Latest / Banter At The Bedside / Too Much IV Fluid? Part 2: Albumin, LR vs. Normal Saline, and Fluid Creep in the ICU

Transcript

Too Much IV Fluid? Part 2: Albumin, LR vs. Normal Saline, and Fluid Creep in the ICU · Banter At The Bedside

• 0:07
  SPEAKER_02: Hey everyone, and welcome back to Banter at the Bedside.
• 0:11
  SPEAKER_02: We are here this week for part two on our fluids education episode with Dr.
• 0:16
  SPEAKER_02: Michael.
• 0:17
  SPEAKER_02: Just to recap, last week, Dr.
• 0:19
  SPEAKER_02: Michael went through all of the evidence on why we give fluids, what we're doing, and how we are approaching it from a physiological standpoint.
• 0:27
  SPEAKER_02: This week we're going to talk all about picking those fluids because picking is just as important as understanding why we're doing it.
• 0:35
  SPEAKER_02: Now we're going to get to those disclaimers.
• 0:38
  SPEAKER_02: As always, this is not medical advice.
• 0:40
  SPEAKER_02: Please seek the care of your own medical professional.
• 0:43
  SPEAKER_02: These thoughts and opinions are our own.
• 0:45
  SPEAKER_02: We don't represent any entity at all.
• 0:48
  SPEAKER_02: I'm Abby.
• 0:49
  SPEAKER_02: I'm one of your main co-hosts, and I've been in healthcare 17 years, and I've been a nurse practitioner for the last eight in ICUs.
• 0:59
  SPEAKER_02: Dr.
• 0:59
  SPEAKER_02: Michael has been a physician for 17 years, spanning emergency medicine, critical care medicine, and has been the director of several programs.
• 1:10
  SPEAKER_02: And then we're joined by our other main co-host, Kaylee, who has been a nurse for 18 years, most of that being in critical care medicine as well.
• 1:20
  SPEAKER_02: So let's get into part two and finish up this fluid learning.
• 1:25
  SPEAKER_00: Now we can have a conversation about like the type of fluid.
• 1:31
  SPEAKER_01: Oh, here we go.
• 1:33
  SPEAKER_00: And I can't go into like a ton of details because I could talk for like it's a full hour-long talk on acid base and strong ion difference and like why the fluids are better than other fluids.
• 1:47
  SPEAKER_00: I will give a brief kind of explanation to it.
• 1:51
  SPEAKER_02: We'll do the whole SID and all of that the next time.
• 1:55
  SPEAKER_00: That'll be fantastic.
• 1:56
  SPEAKER_00: I would love to get into that with it.
• 1:58
  SPEAKER_00: So with this in mind, you have to talk about like what fluids you're going to give.
• 2:04
  SPEAKER_00: And your fluids, whenever you're talking about resuscitative fluids, are going to be crystalloid, they're going to be colloid, or you can start talking about like hypertonic fluids as well in there.
• 2:17
  SPEAKER_00: Because, like I said, and what I mentioned at the very beginning was if you change the osmolarity, you can't, you're more likely to go intravascular.
• 2:24
  SPEAKER_00: And like I mentioned before, if you want to, if you want to replace intravascular volume versus extracellular volume, uh, it's going to be a little bit different.
• 2:34
  SPEAKER_00: So crystalloid is by far the most abundant.
• 2:38
  SPEAKER_00: It is easy to give, it's cheap, it's all around, like in terms of all the hospitals, all the floors, all the units, type of stuff with it.
• 2:46
  SPEAKER_00: But because of it being isotonic, it replaces extracellular volume.
• 2:51
  SPEAKER_00: So it's going to go over that 14 liters.
• 2:54
  SPEAKER_00: So it's going to redistribute within that 14 liters.
• 2:57
  SPEAKER_00: Whereas if you're going to talk about colloid, colloid, because it's protein, doesn't want to leak out because of the intravascular space with it, with the walls, is that it's going to replace intravascular volume.
• 3:12
  SPEAKER_00: Hypertonic fluids, because of its osmolarity, is going to replace intravascular volume.
• 3:18
  SPEAKER_00: So if you need intravascular volume immediately, then you have to consider for like over a time period, you have to consider that you may want to consider colloids or uh hypertonic fluids versus if you're just looking for overall replacement resuscitative fluids like putting something in, then you can do the isotonic fluid, but eventually within an hour, it will redistribute through there.
• 3:44
  SPEAKER_02: And just for like our maybe less experienced listeners, colloids and hypertonic, what would be some examples?
• 3:52
  SPEAKER_02: Sure.
• 3:53
  SPEAKER_00: Yeah.
• 3:53
  SPEAKER_00: So like the really only colloids we use now are going to be albumin.
• 3:58
  SPEAKER_00: I mean, I guess technically blood.
• 3:59
  SPEAKER_00: Like if your hemoglobin's four, then yes, please give some blood.
• 4:04
  SPEAKER_00: But this is like the idea of under the assumption that you are at your hemoglobin level that you would like to have like your goal hemoglobin.
