? for Jet re: myths perpetuated in academia

[Jeff05]

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neither cvp or wedge pressure should be used to measure right or left ventricular preload/fluid status/changes in fluid status (please refer to recent review by Leibowitz, et al.). putting in a central line to measure CVP is has little clinical utility.

there is no indication for using albumin for fluid resuscitation. this has been studied ad nauseum.

the best evidence we currently have suggests that transfusion is of benefit starting at hb of 7, or 10 in patients with active ischemic dz. i would make an exception if pt is clearly hypotensive, has large volume acute blood loss and is unable to compensate or has low MvO2.

research suggests that infections s/p bowel cases may be decreased by running a higher fio2 (ie 0.8). i do this routinely.

but, then again, who TF knows...

 

[militarymd]

neither cvp or wedge pressure should be used to measure right or left ventricular preload/fluid status/changes in fluid status (please refer to recent review by Leibowitz, et al.). putting in a central line to measure CVP is has little clinical utility.

there is no indication for using albumin for fluid resuscitation. this has been studied ad nauseum.

the best evidence we currently have suggests that transfusion is of benefit starting at hb of 7, or 10 in patients with active ischemic dz. i would make an exception if pt is clearly hypotensive, has large volume acute blood loss and is unable to compensate or has low MvO2.

research suggests that infections s/p bowel cases may be decreased by running a higher fio2 (ie 0.8). i do this routinely.

but, then again, who TF knows...

100% agree with that statement...but it is ironic that the lack of usefulness of albumin is the result of data accummulated by ACADEMIA, however, its continued MISUSE is the result of myths that are perpetuated by ACADEMIA.

 

[VentdependenT]

SO yall never use colloids? I do NOT want to get into this in any sort of depth.

I don't find that a CVP is all that useful but as a rough guide its nice to have for long cases with potential large fluid shifts. I said it damn it. Plus our surgeons always wanna know what the cvp is so they can follow some number in the unit.

 

[militarymd]

SO yall never use colloids? I do NOT want to get into this in any sort of depth.

I don't find that a CVP is all that useful but as a rough guide its nice to have for long cases with potential large fluid shifts. I said it damn it. Plus our surgeons always wanna know what the cvp is so they can follow some number in the unit.

I personally NEVER use albumin, starches, etc.

However, I use PRBCs, FFP, cryo, platelets, when they are indicated, and I think they are considered colloids.

 

[Planktonmd]

SO yall never use colloids? I do NOT want to get into this in any sort of depth.

I don't find that a CVP is all that useful but as a rough guide its nice to have for long cases with potential large fluid shifts. I said it damn it. Plus our surgeons always wanna know what the cvp is so they can follow some number in the unit.

I use Albumin for patients with advanced liver disease and ascitis and for people with a nephrotic syndrome.
I like CVP and use it often, I think it is helpful as long as you understand it's limitations, like everything else we use.

 

[militarymd]

I use Albumin for patients with advanced liver disease and ascitis and for people with a nephrotic syndrome.
I like CVP and use it often, I think it is helpful as long as you understand it's limitations, like everything else we use.

The Barcelona group from Spain has a series of publications in the gastroenterology journals in the 90's that specfically addressed the use of albumin (25%) vs NS in its use during large volume paracentesis (5 liters) in its efficacy in preventing hypotension, rise in creatinine, etc....

essentially no difference in the endpoints studied...and believe the Am Col of Gastro does not advocate use of albumin over NS....having said that, there are a couple of GI docs who I respect who will use Albumin but freely admit that there is no evidence to support its use.


Nephrotic syndrome....I don't know the data, but I suspect it's the same as cirrhotic syndrome.

 

[coprolalia]

I think there is general agreement out there that there is little (if any) evidence that albumin should be given as a treatment in an attempt to mitigate protein loss, however it occurs. I've never heard any practitioner across the multitude of disciplines we, as anesthesiologists, interact with who would state that. Having said that, there are still those that do it.

-copro

 

[urge]

neither cvp or wedge pressure should be used to measure right or left ventricular preload/fluid status/changes in fluid status (please refer to recent review by Leibowitz, et al.). putting in a central line to measure CVP is has little clinical utility.

Could you post references?

