Ordering IV fluids in the ER

[VA Hopeful Dr]

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And the "cost" of saline to the hospital is approximately a dollar a liter. Add in the nursing time to administer it and all, but the only people actually being charged $200+ with an expectation to pay it are the uninsured. Every single insurance company has bundled payments and while they may get a bill for $X00 for a saline infusion, they aren't paying anywhere close to that. So yes, for a patient who isn't uninsured, the cost of fluid administration is bupkis. And yes, the uninsured get boned. Welcome to America.

As with so many hospital-based things, this pisses me off. Saline has gotten a little pricier of late (a liter runs me about $5), IV supplies another $15-20 if we're being generous, and a nurse is $30/hour. So worst case this actually costs at most $50. But yeah, it will get billed for several hundred.

 

[Taddy Mason]

As with so many hospital-based things, this pisses me off. Saline has gotten a little pricier of late (a liter runs me about $5), IV supplies another $15-20 if we're being generous, and a nurse is $30/hour. So worst case this actually costs at most $50. But yeah, it will get billed for several hundred.

This made me curious so I just checked with my wife who happened to be working on an infusion claim out of CA. The overall cost for an infusion of 1L of NS with everything factored in (tubing, nursing/administration time, etc.) was billed for ~$1000, but if you looked at a breakdown of the individual components of the infusion, the NS alone was billed at $120. Though only a fraction of what was billed for will actually be reimbursed to the facility/provider. Regardless $120 just for 1L of NS😵

 

[cbrons]

Please forward your concerns on to CMS and the surviving sepsis guidelines as they mandate 30cc/kg bolus regardless of pre existing conditions.

Whatever. I don't think we are sayings different things. But keep on keepin on

Ss guidelines are bad. Majority of patients with sepsis are not volume responsive, and in the ones who are the duration of the hemodynamic effect is very short lived, and most ends up going straight into the interstitium causing profound tissue edema. Its essentially iatrogenic salt water drowning, as Dr. Paul Marik calls it.

Sent from my SM-N910P using SDN mobile

 

[cbrons]

1. It is tremendously overused, and it does risk iatrogenic injury. But in what context? That's the point I was making about "the real world" and the original post being a "subtle troll." Marik is an intensivist; intensivists clean up the mess from fluid resuscitation. And he and other intensivists have made a strong case that we're simply pushing fluids too hard, mostly in response to Guideline Driven Medicine (like EGDT).

We've all been on the wet-versus-dry-in-sepsis merry-go-round since forever, but the more we learn about the microcirculation, the more we develop longitudinal datasets for fluid resuscitation, and the more we appreciate the dangers of supra-physiological doses of chloride, the more the evidence seems to fall on the side of neither wet nor dry but too damn much (FEAST, ARISE, PROCESS, etc.). Given the data on chloride, I'm starting to think too damn much in general. There's surely a meaningful number-needed-to-harm here, and it probably doesn't exceed the number-needed-to-treat for some yet-unappreciated low-risk patient subgroups.

But Marik is also hilariously opinionated. That's why @cbrons' post was so funny to me. Because there's no way NS kills more than it saves--generally speaking (but again, in what context).

Check this podcast out: http://intensivecarenetwork.com/myburgh-fluids-2015/

 

[lymphocyte]

Check this podcast out: http://intensivecarenetwork.com/myburgh-fluids-2015/

1. Great talk. Have you been following Marik and friends' rants on lactate? http://emcrit.org/wee/lactate-clearance-flawed/
2. For preclinicals reading this, I urge you to read into the (IMHO) travesty that was the Rivers' paper, the paper that launched a thousand EGDT bundles across the country. (Respectful) skepticism is good.
3. Generally speaking, nonsense like CVP, lactate clearance, permissive oxygenation... this is what happens when medicine gets routinised and politicised (Who doesn't support the concept of Surviving Sepsis? Hospital administrators love that kind of stuff. And it takes forever to implement or change a bundle. So much for clinical judgement in the face of new evidence...).

