ESRD - dialysis patients

[militarymd]

I'm running into this from a number of physicians ...including even nephrologists and it is NOT making any sense to me.

These patients on dialysis will be coming to the OR for some minor procedure....like hernia repair, tank off cathether placement, fistula revision....anyways, you get the idea, some minor procedure where you get less than 500cc of IVF,

and I'm running into all these MD's (gas, nephro, im) who insist that these patients get normal saline as their fluid of choice....when I hang LR for the case, they whine and moan....

Do you guys get that? I would like responses from both PP and academia.

I had one nephrologist WIGG out ...not to my face...but behind my back....and I just don't get it.

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[Planktonmd]

I'm running into this from a number of physicians ...including even nephrologists and it is NOT making any sense to me.

These patients on dialysis will be coming to the OR for some minor procedure....like hernia repair, tank off cathether placement, fistula revision....anyways, you get the idea, some minor procedure where you get less than 500cc of IVF,

and I'm running into all these MD's (gas, nephro, im) who insist that these patients get normal saline as their fluid of choice....when I hang LR for the case, they whine and moan....

Do you guys get that? I would like responses from both PP and academia.

I had one nephrologist WIGG out ...not to my face...but behind my back....and I just don't get it.

It probably doesn't matter what type of fluid you use but why do you feel that you need to give LR?

 

[Pilot Doc]

I have heard rumors of a RCT showing that NS raises K MORE than LR. Presumed mechanism is alteration of acid/base balance. I'll see if I can find the citation.

 

[dhb]

2 mmol of K+ can't raise your potassium very much...

 

[militarymd]

It probably doesn't matter what type of fluid you use but why do you feel that you need to give LR?

It does if the patient is VERY sodium sensitive, but those are rare birds.

I choose LR because we use LR for everything...and it is stocked EVERYwhere.

 

[numbmd]

Easy, nephrologists fall into one of two categories, either really f***in smart or really f****in stupid. You have come into contact with one of the latter.

Medicine has 3 F's: Fact, Fiction, and Fetish.

Renal patients getting only NS is a fetish.

 

[militarymd]

Easy, nephrologists fall into one of two categories, either really f***in smart or really f****in stupid. You have come into contact with one of the latter.

Medicine has 3 F's: Fact, Fiction, and Fetish.

Renal patients getting only NS is a fetish.

 

[urge]

I have heard rumors of a RCT showing that NS raises K MORE than LR. Presumed mechanism is alteration of acid/base balance. I'll see if I can find the citation.

True. It's not a rumor. Supposedly the acidosis caused by NS raises the K more than LR by itself. I'll look it up later. Don't have good internet access now.

 

[IceDoc]

My slice of academia: Most people know that there were studies (from Duke I belive) showing better electrolyte profiles for patients with ESRD who received LR. However, we recently had a policy change so that EVERYONE's first bag in preop was NS, so that ESRD patients wouldn't accidently get LR. Go figure.

I wouldn't want to hang litres of the stuff (the K+ will eventually add up), but 500cc of pretty much anything will be fine.

 

[seinfeld]

yeah the kidney guy is wrong. the study i believe people are quoting is " a randomized, double blind comparison of LR and NS during renal transplant" Anesthesia and Analgesia 2005; 100: 1518-24.

As someone else has reminded us a liter of LR contains only 4 mEq. Enough to raise the K+ from 4.0 to 4.04

Our institution since the publication of that paper has switched to LR for our Kidney tranplants, during which we give 3-5 liters, and have not expierenced a hyperkalemic arrest and not all the kidneys work at first

 

[Planktonmd]

, but 500cc of pretty much anything will be fine.

That is the bottom line!
And it doesn't matter if they are "sodium sensitive" whatever that means!

 

[militarymd]

That is the bottom line!
And it doesn't matter if they are "sodium sensitive" whatever that means!

think back to your IM days...and indications for dialysis...and daily sodium flux when you have a stiff myocardium...it'll come back to you.........or not.

 

[militarymd]

You guys need to remember....I practice in Alabama......

anyways, I'm glad everyone is saying things that I agree with.

Patients are sodium restricted when on HD....so I personally use 1/2 or 1/4 NS for small cases....

I've never seen a patient on a potassium restricted diet.......so K intake doesn't appear to be an issue for ESRD.

A banana has 10 meq of K......