• 4:13
  SPEAKER_02: Or Jehovah's Witness.
• 4:14
  SPEAKER_00: Or a Jehovah's Witness, sure.
• 4:16
  SPEAKER_00: To be able to summon that can't get their something with it.
• 4:19
  SPEAKER_00: So if you if you give oncotic pressure or albumin, typically we give it in like 5% albumin.
• 4:28
  SPEAKER_00: We also have concentrated albumin, which is 25% albumin.
• 4:31
  SPEAKER_00: So it's just more albumin per volume.
• 4:34
  SPEAKER_00: So it's it's because it's so concentrated, as you give it, it actually sucks in interstitial fluid back into the intravascular space.
• 4:43
  SPEAKER_00: Same thing with hypertonic.
• 4:45
  SPEAKER_00: Like our most the the most one that people have heard of would be just hypertonic saline, which is 3%.
• 4:52
  SPEAKER_00: Uh I actually also do like a hypertonic bicarb solution, which is Yeah, you do.
• 5:03
  SPEAKER_00: There are studies.
• 5:04
  SPEAKER_00: The bicar ICU1 trial showed that it actually improved mortality in acidotic patients with AKI.
• 5:11
  SPEAKER_00: The bicar ICU2 trial showed benefits with like reducing dialysis and stuff, but didn't show that same mortality benefit.
• 5:18
  SPEAKER_00: But the idea behind it is that you would take a vial of high of bicarb is already hypertonic.
• 5:27
  SPEAKER_00: It's 8.4%.
• 5:28
  SPEAKER_00: It's very hypertonic.
• 5:30
  SPEAKER_00: And so you would take five amps of bicarb and mix it in 250 ml of free water or D5W.
• 5:38
  SPEAKER_00: And so because you have 250 of water and 250 of 8.4% bicarb, you end up with 500 milliliters of a 4.2% solution.
• 5:48
  SPEAKER_00: 4.2% sodium bicarb has about the same amount of sodium as a 3% sodium chloride.
• 5:55
  SPEAKER_00: So it's about the same amount of sodium when you're talking about from an osmolarity standpoint.
• 6:00
  SPEAKER_00: So if you have a superacidotic patient and you want to give them hypertonic fluids, I like to give it in that situation for certain septic shock patients versus if if you're giving it for other reasons and stuff, then you would do like hypertonic saline.
• 6:14
  SPEAKER_00: But those stay intravascular.
• 6:16
  SPEAKER_00: So if you need intravascular volume that's not going to leak out into the periphery, then you want to consider oncotic pressure or hypertonic fluids.
• 6:26
  SPEAKER_00: I run that 500 mls over about seven hours.
• 6:29
  SPEAKER_00: And what it does is it just because it's it's hypertonic, it really wants to just have seven hours of just pulling that interstitial fluid back into the intravascular space.
• 6:40
  SPEAKER_00: And so that six, seven-hour time period while you have it on there, uh, it's about, I put it at 75 milliliters an hour, is it buys you time for them to start getting better, for your antibiotics to kick in, for your stress dosteroids to kick in.
• 6:55
  SPEAKER_00: So you're not just dumping liters and liters and liters of volume while it's leaking out.
• 7:00
  SPEAKER_00: So there was one study that whenever they talked about giving albumin, people were like, we shouldn't give albumin.
• 7:07
  SPEAKER_00: It only lasts in the intervascular space for like six hours in septic shock patients.
• 7:13
  SPEAKER_00: And I read that study and it did say that.
• 7:16
  SPEAKER_00: It said it would let last it about six hours because of the uh cell walls became leaky and things leaked out and that type of stuff with it.
• 7:23
  SPEAKER_00: That same article said that normal saline leaked out in 52 minutes.
• 7:28
  SPEAKER_00: So if you're saying don't give albumin because it leaks out in six hours, then you 100% shouldn't give normal saline.
• 7:35
  SPEAKER_00: It leaks out in under an hour.
• 7:37
  SPEAKER_00: But if you're in inseptic shock, you're buying time, right?
• 7:41
  SPEAKER_00: You're waiting for that infection to start calming down so that you have less cytokines, less distributive shock.
• 7:49
  SPEAKER_00: Your vessels start to clamp back down, you're starting to bring things together.
• 7:52
  SPEAKER_00: So those that six-hour time period can be a huge lifesaver of just trying to keep intervassar volume.
• 7:59
  SPEAKER_00: And so I'll do like 500 milliliters.
• 8:02
  SPEAKER_00: And then at the end of it, I typically don't have to give another 500 milliliters because most of the time you start to see these patients just slowly starting to get better where you're not just dumping fluid into them, dumping fluid into them.
• 8:14
  SPEAKER_00: And so those are considerations for like hypertonic colloid again, like resuscitation with albumin is very controversial.
• 8:23
  SPEAKER_00: There was a trial that was called the SAFE trial, and it looked at normal saline versus albumin and just like resuscitation and shock.