I bet there are about 5 million articles saying they are useful. 1 vs 5 million. Take your pick.

 

[DrDre']

I prefer using systolic pressure variation (SPV) to CVP for determining volume responsiveness. The literature supports SPV as being better, from my reading.

I use CVP as a trend.

 

[Planktonmd]

The Barcelona group from Spain has a series of publications in the gastroenterology journals in the 90's that specfically addressed the use of albumin (25%) vs NS in its use during large volume paracentesis (5 liters) in its efficacy in preventing hypotension, rise in creatinine, etc....

essentially no difference in the endpoints studied...and believe the Am Col of Gastro does not advocate use of albumin over NS....having said that, there are a couple of GI docs who I respect who will use Albumin but freely admit that there is no evidence to support its use.


Nephrotic syndrome....I don't know the data, but I suspect it's the same as cirrhotic syndrome.

Yes,
There is really no strong evidence but it still makes sence (anecdotally) to give albumin in a situation where albumin deficiency is part of the problem.

 

[Idiopathic]

of the top of my head, ARDS net showed improvement in ARDS patients who were hypoalbuminemic who were treated with push-pull (albumin and lasix), but thats a pretty specific indication. Usually albumin does not help correct hypoalbuminemia

as for the rest, obviously limiting intraoperative fluid load is a huge point of discussion and is improving outcomes. With that said, to say that there are no indications for colloid is pretty shortsighted. I agree SAFE pretty much said it doesnt matter, but Id like to see more.

Obviously 10 cc/kg/hr is falling out of favor.

 

[Jeff05]

Pulmonary Artery Catheter in Anesthesia Practice in 2007: An Historical Overview With Emphasis on the Past 6 Years

Andrew B. Leibowitz, MD
Departments of Anesthesiology and Surgery, Mount Sinai School of Medicine, New York, New York

John M. Oropello, MD

Departments of Anesthesiology and Surgery, Mount Sinai School of Medicine, New York, New York, andrew [email protected]

The pulmonary artery catheter has been widely used in anesthesiology and critical care medicine. Until recently, only retrospective or relatively weak prospective studies examining its effect on outcome had been performed. Over the past 6 years, however, a number of well-designed prospective trials and statistically sound retrospective studies have been completed. All of these show no benefit and some even reveal a potential for increased morbidity. Reasons for this device's inability to improve outcome are numerous, including wrong patient selection and misinterpretation, but the most impressive and convincing evidence is that filling pressures measured from the catheter, particularly the pulmonary artery "wedge" pressure, have no physiologic value. The wedge pressure has been shown to not correlate with other accepted methods of determining left ventricular filling or volume or intravascular volume and also does not help to generate cardiac function curves. Therefore, knowledge of it may actually lead to incorrect management more frequently than not.
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Data on CVP is similar and should be included in the review. I must caution those who use CVP to follow fluid "trends" in long cases - the CVP does NOT reflect intravascular volume or right ventricular preload.

if you would like to place a monitor that the surgeons can follow in the unit just strap on a BIS, it's less invasive - it will likely give you more accurate information about right ventricular filling pressures than CVP measurement.

The only reasons to use PAC is to 1. get "true" MvO2 2. measure PAP (3. measure CO, but not the most reliable). Otherwise, it has been PROVEN to be of little use.

Still, PAC measurements and CVP continue to be used routinely, even in large academic centers, because practice habits are hard to break.

A recent study suggests that TTE is may be employed with high sensitivity by novice operators to determine intracardiac volumes and EF. I believe echo is the wave of the future, not only for cardiac anesthesiologists, but for all of us.

Until then, SVV/LitCO technologies seem promising.

 

[militarymd]

of the top of my head, ARDS net showed improvement in ARDS patients who were hypoalbuminemic who were treated with push-pull (albumin and lasix), but thats a pretty specific indication. Usually albumin does not help correct hypoalbuminemia

as for the rest, obviously limiting intraoperative fluid load is a huge point of discussion and is improving outcomes. With that said, to say that there are no indications for colloid is pretty shortsighted. I agree SAFE pretty much said it doesnt matter, but Id like to see more.

Obviously 10 cc/kg/hr is falling out of favor.

