz dats what its all about.
 
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i think the reality is that nobody really "understands" fluid management - not even the real fluid experts (nephrologists)... and they admit it...

if we "overload" them then you have to take into account that internal medicine and some surgeons "dehydrate" them.... so maybe it balances out in the end...

most people don't infarct from the fluid overload right away (unless they have got a real weak heart) --- it is usually 48-72 hours later when everything seems to shunt back into the system... unfortunately, those are not the patients we see because they are on the floor with their CHF exacerbation or MI - and the cardiology fellows and internal medicine fleas are then struggling with the consequences...

so i still think that we need to do what is best intra-operatively but also improve our communication with the medical team to make sure that MR. X is at high-risk of running into trouble and may need a lot of close attention...
 
There is actually a lot of controversy in academia about this issue. Somehow none of the major books seem to talk about this. Yes we tend to overload pts who later on need to diurese a lot. We deal with a different physiology than our medicine colleagues. Our pts are all vasodilated from the anesthetic agents and can tolerate more fliud. But, once surgery is done they become vasoconstrictes rapidly and thus fliud overloaded. The best example for this is a spinal anesthetic. We are taught to prehydrate and hydrate some more if pts become hypotensive. Doesn't really make any sense since the reason they are hypotensive is because they are vasodilated. Why not vasoconstrict them with a neo drip and hydrate as needed for maintenance? I experienced first hand the problem with our current teaching when I was a CA1. I had a CHF pt for a urologic procedure under a spinal. Pt becomes hypotensive. I give a fluid challange first with 500 ml, then another 500ml. My attending relieves me for lunch. He deals with the hypotension the same way I did and the pt gets close to 2 lts total . When I come back from lunch pt is in the PACU doing well. About 1 or 2 hrs later they call a code in PACU. Our pt was in resp distress from pul edema. Needed intubation, ICU stay, had an MI.... It was a big deal that could have been prevented by having a neo drip running and just giving maintenance fliuds. I don't make the same mistake twice.
 
Our pts are all vasodilated from the anesthetic agents and can tolerate more fliud. But, once surgery is done they become vasoconstrictes rapidly and thus fliud overloaded.

So maybe we are using too much fluid, which hangs around a long time, and not enough pressors, which doesnt hang around a long time, to COUNTERACT the vasodilatory nature of our anesthetics.

The best example for this is a spinal anesthetic. We are taught to prehydrate and hydrate some more if pts become hypotensive. Doesn't really make any sense since the reason they are hypotensive is because they are vasodilated. Why not vasoconstrict them with a neo drip and hydrate as needed for maintenance?

EXACTAMUNDO.


I experienced first hand the problem with our current teaching when I was a CA1. I had a CHF pt for a urologic procedure under a spinal. Pt becomes hypotensive. I give a fluid challange first with 500 ml, then another 500ml. My attending relieves me for lunch. He deals with the hypotension the same way I did and the pt gets close to 2 lts total . When I come back from lunch pt is in the PACU doing well. About 1 or 2 hrs later they call a code in PACU. Our pt was in resp distress from pul edema. Needed intubation, ICU stay, had an MI.... It was a big deal that could have been prevented by having a neo drip running and just giving maintenance fliuds. I don't make the same mistake twice.

Great discussion.

Great anecdotal (read: private practice literature if same clinical scenerio repeats over and over) evidence.
 
Absolutely.

I had to unlearn
my resident education.

Thats f u kk ed up.

Hopefully the resident studs on this forum will intellectually challenge themselves, and their attendings, on this subject.

Cuz dats what its all about.

like you resident studs, I read books and emulated attendings when I was a resident.

I am telling you I've figured out some of the stuff I was taught is actually deleterious to patient outcome.

Some of the deleterious sequelae is stuff that we do.... like this fluid discussion....or giving meds preoperatively that havent been proven to change patient outcome.

and some of the deleterious sequelae is a result of the stuff we DONT do...

Like delaying urgent but not emergent cases because of NPO guidelines.

Or ordering too much pre op stuff, then needlessly waiting or cancelling based on ordering too much pre op stuff.


Think about everything you do, and dont do, as a resident.

And ask yourself why you are doing it, or not doing it.