• 8:32
  SPEAKER_00: In that study, they used 4% albumin because I mean it wasn't done here, and so not here, they have 4% solution versus 5% solution.
• 8:43
  SPEAKER_00: And if you do the math on osmolarity, it's hypotonic.
• 8:49
  SPEAKER_00: And what it showed was is that it did about the same as normal saline, maybe even a little bit better in septic shock, but not statistically significant, but did significantly worse in anything neurorelated.
• 9:03
  SPEAKER_00: So all that type of world.
• 9:05
  SPEAKER_00: So it became very much don't give albumin in neuropatients.
• 9:11
  SPEAKER_00: But you also just gave a hypotonic solution.
• 9:13
  SPEAKER_00: So to me, it wasn't like, oh, I it's just because like if you do the math and normal osmolarity is 270 to 300, uh the osmolarity of normal saline is 154 mil equivalents of sodium, 154 mile equivalents of chloride for 308 mil equivalents.
• 9:32
  SPEAKER_00: So it's like right on the upper end of like high on your osmolarity versus a 4% albumin, it's much more hypotonic.
• 9:41
  SPEAKER_00: So I don't know.
• 9:42
  SPEAKER_00: I think it's a little bit unfair on that.
• 9:45
  SPEAKER_00: It certainly didn't like help, so I get not using it, don't get me wrong, but it is kind of interesting in that trial.
• 9:52
  SPEAKER_02: Yeah.
• 9:54
  SPEAKER_02: That's why I never gave albumin as a neuronurse.
• 9:57
  SPEAKER_02: Yeah.
• 9:58
  SPEAKER_02: Not once.
• 9:58
  SPEAKER_00: It it would have probably come from that trial.
• 10:00
  SPEAKER_00: That was like a huge trial.
• 10:02
  SPEAKER_00: And there have been other trials and things that are going with it, but that was one of the big trials that just said it it caused worse outcomes whenever it came to things that were neural related.
• 10:11
  SPEAKER_00: Interesting.
• 10:11
  SPEAKER_00: I think 5% is a different conversation.
• 10:14
  SPEAKER_00: I think there was a trial called the swipe trial that they looked at 25% or 20% albumin in large vol, like if you're doing septic shock and you're doing a lot of resuscitation.
• 10:24
  SPEAKER_00: And so this becomes more of like semantics where I've given albumin to septic shock patients, but I haven't given it as resuscitative fluid.
• 10:33
  SPEAKER_00: I'm not giving it to like increase their ability to go up higher on the starling curve.
• 10:38
  SPEAKER_00: I'm giving it because they had low oncotic pressure, like they had an albumin of two or 1.8 or 2.2.
• 10:45
  SPEAKER_00: So I'm just giving them oncotic pressure so all of their crystalloid can stay more intravascular so it can be higher up on the starling curve.
• 10:53
  SPEAKER_00: So if people are like, I don't give albumin for resuscitation, I say I don't give albumin for resuscitation either.
• 11:00
  SPEAKER_00: I give albumin for oncotic pressure to get above like that Gibbs-donant effect to get a higher amount of oncotic pressure to draw that volume in that we're currently trying to use.
• 11:12
  SPEAKER_00: Yeah.
• 11:13
  SPEAKER_00: It is in the surviving sepsis guidelines that says you can consider albumin in large volume resuscitation.
• 11:20
  SPEAKER_00: So if you're giving one, two, three liters of fluid, definitely not.
• 11:25
  SPEAKER_00: If you're on your fourth, fifth, that magic sixth liter, whatever, then they're saying, hey, you're just diluting out, you're diluting out your hemoglobin, you're diluting out your albumin.
• 11:35
  SPEAKER_00: You're gonna, every liter you give, that liter is more likely to leak out into the interstitium because you keep having lower and lower oncotic pressure because you keep diluting it out.
• 11:47
  SPEAKER_00: And so by giving that albumin, you're replacing some of that lost oncotic pressure so that you don't have to give as much fluid.
• 11:54
  SPEAKER_00: That's that's what's in the surviving substance guidelines, is in large volume resuscitation.
• 12:00
  SPEAKER_01: Okay.
• 12:02
  SPEAKER_00: In talking about fluids, crystalloids in general, we typically have normal saline, lactated ringer, and we have normosol or plasma lite.
• 12:12
  SPEAKER_00: Those are kind of our three categories.
• 12:17
  SPEAKER_00: When we can talk about the acid-base status or the CID, which would be a whole separate talk to talk about with it, is we would talk about normal saline has a ton of chloride.
• 12:30
  SPEAKER_00: So normal saline, like I said, is 154 of sodium, 154 of chloride, they equal each other, it's just sodium chloride.
• 12:37
  SPEAKER_00: A normal sodium in your body is 140.
• 12:40
  SPEAKER_00: 154 and 140, it's not that far apart.
• 12:44
  SPEAKER_00: A normal chloride is around 100.
• 12:47
  SPEAKER_00: If you're giving somebody a chloride of 154, that's like a 50% higher amount of chloride.