 

[fakin' the funk]

As someone else has reminded us a liter of LR contains only 4 mEq. Enough to raise the K+ from 4.0 to 4.04

I thought it was 200 mEq K+ for every point of serum K+ osmolality

Anyway, it's tiny

 

[Planktonmd]

think back to your IM days...and indications for dialysis...and daily sodium flux when you have a stiff myocardium...it'll come back to you.........or not.

Remember: We are talking about the difference in sodium load between 500 cc LR and 500 cc NS, do you honestly think that you can have a stiff myocardium that will tolerate 500 cc LR and not 500 cc NS?
Are you serious?

 

[militarymd]

Remember: We are talking about the difference in sodium load between 500 cc LR and 500 cc NS, do you honestly think that you can have a stiff myocardium that will tolerate 500 cc LR and not 500 cc NS?
Are you serious?

read post number 13.

 

[Planktonmd]

read post number 13.

Yeah, I know that you are practicing in Alabama!

 

[militarymd]

Yeah, I know that you are practicing in Alabama!

you know...Joy and I read your posts together...or at least I show them to her.....she laughs....in an embarassed sort of way....to have trained you.

 

[Planktonmd]

you know...Joy and I read your posts together...or at least I show them to her.....she laughs....in an embarassed sort of way....to have trained you.

I have the same embarrassed feeling seeing your posts although I did not train you!
I feel embarrassed that a fellow anesthesiologist could be advocating the reckless and dangerous ideas you advocate on a forum that is intended for residents and students.

 

[Noyac]

you know...Joy and I read your posts together...or at least I show them to her.....she laughs....in an embarassed sort of way....to have trained you.

Uncalled for.

 

[militarymd]

Uncalled for.

the truth?

 

[Pilot Doc]

As someone else has reminded us a liter of LR contains only 4 mEq. Enough to raise the K+ from 4.0 to 4.04

It does have 4 mEq, but that's in 1L, or 4mEq/L. So it won't raise K above 4. For serum K>4, LR should lower potassium levels.

 

[Planktonmd]

the truth?

The truth is that you feel cornered and you have nothing meaningful to say.

 

[militarymd]

The truth is that you feel cornered and you have nothing meaningful to say.

 

[Planktonmd]

Exactly!
Nothing meaningful.

 

[PMPMD]

Anesth Analg 2005;100:1518-1524

A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation

Abstract

Normal saline (NS; 0.9% NaCl) is administered during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids. Recent evidence suggests that NS may be associated with adverse effects that are not seen with balanced-salt fluids, e.g., lactated Ringer’s solution (LR). We hypothesized that NS is detrimental to renal function in kidney transplant recipients. Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy. The primary outcome measure was creatinine concentration on postoperative Day 3. The study was terminated for safety reasons after interim analysis of data from 51 patients. Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants. Twenty-six patients received NS, and 25 patients received LR. There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P = 0.05). Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis (P = 0.004). NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS. LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.

 

[jacksparrow82]

You guys need to remember....I practice in Alabama......

anyways, I'm glad everyone is saying things that I agree with.

Patients are sodium restricted when on HD....so I personally use 1/2 or 1/4 NS for small cases....

I've never seen a patient on a potassium restricted diet.......so K intake doesn't appear to be an issue for ESRD.

A banana has 10 meq of K......

I had to correct this when I read it....K intake is a major issue for ESRD or anyone with renal insufficiency. Normal kidneys are remarkably good at getting rid of potassium and holding on to sodium. The reason for this is believed to be an adaptation to the way humans used to eat (lots of fruits and vegetables and none of the processed crap that we eat today). Fruits and vegetables are high in potassium and contain virtually no sodium. If your kidneys don't work properly they can't get rid of potassium effectively and its very easy for them to become hyperkalemic. The rule of 10 meq equals a .1 rise in K doesn't apply to patients with renal insufficiency for this reason. 10 meq of K in an ESRD patient could raise their potassium by a lot more than .1 (it of course varies from person to person).
For what its worth, I see a lot of ESRD patients in consultation post-operatively who were placed on LR peri-operatively (I work as a hospitalist). Very often we check repeat labs on them the same day and their potassium is sky high. One of them last week had to be emergently dialyzed. My advice to any surgeons or anesthesiologists reading this would be to consult Nephrology pre-operatively to manage your ESRD patients fluid needs. If they're not available use whatever fluids you want, but check labs immediately before and after surgery.