And see if you can really justify the do or the dont.......with patient outcomes.

Education is not just memorizing Baby Miller and emulating attendings.

Education is asking WHY, and formulating how you'll handle a case in your private practice life based on your conclusions.
 
Education is asking WHY, and formulating how you'll handle a case in your private practice life based on your conclusions.

Unfortunately, Jet, there are still attendings in academia out there whose egos can't handle this approach and often "pay you back" with a negative evaluation (e.g., "resident was 'argumentative' and didn't accept my approach", "wanted to question everything I was doing instead of simply trying to learn", etc... I've seen these in evaluations before).

Two errors I often see in the junior residents (and did them myself until I learned better):

1) WAY too much fluid during a case
2) not NEARLY enough narcotic

-copro
 
Lets get clinical than shall we?

I agree that it doesn't make sense to dump assloads of fluid into someone who you just gave a spinal to. You caused a sympathectomy, now give some adrenergics. Ephedrine and neo vs 2 liters of fluid. Think about those total knees? I now rarely give over 1200 of fluid. Usuall a liter depending on the time of the day of the procedure.

Anyways, here:
75 y/o female with htn and NIDDM 80kg comming in for hemicolectomy. Blood loss 500. Starting Hb 10. Gas towards end of case (3 hours) shows Hb 8.8 How much fluids do you typically give? How do YOU judge?

Books say check: UOP (dubious at best considering stress response to surgery and ADH secretion), SVO2 (uhh ok), arterial bp wave form variation, lactate (sure.......), and doppler based stroke volume (mmmmkayy), CVP/BP response to fluid bolusing.

What about the old THRID SPACING of fluids?

Does it make ANY sense to give albumin/hespan in order to spare giving large/er amounts of crystalloid with the end goal of extubation at the end?

I used to give the stupid 10cc/kg/hr for large open bowel case. Now I'm at 4cc/kg/hr. Give 300-500 cc fluid challenge for BP decreasing in the face of non-hemorrhaging situation. I typically run less than a MAC of the vapor and use plenty of narcotics fo' that big old incision. We typically do NOT use epidurals for abdominal cases per the surgical service desires'.
 
The data is becoming pretty clear that less fluid is better-- it improves outcomes. Several recent randomized trials support this.
 
what is "less" fluid?

that's the 6 million dollar question.

All the researchers are trying to find the holy grail monitor: pac, svi, echo, svo2, u/o, etc...I could go on and on and on and on....

Everyone has their favorite because:

1) that's how they were trained....that is by the way my favorite reason...sarcasm intended
2) they do research on it
3) because their hospital provides it
4) too stupid to know any other ones.
5) etc....and on and on and on

I believe the right answer is a combination of all of the above, and GOOD clinical judgement coming from seeing a LOT of these patients from BEFORE surgery through until they WALK OUT OF THE HOSPITAL.....

but that's just me...
 
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It is refreshing to hear that others have pondered the same stuff. Like everyone else, I suppose, I started out trying to do all of these fluid admin estimation calcs - that typically yield LARGE numbers on how much fluid they "should" receive - and tried to hit that number. It seemed to work pretty well during CA-1, but that is when your primarily living in the ortho room with predominantly ASA1/ASA2 on only the occasional fragile fossil with a bum-ticker. However, when the susceptible ones trundled through, it became pretty apparent that "Gung Ho" on the juice could certainly land the pt in trouble post-op.

As my training advanced, I varied my strategies & tried mixing in some alternates, i.e. Hespan - I elaborated on this in the other thread - but eventually came to feel that one of the better indicators was sort of a gestalt/gut feeling & how the pt reacted to various stimuli...sorta letting the pt 'tell me'.

My concern is, this is virtually the antithesis of a science-based approach & the last thing I want to do is something deleterious to my patients. But, neither do I desire to do harm by floating them off the table simply due to a few papers that may or may not be correct.

Like many things in the lit-base, it seems like if you dig, you can find pretty convincing volumes that for any given question, will support, refute & be equivocal the answer(s).

Please sprinkel your words of wisdom & experience onto me!
 
that's the 6 million dollar question.