 

[Raryn]

1. Great talk. Have you been following Marik and friends' rants on lactate? http://emcrit.org/wee/lactate-clearance-flawed/
2. For preclinicals reading this, I urge you to read into the (IMHO) travesty that was the Rivers' paper, the paper that launched a thousand EGDT bundles across the country. (Respectful) skepticism is good.
3. Generally speaking, nonsense like CVP, lactate clearance, permissive oxygenation... this is what happens when medicine gets routinised and politicised (Who doesn't support the concept of Surviving Sepsis? Hospital administrators love that kind of stuff. And it takes forever to implement or change a bundle. So much for clinical judgement in the face of new evidence...).

Not all of Rivers conclusions were absolutely valid, but by launching an effort to standardize treatment of sepsis, that paper certainly saved untold numbers of lives. The standard of care that is tested against EGDT in the last few years in the trials like PROCESS is worlds apart from the standard of care in 2001, when patients were routinely grossly under-resuscitated and everyone was approaching patients via strategies that they pulled out of their you-know-whats.

Could the pendulum have swung too far the other direction? Sure. But to call the entire efforts to improve sepsis care over the last 15 years a travesty is to do a true disservice. The standard of care has evolved, and many of the individual components of the EGDT bundle may not be worth it as we break apart the studies, but you will never turn the clock back to what was going on before (because that would be killing patients).

 

[lymphocyte]

Not all of Rivers conclusions were absolutely valid, but by launching an effort to standardize treatment of sepsis, that paper certainly saved untold numbers of lives. The standard of care that is tested against EGDT in the last few years in the trials like PROCESS is worlds apart from the standard of care in 2001, when patients were routinely grossly under-resuscitated and everyone was approaching patients via strategies that they pulled out of their you-know-whats.

Could the pendulum have swung too far the other direction? Sure. But to call the entire efforts to improve sepsis care over the last 15 years a travesty is to do a true disservice. The standard of care has evolved, and many of the individual components of the EGDT bundle may not be worth it as we break apart the studies, but you will never turn the clock back to what was going on before (because that would be killing patients).

The paper (IMHO) was a travesty, the service it did was not.

My point was this: the paper itself did a net benefit while suggesting interventions that likely caused harm. That was exactly the problem. The whole thing got taken up as Gospel. It made changing institutional practices really stodgy with respect to some aspects of the bundle. When you read a trial, you take what you can, acknowledge its limitations, and reflect on it in light of new evidence. That's really hard to do when non-clinical administrators are telling you how to do your job based on old (and frankly questionable) evidence.

Again, I'm all in favour of EBM, Guidelines, Checklists, whatever--but usually they provide the most benefit in places of poor, non-deliberate practice to begin with (as could be argued with sepsis care pre-Rivers). They are more about systems of care then care itself, which is important from a population perspective, but doctors should be treating the patient in front of them with the best evidence available.

Gahhh... And now we can debate the Leuven trials by Greet Van Den Berghe, which was, again, Gospel for some until NICE-SUGAR--but it didn't need to be Gospel for so long, because there were signals of harm in the literature way before NICE-SUGAR. This sort of thing happens too often in medicine. I'm just calling for a mindful approach, even to routine practice.

 

[Psai]

When you start using "evidence based medicine" as a proxy for using your brain because administrators without a single shred of medical knowledge tell you to do so, something is terribly wrong. Why should my salary be based on whether or not I put in exactly 30 mL/kg? Makes no sense. I think there was a guy on here who was like 50 mL short and they docked the doc because they refused to count the water in the antibiotic. Insanity with no common sense at all.