• 12:53
  SPEAKER_00: You're giving them a huge amount of chloride.
• 12:55
  SPEAKER_00: The body can't break down chloride, it can't manipulate chloride.
• 13:00
  SPEAKER_00: So the only thing it can do to getting just a huge amount of extra chloride is to stop making bicarb.
• 13:06
  SPEAKER_00: And so normal saline, yes, it's isotonic.
• 13:09
  SPEAKER_00: Yes, it will replace your fluid, but it will make you just your body break down a ton of bicarb and you'll end up with a non-anion gap metabolic acidosis.
• 13:18
  SPEAKER_00: So your bicarb will drop to like 18 or 15 or whatever, depending on how much you give, because it can't do anything with the negatively charged chloride.
• 13:27
  SPEAKER_00: So it gets rid of the negatively charged bicarb, which it can do something with.
• 13:32
  SPEAKER_00: So you end up with just badness.
• 13:34
  SPEAKER_00: It causes acute kidney injury, it worses mortality, it's just overall bad if you give enough to cause that non-anion gap metabolic acidosis, right?
• 13:43
  SPEAKER_00: A lot of fluid.
• 13:44
  SPEAKER_00: A lot of fluid.
• 13:46
  SPEAKER_00: The argument lactated ringer is considered a balanced crystalloid.
• 13:51
  SPEAKER_00: It's not quite like normal, it's slightly acidotic.
• 13:56
  SPEAKER_00: But the reason that I don't love it, I used to just get irritated because everyone would be like, you can't give lactated ringer if they have a lactic.
• 14:05
  SPEAKER_00: I was like, it's not you're not giving them lactic acid, you're giving them lactic salt.
• 14:10
  SPEAKER_00: You can give it, it's fine.
• 14:12
  SPEAKER_00: The other part of it is the other part of it is I say it all the time.
• 14:20
  SPEAKER_02: I said it as a joke the other day to one of the doctors.
• 14:25
  SPEAKER_02: I was like, well, they got a bunch of uh LR, so maybe that's where the lactate's coming from.
• 14:30
  SPEAKER_02: And he looked at me like I was really stupid.
• 14:32
  SPEAKER_02: I was like, that's a joke.
• 14:34
  SPEAKER_02: That was a joke.
• 14:35
  SPEAKER_00: Oh God.
• 14:37
  SPEAKER_00: Uh but it has a sodium of 130, so it's actually slightly on the hypotonic side.
• 14:43
  SPEAKER_00: So it doesn't really matter if you're giving like a couple of liters, but if you're like in septic shock resuscitation, it is on the more hypotonic side.
• 14:52
  SPEAKER_00: So a lot more of it's gonna leak out into the interstitium, so it's not gonna be as efficient as other fluids.
• 15:00
  SPEAKER_00: I really like normosol and plasmolite.
• 15:03
  SPEAKER_00: So those are like more of a balanced crystal.
• 15:06
  SPEAKER_00: It has a pH of 7.4, it has a sodium of 140.
• 15:10
  SPEAKER_00: It does lean slightly basic.
• 15:13
  SPEAKER_00: People get really nervous about it uh because it's they say it's super expensive, which it isn't.
• 15:19
  SPEAKER_00: They say, well, it's mixed with stuff, right?
• 15:21
  SPEAKER_00: So you can't like run other things with it.
• 15:24
  SPEAKER_00: Uh like you can push saline behind anything and it's going to be like compatible or whatever, versus having things like magnesium or calcium or different uh electrolytes that can make things a little bit that people worry about with it.
• 15:39
  SPEAKER_00: But it it's still a uh my favorite way of giving crystalloid.
• 15:43
  SPEAKER_00: The reasons that I like it, A, it's balanced, so you're not gonna have that non-anion gap metabolic acidosis.
• 15:50
  SPEAKER_00: I like the fact that it's more isotonic than lactated ringer.
• 15:54
  SPEAKER_00: But one of the reasons I like it is that it is slightly basic.
• 15:57
  SPEAKER_00: So if you're giving somebody a norepinephrine drip, you're giving somebody antibiotics, let's say vancomycin or something, you're giving them just drips in general.
• 16:09
  SPEAKER_00: Every drip that you give somebody is going to be mixed in either D5W or it's mixed in normal saline.
• 16:19
  SPEAKER_00: Both of which are very, very acidotic.
• 16:22
  SPEAKER_00: Free water is acidotic.
• 16:23
  SPEAKER_00: We can't even give it to people.
• 16:25
  SPEAKER_00: They don't like for us to even give it to it through the IV.
• 16:27
  SPEAKER_00: Normal saline is also extremely acidotic, has like a pH of 5, 5.5.
• 16:33
  SPEAKER_00: So everything we give is pushing our patient towards acidosis.
• 16:37
  SPEAKER_00: So if I'm going to resuscitate somebody, I will resuscitate somebody that we would give something that's slightly alkalotic.
• 16:45
  SPEAKER_00: So at least it's trying to like normalize those.
