fluid management - some questiona

[sugababe81]

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I have some questions in regards to fluid management..

- why do you bolus with only LR and NS, and not 1/2 NS, for example?
- postop patients - do you generally put them on LR for the first day or so? why not maintenance right away?
- do you guys give albumin to your postop patients to help increase intra-vasc volume? why not (if you dont)?
- how do you know when to change from LR to maintenance?

 

[tussy]

Why don't you open your surgery text to the chapter on fluids and read it.

 

[RichL025]

What Tussy suggested is a good idea, but the fact is, many aspects of fluid management are traditional, and not evidence-based.

The answers to your questions #1 and (to a lesser extent) #3 ARE found in your textbooks, however.

 

[Winged Scapula]

Much of it, as noted above, is "voodoo" medicine, bound by the tradition of the attending. Some of it is bound by cost (Albumin is extremely expensive and we would get nailed by the ICU attendings every time we ordered it).

You will develop your own patterns based on what the practice is at your institution. God willing, you might even find some reason to choose one patterm over another and advance medical knowledge and practice over the use of hide-bound tradition as a reason for why we do things.

 

[Dr JPH]

What Tussy suggested is a good idea, but the fact is, many aspects of fluid management are traditional, and not evidence-based.

Do what the attending tells you to do!

Most of what I have seen (albeit in my limited experience) is attendings seem to go with whatever they learned in their residency or with the hospital norm.

Some centers use LR more often, some NSS.

 

[surgdo]

My surgery books are already packed up for the move, but I wonder if this research has made it into the books yet? The debate is ongoing, but essentially comes down to a handful of well-designed RCTs that did not show a difference between albumin vs crystalloid therapy in critically ill SICU patients. And, as Dr. Cox pointed out, it's incredibly expensive.

As a med student I rotated in the SICU at two trauma centers in the same city. One program loved Albumin and the other program hated it. I think medicine folks use albumin more consistently in the MICU than do surgeons. I was also amazed at how different similar patients were managed and still had similar outcomes. I guess the voodoo is the art of medicine that everyone talks about.

 

[LuckyMD2b]

Why don't you open your surgery text to the chapter on fluids and read it.

That's exactly what I was thinking.

NEways... here are my thoughts... 1.5 months pre-internship -- I wonder how wrong i am.

1) LR and NS are resusitative fluids... (iso-osmotic) you're bolusing to replace fluids that the patient theoretically has lost. 1/2NS is maintenance fluid (hypo-osmotic) -- you give over time at a rate (x mL/hr)

2) I know that in the OR patients are usually getting LR, but post-op I think they are started on maintenance (D5 1/2NS) until they are taking POs.

3) I don't think anyone gives albumin to your run of the mill post-op patient to increase intravascular volume 4 the following reasons: 1) its hells a expensive; 2) I don't think that there is any evidence that it works -- from my recollection of its use on liver failure patients during my medicine rotation; 3) if your patients are well nourished pre-op (ideally the will be) then their albumin will be in the normal range and there wouldn't be much benefit from giving them more.

4) I don't know when to change from LR to maintenance... I think you're supposed to have some idea of how volume depleted the patient is... if they are -2L, then you give 2L of LR over a short period of time, then start on maintenance. I think most people just keep bolusing 500mL or 1L and see how the patient responds -- it's either not enough (then you bolus again), it's just right (and you're done), or you overshot (and you sent that nice old lady into heart failure) --> way to go doc.

 

[madtowngirl]

On my last rotation month as MS4, one of the things my attendings made me look up was the price of albumin vs. NS. Maybe this is just unique to the place I was rotating, but the two were pretty much equivalent in price. Which floored me, because I always thought that albumin was much more expensive than NS, as many people on this thread have said.

 

[Winged Scapula]

Not sure what you were looking at:

http://www.med.umich.edu/pediatrics/ebm/cats/albumin2.htm

"The cost of albumin is approximately twenty times higher than normal saline."

yeah, that's what I was taught - Albumin about $500 per bag, NS about $20.