 

[Carboxide]

As an ER pharmacist, they give it because (and not necessarily in this order):

a). Most patients are probably at least a little dehydrated. If they're weak, have a headache, etc this is going to help them feel better.
b). It's not going to hurt them. They aren't stupid, they don't give it to patients at risk of fluid overload.
c). Patients hate waiting and if they're sitting in a room with nothing happening they're going to be counting the seconds and getting madder and madder. The drip just makes them feel like we're doing something and can be a powerful placebo.
d). As a corollary to c), unhappy patients both write negative reviews and sue. Lowered Press-Gainey scores are, in fact, used in their annual reviews and influence their raises and job prospects (at least with our contract group).

ER physicians are highly likely to practice what we call 'defensive medicine' - ordering possibly unnecessary tests/treatments because they want to increase patient satisfaction and decrease malpractice. As a pharmacist, I tend to be more lenient with ER physicians than anyone else in the hospital. We've got less information, more critical patients, and higher liability, so I'll occasionally let them get away with using a restricted drug or an expensive med that's designated for treatment failure with a cheaper drug (e.g. nicardipine drip instead of labetalol). Although, most of the time the restricted abx they want are my recommendation.

There are only a few situations in which NS is truly inappropriate. One group is the patients HooliganSnail mentioned above: patients who are fluid overloaded already, HD patients, and non-critically ill patients at high risk for fluid overload. The second group is patients who require fluids but should be getting either colloids or LR. Colloids are really only appropriate for patients with third spacing/cirrhosis/etc. LR is DOC for OB and also patients with pancreatitis (which, by the way, is almost uniformly missed in both acute and necrotizing pancreatitis. Write that down).

We get all this crap about hyperchloremic acidosis. I mean, it's real, don't get me wrong. But it is very uncommon (I've never seen the team use 10-12L NaCl for rescuscitation...) and are mostly restricted to short-term effects such as increased use of bicarb/blood products when it does happen. Unfortunately, we don't tend to know what patients will respond to a couple liters and which ones will need 6 bags, so it's hard to predict that. Ideally we would be switching to LR once we hit 3 or 4 bags, but I don't find it important enough to worry about.

I have a couple things I tell patients, "we are going to give you this medicine together with a liter of fluid because it helps the medicines to be absorbed and processed in your body."

No.

My wife reviews and approves/declines Medicare and Medicaid claims and a number of her co-workers were recently reassigned to just review claims for IVF during ER vists due to over usage and inappropriate usage. So it definitely is an issue...

Reply by hospital: "Physician believed patient to be experiencing mild dehydration."


I imagine the attendings and residents here will agree with me when I say that it's a bit cute that all the posters up in arms about overprescribing fluids are medical students.


At my hospital we can get a liter bag for ~$1 and charge about $105.

 

[lymphocyte]

We get all this crap about hyperchloremic acidosis. I mean, it's real, don't get me wrong. But it is very uncommon (I've never seen the team use 10-12L NaCl for rescuscitation...) and are mostly restricted to short-term effects such as increased use of bicarb/blood products when it does happen. Unfortunately, we don't tend to know what patients will respond to a couple liters and which ones will need 6 bags, so it's hard to predict that. Ideally we would be switching to LR once we hit 3 or 4 bags, but I don't find it important enough to worry about.

Most are familiar with the textbook contraindications to NS. What I don't understand is why everybody keeps mentioning "hyperchloremic acidosis" as the main issue. A few years ago, it was thought to be the main issue--after excessive volume resuscitation.

But there are lots of new signals of harm in the literature, and it's more than just "numbers": AKI, prolonged stay on ventilation, prolonged LOS, and even severity-adjusted, volume-corrected, dose-dependent mortality risk. That seems worrisome. Especially since the findings are being replicated in multiple patient subgroups: sepsis, SIRS, perioperative, trauma, etc.

My worry is for low-acuity patients that we don't follow-up, who might not have as "normal" a physiology as we could appreciate at the time of presentation. What will it take here? A definitive trial like NICE-SUGAR? I don't even know how such a study could be be adequately powered for low-acuity patients.

I agree that there are two sides of this issue. But at least the terms of the debate are changing. What we learn in medical school or pharmacy school or in residency might no longer be the case--even though it seems to work just fine in practice. When your (or anybody's) practice doesn't include longitudinal care, it's easy to value the benefit of short-term interventions over long-term harm.

https://www.acep.org/Content.aspx?ID=101488.