• 16:47
  SPEAKER_00: So that's typically why I pick it with their on it.
• 16:53
  SPEAKER_00: I'll get into more of it as we don't do like our acid-based strong eye indifference talk, but that's kind of the short version, if you can say, this far into this talk of like why I give it.
• 17:04
  SPEAKER_02: Um density.
• 17:09
  SPEAKER_00: Yes.
• 17:10
  SPEAKER_00: This is as condensed as I can get it on the thing.
• 17:15
  SPEAKER_01: So it's hard.
• 17:18
  SPEAKER_01: I am passionate.
• 17:19
  SPEAKER_01: It's really hard to like.
• 17:22
  SPEAKER_02: I think too, like there are a lot of things that are like, for lack of a better term, in my brain right now, like old school way of like doing things.
• 17:32
  SPEAKER_02: And it's hard to beat culture.
• 17:35
  SPEAKER_02: So I feel like you do have to really come heavy with receipts when you're really talking about like, no, like this needs to change.
• 17:43
  SPEAKER_02: Like, we don't need maintenance fluids.
• 17:45
  SPEAKER_02: Like, you really have to like come strong because you're fighting a whole, you know, system, a whole country system of maintenance fluids.
• 17:57
  SPEAKER_00: I actually did this deep dive like six years ago, maybe more, 10 years ago, where I just was like so frustrated at maintenance fluids.
• 18:08
  SPEAKER_00: And I did this full deep dive, and I was just like, I want to find a paper that shows that if you give continuous fluids on these patients, it's shown a mortality benefit.
• 18:21
  SPEAKER_00: And I started looking at volume overload in studies, and basically between like 2000 and 2010, compared to like 2010 and 2020, there was a almost a 400% increase in the number of papers that dealt with fluid overload and the consequences of volume overload in patients in that second 10 years.
• 18:41
  SPEAKER_00: Like it became like a huge topic, and people were starting to get on board with it.
• 18:46
  SPEAKER_00: And then I did my talk and was, or I did my study and was like, it can I just search and find something that says, without a doubt, there's a mortality benefit to continuous fluids.
• 18:55
  SPEAKER_00: The only paper, and this was like me mainly looking in surgery patients because that's who seems to get into surgical ICU, seems to be getting maintenance fluids.
• 19:05
  SPEAKER_00: We don't do it as much in like medical ICU these days and definitely not in like the other ICUs.
• 19:12
  SPEAKER_00: And the only one I could find was post-kidney transplant.
• 19:16
  SPEAKER_00: There there is research that has showed that it that you should probably have continuous fluids going in in people that are post-kidney transplant, like immediately postdoc.
• 19:28
  SPEAKER_02: I guess maybe it makes sense for that organ.
• 19:31
  SPEAKER_02: Sure.
• 19:32
  SPEAKER_00: Like just constantly trying to flush it and just have like an in-and-out type of a thing.
• 19:36
  SPEAKER_00: That was it.
• 19:37
  SPEAKER_00: That was the only one I could find.
• 19:38
  SPEAKER_00: And I I wanted to be wrong, right?
• 19:41
  SPEAKER_00: Like I wanted to be like I tried to like take away my bias and be like, I'm trying to at least apply my bias to this one.
• 19:52
  SPEAKER_00: I wanted to I wanted to find something so that I wouldn't be so frustrated by it.
• 19:58
  SPEAKER_00: To be like, okay, I could see how somebody could get here all calm down or whatever.
• 20:05
  SPEAKER_00: And still I couldn't find anything from it.
• 20:08
  SPEAKER_00: Couldn't do it though.
• 20:10
  SPEAKER_02: You didn't want to be wrong.
• 20:12
  SPEAKER_02: You just wanted to give a justification for someone else's actions where you could maybe understand, but still argue why you were right.
• 20:20
  SPEAKER_02: Sure.
• 20:20
  SPEAKER_00: Yeah.
• 20:20
  SPEAKER_00: I could like me be more right than they were right.
• 20:23
  SPEAKER_00: Yeah, yeah, sure.
• 20:24
  SPEAKER_00: I'm sure that's probably uh that's probably a more accurate statement on there with it.
• 20:29
  SPEAKER_00: Um But it, I mean, it's become such a big deal.
• 20:38
  SPEAKER_00: It's become such a big deal that I I would I would also want to give another talk about deresuscitation, right?
• 20:45
  SPEAKER_00: Like talk about not just about giving all these fluids, but like understanding how to remove all these fluids and like the the things that come up with it.
• 20:55
  SPEAKER_00: Um Dr.
• 20:56
  SPEAKER_02: Michael, we can do as many talks as you want.
• 20:59
  SPEAKER_00: So there's this thing, there's this thing called like the Rose concept.
• 21:03
  SPEAKER_00: I don't know if you guys know about this.
• 21:06
  SPEAKER_02: No.
• 21:06
  SPEAKER_00: So it's like resuscitation, optimization, stabilization, and then like evacuation.