 

[fakin' the funk]

For what its worth, I see a lot of ESRD patients in consultation post-operatively who were placed on LR peri-operatively (I work as a hospitalist). Very often we check repeat labs on them the same day and their potassium is sky high. One of them last week had to be emergently dialyzed. My advice to any surgeons or anesthesiologists reading this would be to consult Nephrology pre-operatively to manage your ESRD patients fluid needs. If they're not available use whatever fluids you want, but check labs immediately before and after surgery.

I agree with you -- that any surgical case where an ESRD patient might get enough fluid (of any type), or have enough fluid shifts, to predispose or lead to hyperkalemia (or volume overload or any other AEIOU) should have frequent labs and frequent assessments of volume status etc.

I also agree that a preoperative plan with the pt's nephrologist as to the timing of preop dialysis, preop lab ordering, postop dialysis etc is prudent and appropriate. Risk stratification and preop optimization. Y'know, the stuff we like.

But the day I ask a nephrologist how to manage perioperative fluids is the same day I hand a laryngoscope to a hospitalist or call in a hematologist to help me decide which blood products to transfuse in a massive hemorrhage case. Oh, and I'll try to avoid hypoxia and hypotension too.

 

[deleted171991]

I had to correct this when I read it....K intake is a major issue for ESRD or anyone with renal insufficiency. Normal kidneys are remarkably good at getting rid of potassium and holding on to sodium. The reason for this is believed to be an adaptation to the way humans used to eat (lots of fruits and vegetables and none of the processed crap that we eat today). Fruits and vegetables are high in potassium and contain virtually no sodium. If your kidneys don't work properly they can't get rid of potassium effectively and its very easy for them to become hyperkalemic. The rule of 10 meq equals a .1 rise in K doesn't apply to patients with renal insufficiency for this reason. 10 meq of K in an ESRD patient could raise their potassium by a lot more than .1 (it of course varies from person to person).
For what its worth, I see a lot of ESRD patients in consultation post-operatively who were placed on LR peri-operatively (I work as a hospitalist). Very often we check repeat labs on them the same day and their potassium is sky high. One of them last week had to be emergently dialyzed. My advice to any surgeons or anesthesiologists reading this would be to consult Nephrology pre-operatively to manage your ESRD patients fluid needs. If they're not available use whatever fluids you want, but check labs immediately before and after surgery.

I find it royally stupid to blame LR for all periop hyperkalemia. It contains 4 mEq/L, while intracellular water contains 140. If an ESRD patient is severely hyperkalemic after surgery, that's a sign of cell destruction or acidosis, not of 1-2 liters of LR.

We are not idiots; we don't give liters and liters of potassium-containing fluids to dialysis patients. Nope, those are the surgeons. Heck, we try to give as little fluid as possible intraop, as in any fluid, even NS, and not only in ESRD patients. Why? Because it's been proven that conservative fluid management (i.e. treating hypotension with pressors not fluids), in the absence of blood loss (when it's a different story), is associated with improved outcomes.

 

[Triple AAA]

The way I learned it, 20 mEq of KCl IV will raise K levels by 0.5 mEq, and 40 mEq KCl IV will raise K levels by 1.0 mEq. LR has 4.0 mEq and is given over 8-10 hours in a floor or ICU. Now, I wouldn't bolus someone with ESRD repeatedly with LR, but I don't see the harm to using it as a maintenance infusion at that rate. Lately, more evidence has stacked up against 0.9, as it is a hypernatremic, hyperchloremic solution which can worsen acidosis. I've run into the problem of physicians who hate using LR on ESRD patients too, but honestly, it's an antiquated and outdated mentality for the most part.

 

[deleted171991]

Lately, more evidence has stacked up against 0.9, as it is a hypernatremic, hyperchloremic solution which can worsen acidosis.

NS does not just worsen acidosis, it causes acidosis by urinary loss of bicarbonate. Hyperchloremic metabolic acidosis is among the few situations when it actually makes sense to give a patient IV bicarbonate, even at a non life-threatening pH.

 

[SouthSideSteve]

My advice to any surgeons or anesthesiologists reading this would be to consult Nephrology pre-operatively to manage your ESRD patients fluid needs.

lol

 

[deleted171991]

yeah the kidney guy is wrong. the study i believe people are quoting is " a randomized, double blind comparison of LR and NS during renal transplant" Anesthesia and Analgesia 2005; 100: 1518-24.