 

[jdh71]

Good post. And most are familiar with the textbook contraindications to NS. What I don't understand is why posters keeps mentioning "hyperchloremic acidosis" as the main issue. A few years ago, it was thought to be the main issue--after excessive volume resuscitation.

But there are lots of new signals of harm in the literature, and it's more than just "numbers": AKI, prolonged stay on ventilation, prolonged LOS, and even severity-adjusted, volume-corrected, dose-dependent mortality risk. That seems worrisome. Especially since the findings are being replicated in multiple patient subgroups: sepsis, SIRS, perioperative, trauma, etc.

My worry is for low-acuity patients that we don't follow-up, who might not have as "normal" a physiology as we could appreciate at the time of presentation. What will it take here? A definitive trial like NICE-SUGAR? I don't even know how such a study could be be adequately powered for low-acuity patients.

I agree that there are two sides of this issue. But at least the terms of the debate are changing. What we learn in medical school or pharmacy school or in residency might no longer be the case--even though it seems to work just fine in practice. When your (or anybody's) practice doesn't include longitudinal care, it's easy to value the benefit of short-term interventions over long-term harm.

https://www.acep.org/Content.aspx?ID=101488.

I don't think chloride is "poison" (zomg poison I tell you!!) and I have zero problems reaching for it in the patient you think needs fluid resuscitation and need it now. It also "works" in a familiar and predictable fashion so when it doesn't it's very valuable information to me. With that said my practice has evolved and I'm using a lot more LR and albumin these days based on what seems to make sense in any given case. And I'm trying to avoid hyperchloremia. Definitely anything over 110 mMol/L. I have no reason for that bring my cut off. Probably my monkey mind lizard brain liking the roundness of the number.

I hope the future is using physiologic resuscitation solutions. They are out there but cost prohibitive even if not even that much, relatively speaking. I mean we have the technology that should be able to produce these solutions as cheap at the NS or LR but suppliers want to make MORE money than seems reasonable given the fact we are really talking about mixing in common and inexpensive salts. I would reach for nothing but something like Plasmalyte if it were available to me. I mean I can probably get some but pharmacy will crap themselves.

 

[lymphocyte]

I And I'm trying to avoid hyperchloremia. Definitely anything over 110 mMol/L. I have no reason for that bring my cut off. Probably my monkey mind lizard brain liking the roundness of the number.

I hope the future is using physiologic resuscitation solutions. They are out there but cost prohibitive even if not even that much, relatively speaking. I

I think hyperchloremia is the key. That's what the Australian study most closely associated with mortality risk, and based on first principles seems to best reflect the underlying pathophysiology of chloride loading.

I don't think chloride is necessarily a poison (although that's what Scott Weingart calls it: http://emcrit.org/podcasts/chloride-pressure-poisoning/ ), but as always, dose makes the poison, and supra-physiological doses of chloride seems to be associated with harm, even with "just a few litres" of NS. NS is a drug like any other, with risks and benefits. We shouldn't be dolling it without at least thinking about what we're doing.

I suspect the cost of more balanced solutions will come down over time, and if more signals of harm emerge (like LOS, RRT, ventilation time), then there's a business case to be made too.

 

[jdh71]

I think hyperchloremia is the key. That's what the Australian study most closely associated with mortality risk, and based on first principles seems to best reflect the underlying pathophysiology of chloride losing. I don't think chloride is necessarily a poison (although that's what Scott Weingart calls it: http://emcrit.org/podcasts/chloride-pressure-poisoning/ ), but as always, dose makes the poison, and supra-physiological doses of chloride seems to be associated with harm, even with "just a few litres" of NS. NS is a drug like any other, with risks and benefits. We shouldn't be dolling it without at least thinking about what we're doing.