• 21:12
  SPEAKER_00: Like it's the idea of how whenever you have a person in like septic shock, you want to resuscitate them.
• 21:20
  SPEAKER_00: That's the R part of Rose.
• 21:23
  SPEAKER_00: And in that, you as you put that in there, you want to do that over like minutes.
• 21:31
  SPEAKER_00: So you're giving them all that fluid over the first hour, like you're trying to do it in a very short time span.
• 21:37
  SPEAKER_00: You're trying to get them out of shock.
• 21:39
  SPEAKER_00: Then you have like optimization, right?
• 21:42
  SPEAKER_00: You've given them their first little like couple liters of fluid.
• 21:46
  SPEAKER_00: Now you're maybe starting pressors, you're maybe gonna give them a little bit more fluid.
• 21:50
  SPEAKER_00: So if you look at like total fluid balance, then you're talking about how you're gonna give a lot of fluid in that first hour to try to like get them out of shock.
• 22:00
  SPEAKER_00: You're maybe going to give a little bit more fluid over the next day, but then you get to the stabilization area where you actually start trying to remove fluid.
• 22:09
  SPEAKER_00: And so if you look at organ failure, patients are in organ failure when they present in shock, because that's the definition of shock or organ injury.
• 22:18
  SPEAKER_00: And so as you resuscitate them, you're going to get them out of organ injury or organ failure.
• 22:23
  SPEAKER_00: But then day two or day three, they are actually start getting organ failure again because all that fluid that you gave, that six, seven, eight liters of fluid, is just hanging out inside the body.
• 22:35
  SPEAKER_00: And you have things like your kidneys are surrounded by a layer of fascia called gyrotius fascia.
• 22:41
  SPEAKER_00: So your kidneys cannot grow.
• 22:43
  SPEAKER_00: Your liver can swell, your intestines can swell.
• 22:46
  SPEAKER_00: Basically, most of your organs can swell.
• 22:49
  SPEAKER_00: Your brain can't swell because it's encased in skull, and your kidneys can't swell because it's encased in gyrotius fascia.
• 22:55
  SPEAKER_00: So anytime you have edema, edema of your kidneys is bad, you end up with an acute kidney injury very quickly because it just is getting crushed within its itself as you do that.
• 23:07
  SPEAKER_00: So deresuscitating, getting that volume off becomes huge.
• 23:11
  SPEAKER_00: That's like a whole separate talk.
• 23:13
  SPEAKER_00: And talking about fluid balances.
• 23:16
  SPEAKER_00: So talking about fluid like cumulative fluid balance, talking about daily fluid balance, talking about uh losses, talking about like total output, talking about your output of saying fluid creep.
• 23:28
  SPEAKER_00: Fluid creep is a whole other thing that I wanted to absolutely talk about.
• 23:32
  SPEAKER_00: We can talk about it since I didn't like talk about it on the thing with it.
• 23:35
  SPEAKER_00: But fluid creep is huge.
• 23:37
  SPEAKER_00: That's like a big thing that I like to talk about that people don't realize.
• 23:42
  SPEAKER_00: So fluid creep is the idea is that we have obligate ends.
• 23:48
  SPEAKER_00: Obligate ends is not realizing that when you order stuff, you have to give it, right?
• 23:55
  SPEAKER_00: If you order vancomycin, it could be a 500 ml bag of vancomycin.
• 24:00
  SPEAKER_00: If you order um IV sodium foss, it could be a 500 ml bag.
• 24:05
  SPEAKER_00: Sometimes it's like a liter bag if you're giving like a large amount.
• 24:08
  SPEAKER_00: If you have norepinephrine in a drip, if it's not concentrated, you could be giving, you know, 40, 50, 60 milliliters an hour.
• 24:18
  SPEAKER_00: Uh, it adds up.
• 24:19
  SPEAKER_00: So you may be like, How much fluid did you give your patient today?
• 24:22
  SPEAKER_00: And you're like, I gave them one liter bolus.
• 24:24
  SPEAKER_00: And you look and they got six liters of fluid total because of all this like other things you didn't account for.
• 24:31
  SPEAKER_00: And so that's that fluid creep.
• 24:33
  SPEAKER_00: But people don't realize it.
• 24:34
  SPEAKER_00: They'll be like, people don't.
• 24:36
  SPEAKER_00: They'll be yeah.
• 24:37
  SPEAKER_00: Yeah, they'll be like, did you give yourself did you give your patient a lot of fluid today?
• 24:41
  SPEAKER_00: Nope.
• 24:41
  SPEAKER_00: Gave them one liter.
• 24:43
  SPEAKER_00: Because they just don't think about you.
• 24:46
  SPEAKER_00: And bedside nurses know this because they're the ones hanging it, being like, I am giving, I got seven channels here.
• 24:52
  SPEAKER_00: I am like pounding this person with fluid.
• 24:55
  SPEAKER_00: And they'll be like, Do you have the maintenance fluid on?
• 24:57
  SPEAKER_00: I think they're gonna get dry.