All the researchers are trying to find the holy grail monitor: pac, svi, echo, svo2, u/o, etc...I could go on and on and on and on....

Everyone has their favorite because:

1) that's how they were trained....that is by the way my favorite reason...sarcasm intended
2) they do research on it
3) because their hospital provides it
4) too stupid to know any other ones.
5) etc....and on and on and on

I believe the right answer is a combination of all of the above, and GOOD clinical judgement coming from seeing a LOT of these patients from BEFORE surgery through until they WALK OUT OF THE HOSPITAL.....

but that's just me...

It is refreshing to hear that others have pondered the same stuff. Like everyone else, I suppose, I started out trying to do all of these fluid admin estimation calcs - that typically yield LARGE numbers on how much fluid they "should" receive - and tried to hit that number. It seemed to work pretty well during CA-1, but that is when your primarily living in the ortho room with predominantly ASA1/ASA2 on only the occasional fragile fossil with a bum-ticker. However, when the susceptible ones trundled through, it became pretty apparent that "Gung Ho" on the juice could certainly land the pt in trouble post-op.

As my training advanced, I varied my strategies & tried mixing in some alternates, i.e. Hespan - I elaborated on this in the other thread - but eventually came to feel that one of the better indicators was sort of a gestalt/gut feeling & how the pt reacted to various stimuli...sorta letting the pt 'tell me'.

My concern is, this is virtually the antithesis of a science-based approach & the last thing I want to do is something deleterious to my patients. But, neither do I desire to do harm by floating them off the table simply due to a few papers that may or may not be correct.

Like many things in the lit-base, it seems like if you dig, you can find pretty convincing volumes that for any given question, will support, refute & be equivocal the answer(s).

Please sprinkel your words of wisdom & experience onto me!

see above post.

The "holy grail" monitor...what are we trying to measure?

During the periperative period, the patients total body sodium and water change because of what their body is going through...and we facilitate the change by adding sodium and water in an endeavor to improve oxygen delivery (I think that's is good...hell maybe it is beneficial to have periods of oxygen delivery...I don't know)...

I think "gestalt" is the right answer for now.
 
SOOOOOOOOO........WHAT IS IT?????

FLUID REPLACEMENT

Reading the responses in the Jet's Academia B.S. thread rekindled a conversation I remember from my intern year with a cardiology fellow during my cards rotation.

He commented on how anesthesiologists needlessly FLOODED patients during surgery with IVF, and he didnt understand it.

I remembered this conversation when I was a resident...and since I was taught to replace NPO loss, insensible loss, 3:1 for blood loss......I concluded when I was a resident that the cardiology fellow was uneducated.

Eleven years into private practice, I now conclude that cardiology fellow was correct.

I think on alotta cases we use way too much IV fluids.

Don't misintrepret, though.....

cuz even on dialysis patients, history-of-CHF patients, etc.....there are times where you have to...in order to maintain perfusion... flood them intraoperatively, and deal with the sequelae in the ICU...

but I think our resident education on empiric fluid administration leaves too many patients overloaded.

Doesnt matter on ASA 1-2 patients......I had some kinda GI bug at work today so had a CRNA start an IV on me.....Zofran, Decadron, and 3 liters later I felt like a new man....


but pump 3 liters IVF in the wrong patient on the wrong case because "the book" says you should.......I think is wrong.

JPP-

interesting discussion.

We have an attending where I'm at that swears by Hespan. Obviously case specific, but generally speaking he's pretty quick to use Hespan. Almost no other attending at my program has used it (atleast for the cases I've worked with them on. I'm sure they use it though).

But what are people's thoughts on Hespan? It's a volume expander and less expensive than albumin.. It's a colloid. Almost no side effects (very rare). Coag studies and bleeding times are not affected.

I've used it a handful of times. Used only maybe 0.5L. The results I've seen are amazing. The pt's BP is seriously rock solid and I barely have to use much LR.

What are attendings/residents thoughts on Hespan. I just find people dont use it much and so it's foreign to them. But without much anaphylactoid rxns and being nonantigenic...why not use it more often??
 
JPP-

interesting discussion.

We have an attending where I'm at that swears by Hespan. Obviously case specific, but generally speaking he's pretty quick to use Hespan. Almost no other attending at my program has used it (atleast for the cases I've worked with them on. I'm sure they use it though).