I suspect the cost of more balanced solutions will come down over time, and if more signals of harm emerge (like LOS, RRT, ventilation time), then there's a business case to be made too.

I like Weingart (a lot) but think that he's a bit too dogmatic and relies too much of data only (is there such a thing?!?!). Though if you were doing what he does, you'd want to be able to appeal to something if and when you find someone unhappy with the outcomes that are inherent in being very sick. But he drives a lot of the "unthinking" you can see in the EM world sometimes. Medicine is nuanced and those guys have an important thankless job and I don't argue with those too much, sometimes the best way to get the work up the patient really needs is to admit them and do it yourself. They're not budging!

 

[Psai]

I don't think chloride is "poison" (zomg poison I tell you!!) and I have zero problems reaching for it in the patient you think needs fluid resuscitation and need it now. It also "works" in a familiar and predictable fashion so when it doesn't it's very valuable information to me. With that said my practice has evolved and I'm using a lot more LR and albumin these days based on what seems to make sense in any given case. And I'm trying to avoid hyperchloremia. Definitely anything over 110 mMol/L. I have no reason for that bring my cut off. Probably my monkey mind lizard brain liking the roundness of the number.

I hope the future is using physiologic resuscitation solutions. They are out there but cost prohibitive even if not even that much, relatively speaking. I mean we have the technology that should be able to produce these solutions as cheap at the NS or LR but suppliers want to make MORE money than seems reasonable given the fact we are really talking about mixing in common and inexpensive salts. I would reach for nothing but something like Plasmalyte if it were available to me. I mean I can probably get some but pharmacy will crap themselves.

Just steal it from the VA

 

[jdh71]

Just steal it from the VA

That's federal ass rape prison time son.

I wouldn't do well in prison.

 

[lymphocyte]

Read this today for the first time. I laughed. Had to share it. What Marik says about the Rivers' paper in his book "Evidence Based Intensive Care" (this part is from the free preview). I love the way he put studies in quotes. Yes, he's a bombastic writer--that doesn't make him any less correct though. I know more than a few intensivists who feel the same way.

EGDT improved systems of care, while likely harming many individual patients--on balance creating a net benefit. But we probably could have saved even more lives if we had been responsive to signals of harm in the literature, as now with "just a few litres of NS." Anyway, to each his own. Realistically, I'm not going to convince anybody.

 

[Raryn]

I had to share this. Today, for the first time, I read a few chapters from Marik's "Evidence-Based Intensive Care." For preclinicals, the excerpt below is how some intensivists feel about the Rivers' paper (and the Leuven trial). It's the view I was trying to get across above. I love the way he puts studies in quotes. (And yes, he's a vivid but sometimes bombastic writer.)

EGDT improved systems of care, while suggesting interventions that likely caused harm. We could have done just the same with much less harmful interventions--at least by being more sensitive to signals of harm in the literature (as with "just a few litres" of NS).

View attachment 206388

This is from the free preview portion, so I hope I'm violating copyright.

If we compare in-hospital sepsis mortality from the late 1990s to the early 2010s, the timeline during which EGDT and related strategies were implemented, you see a frank improvement in absolute mortality on the order of 1-2% a year. That's anywhere from a 10-20% absolute improvement in mortality depending on what country's data you're looking at. Relative mortality was improved up to 50% (once again, somewhat variable depending on your baseline). Obviously EGDT isn't the only factor there (new abx, new ventilatory strategies, etc etc all play a part) but it is a major one. To call one of the primary drivers of that change a travesty or a dark day in critical care is absurd.

Look, resuscitation strategy has a spectrum of approaches. 20 years ago, patients were grossly under-resuscitated and had a lot more morbidity due to pressor use in that setting. A change in strategy towards approaches that emphasized adequate resuscitation (which is really the most important part of what Rivers accomplished) saved lives and continues to do so every single day. Now, the pendulum may have swung a little too far the opposite direction with some proportion of patients over-resuscitated, but don't throw the baby out with the bath water. We're talking about tinkering with a strategy that is the new standard of care because it's *working*.