• 24:59
  SPEAKER_00: And you're like, they have more leva fed running in milliliters an hour than they have maintenance fluid.
• 25:04
  SPEAKER_00: They're not gonna get dry.
• 25:06
  SPEAKER_01: But yeah, now we have to dialize them simply because of all the leva fed working.
• 25:10
  SPEAKER_00: And you but but if you've never worked at the bedside, if you've never stood at the bedside, in their mind, they're like, Well, they're getting 100 cc's an hour of maintenance fluid.
• 25:19
  SPEAKER_00: That's all I'm giving them.
• 25:23
  SPEAKER_00: And so like fluid creep becomes huge.
• 25:25
  SPEAKER_00: They did a study and they looked at like how much fluid people were getting, and two-thirds of the fluid they were getting were just fluid that were diluents, like they were just dilutants in stuff, like to give your levifed, to give your electrolytes, to give whatever you're giving your antibiotics.
• 25:41
  SPEAKER_00: And it it adds up.
• 25:43
  SPEAKER_01: Yeah.
• 25:44
  SPEAKER_01: Like you said, a liter bag for some sodium fossil or whatever.
• 25:47
  SPEAKER_01: And I'm like, the patient can take a pill.
• 25:51
  SPEAKER_00: I mean, they're gonna be able to do it.
• 25:54
  SPEAKER_00: All this time trying to diurese them, you're spending like so much time time trying to diurese, and then they'll order like peripheral potassium.
• 26:03
  SPEAKER_01: Yeah.
• 26:03
  SPEAKER_00: And then they're like, well, you just gave it all back.
• 26:06
  SPEAKER_00: So great.
• 26:08
  SPEAKER_00: Um yeah.
• 26:10
  SPEAKER_02: We can give it PS.
• 26:11
  SPEAKER_02: I the other thing too about like fluid creep that I don't I've had to teach people is that you have to think about what's in it too, like what you're mixing the bank in.
• 26:23
  SPEAKER_02: And I recently was talking to a learner and I was like, ooh, like this is not going well.
• 26:29
  SPEAKER_02: They're hypoglycemic, and they're like, just add dextrose.
• 26:32
  SPEAKER_02: I'm like, literally, everything running right now is mixed in dextrose.
• 26:36
  SPEAKER_02: I was like, every single jerk they're currently on is mixed in dextrose, they're getting D5 constantly.
• 26:43
  SPEAKER_02: I was like, so the fact that they're still like I'm having to add on more, I was like, that tells me their liver is dying.
• 26:52
  SPEAKER_02: And they were like, I never thought of that.
• 26:54
  SPEAKER_02: And it's like you just think it's bank, but it's it's bank mixed in something.
• 26:59
  SPEAKER_02: It's potassium mixed in something.
• 27:02
  SPEAKER_00: Yeah, 100%.
• 27:03
  SPEAKER_00: And you can even like you could go the other way with it though, to be like, this person's uh hypernatremic.
• 27:10
  SPEAKER_00: Uh, can you a lot of times you can switch what your stuff is mixed in and like be like, can you mix your stuff in D5W or the other way around?
• 27:18
  SPEAKER_00: Can you mix their sugars are out of control?
• 27:22
  SPEAKER_00: You mix it in like something else with it.
• 27:25
  SPEAKER_00: So it's important to know.
• 27:27
  SPEAKER_00: And I like you, like you know, I really like you know, having these different viewpoints on this of just being like, for you, that's super easy to be like, yeah, we're giving this person a ton of fluid.
• 27:38
  SPEAKER_00: But someone that's I, you know, I had never been at the bedside, and you know, you go to med school and then you're all of like you don't know that world until you want to spend time at the bedside and realize all the stuff you don't know.
• 27:51
  SPEAKER_02: Yeah.
• 27:52
  SPEAKER_02: It's easy too when you're physically hanging it and you're like, this is a lot.
• 27:58
  SPEAKER_02: Yeah, it's like the practical side.
• 28:00
  SPEAKER_01: You know, it's like you have the the this like what you what you've learned, what you know, but then it's like the practical side of medicine and nursing that you just don't realize until you're doing it.
• 28:11
  SPEAKER_01: Like exactly what you said.
• 28:12
  SPEAKER_00: And and there's so many times, right?
• 28:14
  SPEAKER_00: Like I'm you I've had where like we'll have learners that are like residents or fellows, and the nurse will come up to them and be like, hey, I'm putting 150 cc's an hour of Leva Fed.
• 28:27
  SPEAKER_00: Do you want me to order the concentrated LeviFed?
• 28:29
  SPEAKER_00: Could we maybe do that?
• 28:30
  SPEAKER_00: And they're like, oh yeah, like we should do that.
• 28:33
  SPEAKER_00: But it's like it's oftentimes not necessarily the provider's idea.
• 28:38
  SPEAKER_00: It's oftentimes the nurse bringing it to your attention to be like, hey, not only am I having to rehang a new bag like every hour and a half, but like overall I've given them so much fluid.