But what are people's thoughts on Hespan? It's a volume expander and less expensive than albumin.. It's a colloid. Almost no side effects (very rare). Coag studies and bleeding times are not affected.

I've used it a handful of times. Used only maybe 0.5L. The results I've seen are amazing. The pt's BP is seriously rock solid and I barely have to use much LR.

What are attendings/residents thoughts on Hespan. I just find people dont use it much and so it's foreign to them. But without much anaphylactoid rxns and being nonantigenic...why not use it more often??

why use it at all?
 
why use it at all?

hehe

I use it when I need to catch up quickly during hemorrhage. I haven't found it to be useful in other situations meerly because I haven't used it that much.

Everyone's gonna slam on me for using albumin to cut down on long belly cases here but it hasn't burned me yet. Transfusion rxn, sensitization of immune system to foreign proteins, yadda yadda. The chance of anaphlaxis is the same as with hespan. I guess you have to worry about PRIONS but wtf man. I DON'T routinely use it on long cases. However I find it saves me from dumping in another couple of liters of crystalloid.

Anyways, after these discussions, which I dig, I will further refine my techniques and truely see "how low" I can go with the fluids. I'll even nix my albumin in favor of the slightly heartier .9 NS (with that whopping 308 osmol) every few bags for that extra nerdy bang.
 
why use it at all?

so i can maintain a decent pressure without using lots of crystalloids.

MMD tell me what's wrong with using it.:thumbup: aside it being slightly more expensive.
 
Almost no side effects (very rare). Coag studies and bleeding times are not affected.



Ya might want to re-read your label...there are side effects, albeit most of them rare. But, you can definitely impair platelet function with relatively small volumes. In peds, they recommend no more than 10ml/kg & for adults, platelet function begins to fall off after approx 1 liter. So, I generally hold my use of Hespan to 1 liter in an adult.
 
Ya might want to re-read your label...there are side effects, albeit most of them rare. But, you can definitely impair platelet function with relatively small volumes. In peds, they recommend no more than 10ml/kg & for adults, platelet function begins to fall off after approx 1 liter. So, I generally hold my use of Hespan to 1 liter in an adult.

Completely agreed. Again those SE's are very rare. Most of the times I've used Hespan I've only used 500mL and then supplemented earlier and concurrently with LR. I just think in the cases I've done it keeps the BP smooth while avoiding having to use massive amounts of crystalloids.
 
Completely agreed. Again those SE's are very rare. Most of the times I've used Hespan I've only used 500mL and then supplemented earlier and concurrently with LR. I just think in the cases I've done it keeps the BP smooth while avoiding having to use massive amounts of crystalloids.

show me the data that supports this.

Once again I reference the SAFE trial..(though the colloid used is albumin)...the results would not support your beliefs.... 1.5 x is not massive amounts of crystalloid.
 
show me the data that supports this.

Once again I reference the SAFE trial..(though the colloid used is albumin)...the results would not support your beliefs.... 1.5 x is not massive amounts of crystalloid.

What about cardiac, liver transplant and burn patients, who were excluded from the study? The safe trial looked at 4% albumin (which is 96% NS.) What about 25% albumin?

I'm still undecided. There are good attendings I work with on both sides of the fence and both present good arguments in my eyes.
 
What about cardiac, liver transplant and burn patients, who were excluded from the study? The safe trial looked at 4% albumin (which is 96% NS.) What about 25% albumin?

I'm still undecided. There are good attendings I work with on both sides of the fence and both present good arguments in my eyes.

when there is controversy, and when you have respected people on both sides of the fence....what that means to me is that it doesn't matter....

when it doesn't matter???

then it goes to $$$$$$$$ who decides.
 
What about cardiac, liver transplant and burn patients, who were excluded from the study? The safe trial looked at 4% albumin (which is 96% NS.) What about 25% albumin?

According to Marino: 25% albumin simply shifts fluid from interstital to intravascular. It should not be used in patients who are dehydrated or have acute blood loss. There is evidence that albumin does not causes more mortality, and when adverse events are evaluated in total, albumin is safer than crystalloid.
 
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