 

[lymphocyte]

If we compare in-hospital sepsis mortality from the late 1990s to the early 2010s, the timeline during which EGDT and related strategies were implemented, you see a frank improvement in absolute mortality on the order of 1-2% a year. That's anywhere from a 10-20% absolute improvement in mortality depending on what country's data you're looking at. Relative mortality was improved up to 50% (once again, somewhat variable depending on your baseline). Obviously EGDT isn't the only factor there (new abx, new ventilatory strategies, etc etc all play a part) but it is a major one. To call one of the primary drivers of that change a travesty or a dark day in critical care is absurd.

Look, resuscitation strategy has a spectrum of approaches. 20 years ago, patients were grossly under-resuscitated and had a lot more morbidity due to pressor use in that setting. A change in strategy towards approaches that emphasized adequate resuscitation (which is really the most important part of what Rivers accomplished) saved lives and continues to do so every single day. Now, the pendulum may have swung a little too far the opposite direction with some proportion of patients over-resuscitated, but don't throw the baby out with the bath water. We're talking about tinkering with a strategy that is the new standard of care because it's *working*.

You can quote the mortality figures, that's fine and fair. But 1) grossly non-specific, 2) we very likely would have gotten there without Rivers' EGDT, and 3) we could have saved even more lives had we been responsive to signals of harm in the literature (and not relied too much on one flawed study). That's the comparison I'm trying to draw to non-physiological fluids.

Also, define "adequate resuscitation." What's your evidence that most septic patients are volume responsive in clinically meaningful way?

 

[jdh71]

Also, define "adequate resuscitation." What's your evidence that most septic patients are volume responsive in clinically meaningful way?

ITT: dorks

 

[Psai]

You can quote the mortality figures, that's fine and fair. But 1) grossly none-specific, 2) we very likely would have gotten there without Rivers' EGDT, and 3) we could have saved even more lives had we been responsive to signals of harm in the literature (and not relied too much on one flawed study). That's the comparison I'm trying to draw to non-physiological fluids.

Also, define "adequate resuscitation." What's your evidence that most septic patients are volume responsive in clinically meaningful way?

Ivc us

 

[jdh71]

Ivc us

pretty good, better than most

what if they're on a vent with ARDS and lots of PEEP, or just so fat you can't get a good window??

 

[Psai]

pretty good, better than most

what if they're on a vent with ARDS and lots of PEEP, or just so fat you can't get a good window??

Well if they're ards on peep they probably belong in the icu, no matter how much upstairs care Scott weingart tries to bring downstairs. For the fat guy, will probably just have to do the ol capillary refill and mucous membranes. Do a leg lift to see if their hemodynamics parameters change and if so give em a little extra top off. Or maybe just fluid challenge them with a 500 cc bonus

 

[group_theory]

pretty good, better than most

what if they're on a vent with ARDS and lots of PEEP, or just so fat you can't get a good window??

Just paralyze them, hope they are in sinus rhythm (ha! a rare bird in the ICU) ... and look at the pulse pressure variation. 😏

Or bring back the Swans (CPT code 93503), and watch the medical students and residents rush to print off that 2006 NEJM article about swans


To make it easier for the students/residents ---> NEJM 2006 May 25;354(21):2213-24

 

[jdh71]

Well if they're ards on peep they probably belong in the icu, no matter how much upstairs care Scott weingart tries to bring downstairs. For the fat guy, will probably just have to do the ol capillary refill and mucous membranes. Do a little leg lift to see if their hemodynamics parameters change and if so give em a little extra top off. Or maybe just fluid challenge them a little with a 500 cc bonus

And THIS is exactly lots of physicians are uncomfortable with critical care now. You gotta do a lot of thinking outside of the box. But you have to do SOMETHING and hope for the best.