As someone else has reminded us a liter of LR contains only 4 mEq. Enough to raise the K+ from 4.0 to 4.04

Our institution since the publication of that paper has switched to LR for our Kidney tranplants, during which we give 3-5 liters, and have not expierenced a hyperkalemic arrest and not all the kidneys work at first

This is a quote from a CCM-trained anesthesiologist.

 

[Planktonmd]

I miss my dear friend Military MD!

 

[seinfeld]

If you are giving a small volume of fluid (~250-500ml) it doesn't matter. in fact i use 1/2 NS for most AVFs , it keeps all the players "happy" and off my back. But if we are going to get into major blood loss 4-6 liters of NS will create a hyperchloremic acidosis and therefore push your K up. In those cases i am usually checking POC abg with lytes. I tend to use plasmalyte/isolyte/normosol, they don't contain calcium and therefore easily used along side of transfusions.

My biggest pet peeve in the ICU is a patient who was resuscitated with only (ab)normal saline (5-6 liters)and then have to fight the hyperchloremia, hypernatremia, the acidosis for 3-4 days. I don't understand how the medicine people, with all there focus on minutia, don't feel that any of these complications of care are true complications. In fact its well proven that hypernatremia is associated with worse mortality!!

 

[seinfeld]

Forgot about this study of recent note Critical Care Medicine2014, 42; 1585-91

Essentially in a retrospective study of ICU patients who received either NS or Balanced solution in sepsis the risk of mortality was higher in the NS group

 

[Mman]

For what its worth, I see a lot of ESRD patients in consultation post-operatively who were placed on LR peri-operatively (I work as a hospitalist). Very often we check repeat labs on them the same day and their potassium is sky high. One of them last week had to be emergently dialyzed. My advice to any surgeons or anesthesiologists reading this would be to consult Nephrology pre-operatively to manage your ESRD patients fluid needs. If they're not available use whatever fluids you want, but check labs immediately before and after surgery.

Yeah, I'm going to agree with my colleague's earlier reply to you and just say you are quite wrong.

A patient getting 500 mls of LR gets 2 mEqs of potassium administered to them. I can assure you that does not make their K "sky high" postoperatively. Even 3 liters of LR, which no ESRD patient is ever getting in the OR for any reason at all, would only give them 12 mEq of potassium (and to repeat, they aren't getting that much or even close).

What does make their potassium skyrocket after surgery is all the tissue damage that surgery causes. Repeatedly cutting into and tearing apart cells spills a LOT of potassium into their blood stream. That's why we get nervous about starting a surgery with an elevated potassium level, it's only going higher when the surgeon starts cutting.

 

[deleted171991]

Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.

The myth that LR should be avoided in hyperkalemia is not only incorrect, it is probably backwards. For a hyperkalemic patient in renal failure, LR should be preferred over NS. LR has been proven to produce lower potassium levels en vivo. Understanding the effect that a crystalloid will have on serum potassium concentrations involves considering effects on acid-base physiology and intracellular potassium shifts, which are more important than the amount of potassium in the plastic bag.

LR is not necessarily the best fluid for a patient with hyperkalemia. For a patient with hyperkalemia and metabolic acidosis, isotonic bicarbonate is probably superior to LR as it may cause a greater decrease in serum potassium (previously discussed here). Likewise, for a patient with metabolic acidosis, Plasmalyte or Normosol could be preferable to LR because these balanced crystalloids are more alkalinizing. However, LR is not contraindicated and it certainly remains preferable to NS.

Written by an academic IM intensivist. There!

 

[Random Anesthesiologist]

Had a nephrologist lecture that LR is better than NS for most surgical needs.

 

[cchoukal]

In fact its well proven that hypernatremia is associated with worse mortality!!

To say nothing about the effects of hyperchloremia... Both are bad. I use LR for everything in the OR, save for transfusions.

(you can now quote TWO board-certified intensivist-anesthesiologists)

 

[deleted162650]

I would go so far as to say that 1L of LR given to an anuric ESRD pt who has a K of > 4 will actually reduce the plasma K level. Think about this (albeit oversimplified) analogy: I have a bucket of fluid that contains 4mEq K/L. I then add 1L of fluid that also contains 4mEq of K/L. Now measure the the K again. What's it gonna be? Hint > 3.9 and < 4.1.

 

[WheezyBaby]

I would go so far as to say that 1L of LR given to an anuric ESRD pt who has a K of > 4 will actually reduce the plasma K level. Think about this (albeit oversimplified) analogy: I have a bucket of fluid that contains 4mEq K/L. I then add 1L of fluid that also contains 4mEq of K/L. Now measure the the K again. What's it gonna be? Hint > 3.9 and < 4.1.

