Normal Saline

Started by Psai
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Raryn said:
Of course, if you ask Marik we're committing "iatrogenic salt-water drowning". But under-resuscitation is a much worse crime than over-resuscitation IMO, and if you're paying attention to the fluid responsiveness of your patient, continuing the fluids is almost certainly more helpful than not.
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How are you, personally, assessing fluid responsiveness? I'm always interested to see individuals' preferences.
 
Psai said:
There's all this bs out there but basically it's by blood pressure. Anyone who tells you about pulse pressure variation or cvp is full of ****.
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CVP is bull**** at this point. I agree in keeping an eye on blood pressure improvement after a fluid challenge, though you can also try a passive leg raise (really only useful if they have an art line). Or (if you have some experience doing it) ultrasound evaluation of the IVC.
 
Raryn said:
The surviving sepsis guidelines, maligned as they are, are quite clear: You start resuscitation on a patient with a 30cc/kg bolus.

Patient weighs 100kg and is getting admitted for sepsis? You start with three liters. Not 500cc. Not one liter. Three liters. Obviously bad CHF and ESRD are exceptions, but otherwise, don't pussyfoot around. There's lots of conditions other than sepsis where that applies as well. DKAers often need 6+ liters to get close to hydrated (though if you slam it all in at once in a young patient you risk cerebral edema, better to space out a bit). Pancreatitis patients also commonly need that much or more with how much they're third-spacing due to the acute inflammation.

Of course, if you ask Marik we're committing "iatrogenic salt-water drowning". But under-resuscitation is a much worse crime than over-resuscitation IMO, and if you're paying attention to the fluid responsiveness of your patient, continuing the fluids is almost certainly more helpful than not.
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I wasn't specifically talking about sepsis (more like general dehydration, mostly in the post-op patient). I get 30cc/kg in that fresh ED patient, but I saw a case of CPM in a patient who developed sepsis while in the hospital, and when it transitioned to shock, MICU slammed them with 6-10L of NS (in somebody who was already in MICU for a few days prior to that for something else) who then had surgery for dead bowel, then ended up with CPM. I'd be hesitant to do 30cc/kg in a patient who is developing a secondary sepsis in the hospital, who has likely been on 125cc/hr NS for the majority of their hospital stay.
 
Raryn said:
The surviving sepsis guidelines, maligned as they are, are quite clear: You start resuscitation on a patient with a 30cc/kg bolus.

Patient weighs 100kg and is getting admitted for sepsis? You start with three liters. Not 500cc. Not one liter. Three liters. Obviously bad CHF and ESRD are exceptions, but otherwise, don't pussyfoot around. There's lots of conditions other than sepsis where that applies as well. DKAers often need 6+ liters to get close to hydrated (though if you slam it all in at once in a young patient you risk cerebral edema, better to space out a bit). Pancreatitis patients also commonly need that much or more with how much they're third-spacing due to the acute inflammation.

Of course, if you ask Marik we're committing "iatrogenic salt-water drowning". But under-resuscitation is a much worse crime than over-resuscitation IMO, and if you're paying attention to the fluid responsiveness of your patient, continuing the fluids is almost certainly more helpful than not.
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I still think a little bit before I slam 6 liters in the 200 kg septic patient.
 
I think what it really comes down to is cost combined with the rather poor studies out there in the issue that claim equivalence. To many attendings I've worked with in the past, "NS is cheaper and works equally as well as LR." I'm not saying that's right or wrong, because quite frankly I don't think the data is clear, but it always seemed counterintuitive that NS would be equivalent to LR.
 
TooMuchResearch said:
I still think a little bit before I slam 6 liters in the 200 kg septic patient.
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True enough. I also don't start my 200kg patients out at a dose of 300mcg/day levothyroxine. Most of these /kg recommendations fall apart when your BMI is 60.

Mad Jack said:
I think what it really comes down to is cost combined with the rather poor studies out there in the issue that claim equivalence. To many attendings I've worked with in the past, "NS is cheaper and works equally as well as LR." I'm not saying that's right or wrong, because quite frankly I don't think the data is clear, but it always seemed counterintuitive that NS would be equivalent to LR.
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To be honest, I believe it. The human kidney is a powerful thing.
 
Ismet said:
I have another question: why do surgeons put kids on 1/2 NS or 1/4 NS? What do they think they're fixing/doing?
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This is a longstanding issue in peds. The original Holliday-Segar paper in 1957, which defined pediatric maintenance fluids for decades, recommended 3 mEq of sodium per 100 kcal/day, but also established the 4:2:1 rule for pediatric maintenance. So a 10 kg child would need 40 mL/hr -> 960 mL/day of fluid but 100 kcal/kg -> 1000 kcal/day formula -> 30 mEq of sodium/day. So 31 mEq of sodium per liter, or approximately half normal saline.

The practical upshot of this is that everyone has been trained to use 1/4 NS for maintenance fluids in infants and 1/2 NS for maintenance fluids in children (you still bolus with isotonic, of course) The only problem: it doesn't actually work. Trial after trial has shown not only no benefit, but a real risk of hyponatremia with serious complications. A 2014 Cochrane review has started actually shifting some practice patterns.

It was one of the PedsRAP topics this month, actually.
 
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SurfingDoctor said:
Paying attention to response is key... but the protocol driven fluid resuscitation in sepsis is not without some consequences...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269557/
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Right, but the whole purpose of EGDT was to start resuscitating the patients (and to sell fancy proprietary equipment).

Septic shock has a high mortality rate, much higher if untreated. Let's not give early trainees the impression they should under resuscitate to avoid killing a few who would have otherwise died if not resuscitated.
 
Raryn said:
True enough. I also don't start my 200kg patients out at a dose of 300mcg/day levothyroxine. Most of these /kg recommendations fall apart when your BMI is 60.


To be honest, I believe it. The human kidney is a powerful thing.
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I will give a 200 kg patient in septic shock 6 liters, I just think a bit more about it. Their "third space" should be big enough to take it...I hope.
 
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