I see.....data shows no indications...but reporting what the data shows is "shortsighted"....

Interesting perspective....One day...I'll see the light beyond the data.

 

[Idiopathic]

i never said data shows no indications. I said that SAFE argues it doesnt matter which you use.

and isnt fluid replacement a valid reason? cant you electively choose to give albumin/hespan versus saline? i dont think anyone has shown that albumin is worse (except in brain injury)

 

[militarymd]

i never said data shows no indications. I said that SAFE argues it doesnt matter which you use.

and isnt fluid replacement a valid reason? cant you electively choose to give albumin/hespan versus saline? i dont think anyone has shown that albumin is worse (except in brain injury)

$$$$$$$$$$$$$$$$$

 

[VentdependenT]

Ahhh....the old fluid debate.

If it works and your patient does ok, then fine.

 

[fakin' the funk]

$$$$$$$$$$$$$$$$$

Clinicians, help me out here...

How much does a liter of crystalloid cost? I think it's something like $20, right?

And how much does a liter of starch colloid cost? $50?

[I have no idea how much albumin is]

So considering that you're using 1.5x-2x the amount of crystalloid as starch colloid, aren't these basically the same? Aren't we talking a difference of $10-100 for most cases? Couldn't you save more money by using less of the disposable stuff that gets tossed at the end of the case?

 

[DrDre']

Money is important but more importantly, what leads to better outcomes should be our goal as physicians.

Clinicians, help me out here...

How much does a liter of crystalloid cost? I think it's something like $20, right?

And how much does a liter of starch colloid cost? $50?

[I have no idea how much albumin is]

So considering that you're using 1.5x-2x the amount of crystalloid as starch colloid, aren't these basically the same? Aren't we talking a difference of $10-100 for most cases? Couldn't you save more money by using less of the disposable stuff that gets tossed at the end of the case?

 

[coprolalia]

Clinicians, help me out here...

How much does a liter of crystalloid cost? I think it's something like $20, right?

And how much does a liter of starch colloid cost? $50?

[I have no idea how much albumin is]

So considering that you're using 1.5x-2x the amount of crystalloid as starch colloid, aren't these basically the same? Aren't we talking a difference of $10-100 for most cases? Couldn't you save more money by using less of the disposable stuff that gets tossed at the end of the case?

Crystalloid is dirt cheap, my man. Not nearly $20/liter. Probably more along the lines of $1/liter. And, Hespan/Hextend (hetastarch 6%) is cheap too. Albumin is the expensive stuff.

This has been studied extensively...

http://content.karger.com/ProdukteDB/produkte.asp?Doi=50227

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1480134

And, bottomlining it, this one...

Results. No statistically significantly differences in mortality rates were found. The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal solutions is $1493.60.

http://findarticles.com/p/articles/mi_m0689/is_n4_v32/ai_10678512

-copro

 

[SouthSideSteve]

Clinicians, help me out here...

How much does a liter of crystalloid cost? I think it's something like $20, right?

And how much does a liter of starch colloid cost? $50?

According to Marino (fastest and easiest numbers I could find) 1000ml of 0.9% NS or LR is about 1.46 and 250ml of 5% Albumin is 30.63 (a bag of hespan is 27.63). Not sure how reliable these figures our but im sure the difference is quite vast between the two.


Once again I'll have to agree with venty. Theres more than 1 way to skin a cat.

edit: i see im just a minute too slow.

 

[lushmd]

In any case, I doubt that a liter of crystalloid costs anywhere near $20...

 

[proman]

We do most Whipples with 2 good IVs and an a-line. If the patient needs TPN the TPN service wants a fresh line that nothing has touched. Some use 2% hypertonic saline (peripheral) or 3% (central). I've tried it but don't find it reduces how much crystalloid I give. Same with Hextend. My program is very anti-albumin and anti-CVP as a measure of intravascular volume. I wouldn't even know where to find a bottle of it.

 

[urge]

Results. No statistically significantly differences in mortality rates were found. The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal solutions is $1493.60.

Ask you average pt if they want to croak the cheap way or rather do it with some style. This is America...

 

[urge]

If the patient needs TPN the TPN service wants a fresh line that nothing has touched.