Apologies for bumping an old thread, I've just been thinking about this. Do you have more or less equal rate of third spacing electrolytes with third spacing of fluids? I imagine so just thinking physiologically, in which case this logic would hold

 

[repititionition]

threads like this one go a long way towards bringing a guy who is deciding IM vs anesthesiology over the fence to your side.

Thanks, all.

(awaiting predictable "run away from this specialty" response from the usual posters)

 

[WheezyBaby]

threads like this one go a long way towards bringing a guy who is deciding IM vs anesthesiology over the fence to your side.

Thanks, all.

(awaiting predictable "run away from this specialty" response from the usual posters)

Was it plankton and milmed crapping on one another that did it? =)

 

[sigrhoillusion]

Wow... I almost mentally masturbated myself into a coma getting through this thread.

Honetly, when it comes to these short cases I tend to run NS only for the fact that we have 500cc bags readily available so I don't have to worry about resident/CRNA getting to involved in their Candy Crush game that they let a whole liter of fluid into these paitents in 30 minutes. That being said if no NS bags available I just grad whatever liter bag is available which is usually LR. And unless the patient is truly anuric ESRD and 3 days post dialysis or non-compliant 500-1000cc probably won't put them into fluid overload over 1-2 hours which is how long any typical case (at least in academia) lasts including pre-op and post-op management no manner how minor...

But in the anuric ESRD who may be a little "wet" I'd be more concerned about fluid overload than NS vs. LR. As someone else said, I tend to use LR in most cases cause that's what's there. I think the one person who mentioned the high levels of hyperkalemia due to LR needs to break down the actual cases. As another poster said, I think hyperkalemia is more likely due to acidosis than it is from the small amounts of K+. And I also wouldn't be surprised if perhaps succinylcholine had a slight impact. As we know although CKD patients react similarly to normal patients with about a 0.5 K bump, I'm not sure if more people tend to lean towards sux for intubating these patients due to risk of full stomachs, gastroparesis and variability of NMBDs in this population. If I just need relaxation for intubation and the K+ isn't really high I tend to give sux.

But as I tell residents in discussions like this, there really isn't a "right" answer. You have to take each patient individually. If the case is going to be super long, I'd probably stick with LR due to the hyperchloremic metabolic acidosis with lots of NS, but even that can be countered as long as you're aware of the possibility. Fact is, if there was a fluid that was proven to be better than another than it would be a standard of care to give it. Until the ASA posts something that says one is better than another it's really up to us to do what's best for the given situation. And again in the original case of a short procedure it probably doesn't matter. Just close your eyes and reach into your cart and pick whatever flid is stocked.

 

[deleted162650]

Was it plankton and milmed crapping on one another that did it? =)

If you enjoyed that then you really need to dig up the handful of threads that compose the great Plankton v Coprolalia feud that culminated in the vanquishing of Copro from SDN.

Ah those were the days . . .

 

[Planktonmd]

If you enjoyed that then you really need to dig up the handful of threads that compose the great Plankton v Coprolalia feud that culminated in the vanquishing of Copro from SDN.

Ah those were the days . . .

 

[drmwvr]

Wow... I almost mentally masturbated myself into a coma getting through this thread.

Honetly, when it comes to these short cases I tend to run NS only for the fact that we have 500cc bags readily available so I don't have to worry about resident/CRNA getting to involved in their Candy Crush game that they let a whole liter of fluid into these paitents in 30 minutes. That being said if no NS bags available I just grad whatever liter bag is available which is usually LR. And unless the patient is truly anuric ESRD and 3 days post dialysis or non-compliant 500-1000cc probably won't put them into fluid overload over 1-2 hours which is how long any typical case (at least in academia) lasts including pre-op and post-op management no manner how minor....

Why do they hang any fluid at all? They have the arm right in front of them. Just giving the sedation right at the IV catheter is simple enough.

 

[deleted171991]

Why do they hang any fluid at all? They have the arm right in front of them. Just giving the sedation right at the IV catheter is simple enough.

Carrier fluid. Propofol IV infiltration is not nice.

 

[drmwvr]

Carrier fluid. Propofol IV infiltration is not nice.

Jack the Ripper putting in the iv's? It's sitting right there the whole case...pretty hard to miss...to each his own.