 

[2ndyear]

Hespan is about $60/500 mL, 1 L of LR or NS is about $12.

 

[Winged Scapula]

Hespan is about $60/500 mL, 1 L of LR or NS is about $12.

Hey - its a bargain here: http://www.capsulenet.com/info.aspx?t=2

only $20.25 per 500 ml of Hespan. Of course, its "doggie grade".😀

At any rate, several of my attendings wouldn't allow us to use Hespan for fear that it would decrease PLT count and cause bleeding. Ordered it once, on the "advice" of a SICU nurse and got yelled at for it. Fortunately, the RN told the attending it was his idea and not mine.

 

[dynx]

Hey - its a bargain here: http://www.capsulenet.com/info.aspx?t=2

only $20.25 per 500 ml of Hespan. Of course, its "doggie grade".😀

At any rate, several of my attendings wouldn't allow us to use Hespan for fear that it would decrease PLT count and cause bleeding. Ordered it once, on the "advice" of a SICU nurse and got yelled at for it. Fortunately, the RN told the attending it was his idea and not mine.

Yeah i hear that crap all the time where I'm at, then I do an AI and they are using it for septic shock and TBI which there is actually pretty good evidence for. Really brings to light the disadvantages of being in-bred.

 

[Winged Scapula]

Yeah i hear that crap all the time where I'm at, then I do an AI and they are using it for septic shock and TBI which there is actually pretty good evidence for. Really brings to light the disadvantages of being in-bred.

Exactly. If there's any advantage at all to doing an AI or away rotation, its that you can see the "Hospital X" way is not the only way and in many cases may be the wrong way. Doing med school, residency and fellowship at 3 different (make that 6 if you count away rotations during residency and fellowship), really goes to show you how much of medicine is dogma/voodoo.

 

[Winged Scapula]

Yeah, it teaches you a lot, but half the time you look like a tool, especially when you come from from a place with reasonably good EBM practices, then end up in voodoo-land.

I was on one rotation where we had a toddler with a suspected UTI. My plan was to cath. I endured a 5 minute bitch-fest from MDs and nurses alike about how "traumatic" cathing a child was, and why did I want to do such a horrible thing when putting on a bag was "just as good"?

*****s.

How DARE you actually even consider touching the baby. Didn't you know that's off limits for students and residents?!

Besides, there's good touching and bad touching. Catheter is bad touching!

 

[dynx]

Oh no, I'm not one of these wimpy health care workers who thinks that the baby will break in half and need a lifetime of therapy just because I made it cry. I'll suture their faces, catheterize them, and sometimes poke needles in 'em just to show them I'm boss.

that reminds me of a peds nurse. Kids in respiratory failure...we need an ABG. She won't do it...reason...kids had to many sticks allready. Bottom line is the ABG is gonna get done, you know how to do it better than us, we'll stab the kid 39 times, you can probably get it in 1, you decide. F ing nurses.

 

[Winged Scapula]

that reminds me of a peds nurse. Kids in respiratory failure...we need an ABG. She won't do it...reason...kids had to many sticks allready. Bottom line is the ABG is gonna get done, you know how to do it better than us, we'll stab the kid 39 times, you can probably get it in 1, you decide. F ing nurses.

Interesting...when I was on Peds Surgery I NEVER had to worry about putting a line in, taking blood etc. The nurses was so protective that all central lines were started by the Peds Intensivist Attending, all peripheral IVs, blood draws, ABGs, etc. were done by the Peds nurses. They knew what your nurse didn't - if the kid needs the line, the test, etc. they were MUCH better at getting access than we were.

 

[Winged Scapula]

Oh no, I'm not one of these wimpy health care workers who thinks that the baby will break in half and need a lifetime of therapy just because I made it cry. I'll suture their faces, catheterize them, and sometimes poke needles in 'em just to show them I'm boss.

You'll give 'em somethin to cry about!! Little cry-babies.

 

[irie]

You might run this question by the anesthesiology forum. They're fluid fanatics over there!