 

[jdh71]

Just paralyze them, hope they are in sinus rhythm (ha! a rare bird in the ICU) ... and look at the pulse pressure variation. 😏

Or bring back the Swans (CPT code 93503), and watch the medical students and residents rush to print off that 2006 NEJM article about swans


To make it easier for the students/residents ---> NEJM 2006 May 25;354(21):2213-24

My colleagues and I where I'm working are using a lot of NICOM. Again, not a swan, and not perfect, (list all the stuff you don't like about it) but I think really helpful, especially when looks at the differences between pre and post intervention

 

[jdh71]

Last week I actually set up a CVP!! Lol.

Wonder if anyone can guess why.

 

[group_theory]

Last week I actually set up a CVP!! Lol.

Wonder if anyone can guess why.

To measure a useless metrics but one that will make the chief quality officer and chief nursing officer and chief medical officer happy and satisfied that you are providing "good care" because it is recommended in the original surviving sepsis campaign?

They probably want you to re-measure lactic acid too to ensure clearance when your patient is clinically improving, off pressors, up and walking, and waiting floor bed.




*or maybe you had an adult with single ventricle physiology (Fontan) and you really wanted to put in a Swan but was yelled at by a medical student citing a 2006 NEJM article, so you placed a non-femoral central line, and ask the medical student what the CVP reading actually means with this anatomy

 

[jdh71]

To measure a useless metrics but one that will make the chief quality officer and chief nursing officer and chief medical officer happy and satisfy that you are providing "good care" because it is recommended in the original surviving sepsis campaign?

They probably want you to re-measure lactic acid too to ensure clearance when your patient is clinically improving, off pressors, up and walking, and waiting floor bed.

Ha!

It was actually in a very shocky pulmonary hypertension patient whose remodulin pump had gone out, echo looked ok, and NICOM seemed to suggest ok CO, but there was a lot of fib, so I figured what better way to see what kind of stupid pressures are going on over on the right side than a CVP. Again not a swan, but when the numbers were only in the mid to high 20s I felt pretty good I wasn't dealing with RV failure. It was a bad distributive shock and one case I was unfortunately unable to ultimately win.

 

[lymphocyte]

Ivc us

pretty good, better than most

No. No. No. (Better than most? Most frankly suck anyway.) And again, why does fluid responsive mean they need fluid? What's your argument for that vs. doing nothing vs. alpha-1?

Well if they're ards on peep they probably belong in the icu, no matter how much upstairs care Scott weingart tries to bring downstairs. For the fat guy, will probably just have to do the ol capillary refill and mucous membranes. Do a little leg lift to see if their hemodynamics parameters change and if so give em a little extra top off. Or maybe just fluid challenge them a little with a 500 cc bonus

Big fan of history, PLR, small bolus, and doing as little as possible. But how good is physical exam at predicting fluid responsiveness? Useless. (And probably also just as useless for detecting less-than-severe hypovolemia or dehydration...)

For medical students:
1. Rational approach to fluid therapy in sepsis: http://emcrit.org/wp-content/uploads/2015/10/Br.-J.-Anaesth.-2015-Marik-bja_aev349.pdf
2. Fun and recent debate on the utility of predicting fluid responsiveness: http://intensivecarenetwork.com/rob...ting-fluid-responsiveness-is-a-waste-of-time/

 

[Psai]

No. No. No. (Better than most? Most frankly suck anyway.)



Big fan of history, PLR, small bolus, and doing as little as possible. But how good is physical exam at predicting fluid responsiveness? Useless.

For medical students:
1. Rational approach to fluid therapy in sepsis: http://emcrit.org/wp-content/uploads/2015/10/Br.-J.-Anaesth.-2015-Marik-bja_aev349.pdf
2. Hilarious and recent debate on the utility of predicting fluid responsiveness: http://intensivecarenetwork.com/rob...ting-fluid-responsiveness-is-a-waste-of-time/

Well I'm only on podcast 40 or so on emcrit and I'm a little out of date

 

[lymphocyte]

Well I'm only on podcast 40 or so on emcrit and I'm a little out of date

http://criticalcarereviews.com/index.php/home/reggie

I have mixed feelings about EmCrit. I think he's doing the world a huge favour, but some of what he says people just take as Gospel and run with it.