Must be a hell of a hospital if the TPN service can make such demands.

 

[dhb]

prices at my hospital:
cristalloid 3$
colloid HES 12$ gelatin 6$
albumin not sure but i think it's around 50$
blood 300$

 

[numbmd]

prices at my hospital:
cristalloid 3$
colloid HES 12$ gelatin 6$
albumin not sure but i think it's around 50$
blood 300$

You forgot "Working with an incompetent surgeon - Priceless"

 

[OldManDave]

This sounds kind of corny but on my first crash section it was an enormous rush to throw the tube and holler "cut" to the OB. There must of been twenty people in the damn room.

Arch,

I can certainly relate! I had 5 or 6 true crash c-section during my residency; however, the MOST memorable one occured at the very beginning - like the first month - of my CA-3 year. My staff was tied up with an emergent cranie & she asked me to staff a CA-2 for simple c/s under spinal until she could get free. As I walked onto the OB floor, the OB staff grabbed me & said, "We have a problem!" Of course, I asked "what?"

Long story made short - 30wk gestation hit the OB ward from the ED about 30 min ago. She had just been admitted after having been in a MVC where she was ejected -amazing that she was not all f-ed up! Her baby was having deep, sustained d-cels & they needed to crash her. I sent an RN to tell my junior to bag the lady in BPOR1 & move his ass quickly to BPOR2 & set up for a crash. I met the lady - in a c-collar vomiting over the side of the gurney - & did my very basic pre-op as we walked to the OR. I had asked another RN to call the OR to alert my staff - she was tied up with the cranie who was actively trying to die - her message to me...she wished me luck!

You could have made a diamond from a lump of coal in my rectum!!! We got her in, positioned her, I went through the drill of preparing her for what was coming (including some brief "interoperative awareness" stuff) & as soon as the OB waltzed in from washing hands - we induced & tubed her. OB cut immediately upon my OK & the baby was out FAST & then whisked off to the NICU.

I have NEVER been so glad to see a solid EtCO2 tracing in all of my life! My staff showed up a few minutes after the induction, just as the baby came out. She was very impressed...me, I just had freaking ANGINA! LOL!!!

All did well. Mom was d/c'd in a couple of days - c-spine cleared. And the baby went home within a week or two.

 

[OldManDave]

I personally NEVER use albumin, starches, etc.

However, I use PRBCs, FFP, cryo, platelets, when they are indicated, and I think they are considered colloids.

Yes, those are considered colloids.

The only non-native colloid I use is hetastarch & that is purely to temporize the situation until I can get caught up volume-wise. There are a couple of surgeons who do not fully grasp the concept of "hemostasis" & I will pre-emptively use Hespan if they are doing one of their particularly bloody cases. Otherwise, I generally use crystalloids unless I hear that ominous sound of the full & busy sucker draining blood "unexpectedly". The Hespan is a nice accompaniment to pressor/s, if needed.

 

[urge]

In my experience the use of Hespan is highly related to receiving a blood transfusion. I think this is related more to coagulopathy than to dilution since I haven't noticed this with the use of albumin. I stay away from that stuff.

 

[joshmir]

if the pt is a little dry, and yet the operation calls for fluid restriction (pneumonectomy, whipple, gastric band) do you guys then consider colloid?

 

[militarymd]

if the pt is a little dry, and yet the operation calls for fluid restriction (pneumonectomy, whipple, gastric band) do you guys then consider colloid?

I don't...except for prbc, ffp, cryo , etc. when they are indicated.

 

[Planktonmd]

In my experience the use of Hespan is highly related to receiving a blood transfusion. I think this is related more to coagulopathy than to dilution since I haven't noticed this with the use of albumin. I stay away from that stuff.

I heard that Pentaspan (low molecular weight starch) is coming to this country finally (popular in Canada) and it has less issues with coagulation and a better profile overall.

 

[militarymd]

I heard that Pentaspan (low molecular weight starch) is coming to this country finally (popular in Canada) and it has less issues with coagulation and a better profile overall.

Pentaspan is commerically available already, but only approved for platelet or some kind of pheresis, i can't remember which.

and yes, it does not cause bleeding like the higher weight starches....it also has other properties that make it desirable to use in inflamed patients.