• 28:48
  SPEAKER_00: Let's just like concentrate it so we're not doing it uh so often on stuff.
• 28:53
  SPEAKER_01: Yeah.
• 28:53
  SPEAKER_01: But they're new, they gotta learn.
• 28:56
  SPEAKER_01: I remember one day this patient was so acidotic they were unwell.
• 28:59
  SPEAKER_01: Um you were wanted us to start CRT and you wanted us to run it at 999, and you wanted to hypertonic bicarb, and the pharmacist was not understanding about the hypertonic bicarb, and you were trying to explain it to them.
• 29:14
  SPEAKER_01: It's like they didn't get what you wanted them to mix.
• 29:15
  SPEAKER_01: They were like, that's not a thing.
• 29:17
  SPEAKER_01: And it was so busy.
• 29:20
  SPEAKER_01: And I was just like, What is what is happening?
• 29:24
  SPEAKER_01: I've never done any of this before.
• 29:26
  SPEAKER_01: This patient is crashing.
• 29:27
  SPEAKER_01: I'm I have another patient.
• 29:28
  SPEAKER_01: He wants 999, like this patient's gonna die.
• 29:31
  SPEAKER_01: And then we started doing it all, and the patient got better.
• 29:33
  SPEAKER_02: I was like, Good.
• 29:37
  SPEAKER_01: I'm having the patient's better, but the whole time I remember that going, Oh, you make me do all this for nothing.
• 29:43
  SPEAKER_01: And then it started working.
• 29:44
  SPEAKER_01: I was like, that's amazing.
• 29:46
  SPEAKER_01: This patient's getting better.
• 29:48
  SPEAKER_01: I was like, now I'm gonna be doing this all the time.
• 29:56
  SPEAKER_02: Oh yeah.
• 29:57
  SPEAKER_02: Well, we can definitely have you back soon to give us your CID lecture and deresuscitation.
• 30:03
  SPEAKER_02: You're always welcome to come back.
• 30:04
  SPEAKER_02: Our audience definitely loves these education episodes.
• 30:08
  SPEAKER_02: But any final thoughts before we close out?
• 30:12
  SPEAKER_00: There's a couple of papers out there that says you should treat fluids as a prescription, like a medication, and like treat it like you would to say what are the side effects, what are the the harm that could come from it?
• 30:24
  SPEAKER_00: And I I wish people would do that more.
• 30:26
  SPEAKER_00: I know it's kind of like whatever to say it like that, but like there's so many people that you you call them and you're like, hey, your patient's hypotensive, and they're like, give them another liter and call me back, you know, in an hour.
• 30:39
  SPEAKER_00: And I'm like, it has consequences.
• 30:41
  SPEAKER_00: Like it's not just like, oh, that's super benign, just give them another liter and it's not gonna make a difference.
• 30:47
  SPEAKER_00: Like every time I'm I'm I'm ordering a liter of fluid or 500 or whatever, I'm thinking about, you know, like what do I want to see response-wise?
• 30:57
  SPEAKER_00: What do I want to accomplish with this?
• 31:00
  SPEAKER_00: And then just going back to the bedside, like and looking at it, it just like you would treat any other medication that you would give.
• 31:07
  SPEAKER_00: I've seen fluid do bad things, I've seen fluid do amazing things.
• 31:12
  SPEAKER_00: So I just I I wish people treated with a little bit more respect, did maybe a deeper dive and tried to pick the correct fluid, the right time for the fluid, and just kind of put a little bit more thought into it.
• 31:25
  SPEAKER_02: Yeah, I think that's a great call out because it is you do need to be a prescriber to give this, to give these, you not just anyone can give fluids, like you have to have a certain level of training.
• 31:39
  SPEAKER_02: So I think that's a great call out.
• 31:40
  SPEAKER_02: But well, thanks for joining us again.
• 31:43
  SPEAKER_02: We had fun, we learned.
• 31:46
  SPEAKER_02: If you are still with us, send us your questions, send us your comments, make sure you hit the likes, the follow button.
• 31:52
  SPEAKER_02: Dr.
• 31:52
  SPEAKER_02: Michael will be back to give us more lectures on the kind of the continuation of fluid, Sid, strong iron ion difference.
• 32:02
  SPEAKER_02: If you don't know what that is, it is actually a really great lecture.
• 32:05
  SPEAKER_02: I've sat through it many a time.
• 32:07
  SPEAKER_02: And I could use a refresher after a number of years.
• 32:10
  SPEAKER_02: But from all of us shift talkers here at Banter at the Bedside, until next time.
• 32:15
  SPEAKER_02: Bye.
• 32:17
  SPEAKER_02: Bye.
• 32:17
  SPEAKER_02: Bye.
• 32:19
  SPEAKER_02: If this felt your kind of conversation, make sure you're following, leave us a review, and we'll see you back here soon.
• 32:26
  SPEAKER_02: Bye.
• 32:27
  SPEAKER_02: Step into the light where the stories come.