 

[jdh71]

No. No. No. (Better than most? Most frankly suck anyway.) And again, why does fluid responsive mean they need fluid? What's your argument for that vs. doing nothing vs. alpha-1?

Big fan of history, PLR, small bolus, and doing as little as possible. But how good is physical exam at predicting fluid responsiveness? Useless. (And probably also just as useless for detecting less-than-severe hypovolemia or dehydration...)

For medical students:
1. Rational approach to fluid therapy in sepsis: http://emcrit.org/wp-content/uploads/2015/10/Br.-J.-Anaesth.-2015-Marik-bja_aev349.pdf
2. Hilarious and recent debate on the utility of predicting fluid responsiveness: http://intensivecarenetwork.com/rob...ting-fluid-responsiveness-is-a-waste-of-time/

Yeah. I think it's better than guessing. It's better than a random number generator like CVP. And by better than most, I didn't mean it was amazing, merely better than nothing.

As to why should we give what appears to be a fluid responsive patient resuscitation? It decreases pressor needs. Pressors do not come without certain unintended side effects - relative splanchnic ischemia, tachyarrythmmias, bradyarrhthymias, digital necrosis, etc. I've seen plenty of fluid responsive patients on pressers come off of or have a decrease in pressors once given what they need. In fact, it occurs rather predictably, especially with use of the NICOM. If a pateint is not fluid responsive by your best objective measures, then they obviously need the pressors. You, of course, want to run them as dry as possible, but this doesn't mean being stupid with IV fluids. You do the best you can given the situation. It's not a one variable process and there are many moving pieces to consider. It's not static and all happens with context. Reassessments needs to occur regularly. Bottom line is that a physician treating the critically ill needs to have a rationale for doing . . . or . . . not doing.

 

[lymphocyte]

Yeah. I think it's better than guessing. It's better than a random number generator like CVP. And by better than most, I didn't mean it was amazing, merely better than nothing.

As to why should we give what appears to be a fluid responsive patient resuscitation? It decreases pressor needs. Pressors do not come without certain unintended side effects - relative splanchnic ischemia, tachyarrythmmias, bradyarrhthymias, digital necrosis, etc. I've seen plenty of fluid responsive patients on pressers come off of or have a decrease in pressors once given what they need. In fact, it occurs rather predictably, especially with use of the NICOM. If a pateint is not fluid responsive by your best objective measures, then they obviously need the pressors. You, of course, want to run them as dry as possible, but this doesn't mean being stupid with IV fluids. You do the best you can given the situation. It's not a one variable process and there are many moving pieces to consider. It's not static and all happens with context. Reassessments needs to occur regularly. Bottom line is that a physician treating the critically ill needs to have a rationale for doing . . . or . . . not doing.

I actually think it's worse than nothing. Because it gives unmerited and confused confidence. At least with the random number generator, we know we can ignore it--that's confidence!

But good post. Strongly agree with bolded and don't think it just applies to the critically ill.

 

[jdh71]

I actually think it's worse than nothing. Because it gives unmerited and confused confidence. At least with the random number generator, we know we can ignore it--that's confidence!

But good post. Strongly agree with bolded and don't think it just applies to the critically ill.

I might agree with you, IF I didn't see it work regularly enough. It is conceivable given any number of variables that some patients will simply give you funny or paradoxical results. I'm not going to let the small amount of noise interfere with what is and should be a helpful modality in the majority.

 

[Carboxide]

I actually think it's worse than nothing. Because it gives unmerited and confused confidence.

It must be just awful having to deal with people like that.

 

[lymphocyte]

It must be just awful having to deal with people like that.

9 out of 10. I genuinely laughed out loud. Fair point.

Sorry I got ranty. But the discussion and different perspectives were pretty interesting to read.