Tom, More opinionated interpretation of the literature from you NSH physiologist.
Lee's references was NS vs balanced electrolyte of colloid (starch) solutions. Colloids most likely have no value for head injury. The blood brain barrier does not respond to oncotic (colloid osmotic) pressure gradients, but to osmotic pressure gradients. Systemic capillaries respond to oncotic and limited response to osmotic gradients. Colloids do reduce total volume requirements, even with permeability leaks. Better volume expanders in smaller volumes. However, starches in large volume have serious bad effects. I believe starches are almost killed by convincing recent meta analysis and/or multi center trial. Itching, renal failure, coagulopathy I don't believe the renal failure of starches is due to the NS, but it may be made worst when in a NS carrier. Again, these mostly show up in large volumes. Data in small volumes is not known, maybe the effect is still there, but small or maybe there is no deleterious effect. This is same about the argument. Is a little radiation without harm or just less harmful. Recent starch trials and the shameful fraud by Dr. J. Boldt has generated much less confidence in starch. More interest in albumin and FFP. I must say though, maybe Boldt was a crook, I suspect is dishonesty crept up over time. And some of his work was mostly hones, and even his fraud does not mean that all is conclusion should be reversed, just that we can not use them as positive evidence. Yes, UK and Duke, US, (with UK transplants on faculty) lead the movement educating the "normal saline is not normal and dangerous and should be dead." As to Na and and sugar, ok for maintenance fluid, maybe for dehydration, but not for shock, you need the salt, during the resuscitation phase. Na and its obligatory other balance electrolytes. American really like salt and sugar in their diets, and why we are so fat. But another story. By the way the 'bad' D-lactate, the racemic mixtures, are not found in US LR anymore. The industry quietly changed to all L-Lactate when there was concern. FDA never stepped in. Industry can sell either mixtures or pure L-Lacate. But industry did believe the dangers of D-Lactate, US Baxter and Abbott, did. I also believe large large volumes of NaCl or racemmic LR are dangerous, but the later is not a concern in the US as it is not on the market. As far as I know. If in doubt about your hospital's LR or Hartman's send a syringe of it to the lab for a lactate value. I think most chem labs and some blood gas machines can run clear fluid lactate test, some instruments report error as there are no red cells. Some cranky lab folks refuse to run it. I feel that all the early work in the 1990's and scare of LR by Rhee and colleagues and others is totally bogus and irrelevant to current LR solutions in the US. Above is opinionated and maybe some out of date or misinterpretations on my part. g On 4/20/13 7:16 AM, "Thomas Morris" <[email protected]> wrote: >Thanks Leopoldo > >Although this paper uses a concept other than sepsis >(brain injury), it is interesting to note that N. saline >can indeed cause hyperchloraemic acidosis if used alone >for 48 hrs, and that in separate small/animal studies, >this correlates with reduced renal function. > >I don't think anyone in the UK would ever give just N. >saline alone for this long in sepsis though, without >alternating with 5% dextrose or D/saline, and part of >surgical training in the UK, certainly, is to give "one >salt for every two sweet (ie. litre bags)" for >maintenance. > >We do have tetraspan in the UK National Formulary (BNF), >although I can't see Isofundine or other balanced >crystalloid in there. At the moment I think our practice >is to alternate N. saline with 5% dextrose, perhaps erring >on the side of slightly more saline to give it a lean >towards volume expansion. > >Q: Does anyone want to correct me on this wrt. UK >practice? >Q: Does anyone know about the impact of using >lactate-containing solutions such as Hartmann's which has >29mmol/L of lactate in it for sepsis? > >Thanks very much indeed > >Tom Morris > > >On Sat, 20 Apr 2013 01:21:06 -0400 > "Cancio, Leopoldo C COL MIL USA USAMEDCOM" ><[email protected]> wrote: >> UNCLASSIFIED >> info >> >> Balanced versus chloride-rich solutions for fluid >>resuscitation in brain-injured patients: a randomized >>double-blind pilot >>study(blockedhttp://ccforum.com/content/pdf/cc12686.pdf) >> Roquilly A, Loutrel O, Cinotti R, Rosenczweig E, Flet L, >>Mahe P, Dumont R, Chupin A, Peneaux C, Lejus C, Blanloeil >>Y, Volteau C, Asehnoune K >> Critical Care 2013, 17:R77 (19 April 2013) >> >> >> On 04/19/13, Thomas Morris wrote: >>> Hi George >>> >>> Thanks for that: my main feeling is that the ideal fluid >>>to give in severe sepsis/shock would presumably be >>>plasma, or the exact consituents of that which leak out >>>of the capillaries. Clearly this is not going to be >>>possible, so, whilst it is important to ascertain which >>>fluids are better (or least futile, dare I suggest it) >>>than others, what we clearly also need are better >>>adjunctive therapies for sepsis (ie. alongside >>>antibiotics) to help switch off the SIRS and capillary >>>leak, rather than just focussing on which horses are >>>running away. Make any sense? >>> >>> Two questions from me while we wait for an effective >>>adjunctive treatment to come out: >>> >>> i) Are the lactate components of Ringers' or Hartmann's >>>anything to worry about? >>> >>> ii) How much Normal Saline can we give before >>>hyperchloraemic acidosis becomes an issue. >>> >>> Thanks very much indeed >>> >>> Tom Morris >>> Infectious Disease/General Medicine Registrar >>> Leicester, UK >>> >>> >>> On Fri, 19 Apr 2013 11:06:45 +0000 >>> "Kramer, George C." <[email protected]> wrote: >>> >A perspective from a not so humble physiologist >>>studying fluid resuscitation of shock. >>> > >>> >Large volumes of Normal Saline can contribute to >>>hyperchoremic acidosis and renal dysfunction. Normal >>>saline is not normal. >>> > >>> >Lactated Ringers or better Plasmalye are electrolyte >>>balanced. plasmalyte is isotonic. Normal saline is >>>hypertonic (maybe ok, except for the chloride), but LR is >>>hypotonic, can contribute to cerebral edema. In large >>>volumes. >>> > >>> >In small volumes or relatively 'healthy' patients these >>>differences are not important. >>> > >>> >Albumin ‹ best available evidence from mortality >>>outcomes, is Albumin is not better and may be worst. >>>However, when you need rapid boast to cardiovascular >>>function it is superior. Many suggest that mortality >>>outcomes is not the whole story. And the trial data is >>>muddled. And the meta-analyses are flawed. >>> > >>> >The downside of albumin may be that it leaks into >>>interstitial space some and holds water and long term is >>>worst. Lung may be particularly concern. This is more >>>likely when you have permeability leak and you have that >>>big time with sepsis. >>> > >>> >These topics remain controversial by experts in fluid >>>space and under appreciated and confusing to non experts. >>> > >>> >Best email for me is >>> >[email protected] >>> > >>> >George C Kramer, PhD >>> >Director, Resuscitation Research Lab >>> >Professor, Dept. of Anesthesiology >>> >301 University Blvd. >>> >UTMB, Galveston, TX 77555-1102 >>> > >>> >Office (Mary) 409-747-0077 >>> >Direct: 409-772-3969 >>> >Cell: 409-939-3040 >>> >Lab (Muzna) 409-772-6885 >>> >Fax: 409-772-8895 >>> >UTMB email: [email protected] >>> >http://www.utmb.edu/rrl/ >>> > >>> > >>> >G >>> > >>> > >>> > >>> > >>> > >>> >From: >>>"[email protected]<mailto:[email protected] >>>m(javascript:main.compose()>" >>><[email protected]<mailto:[email protected] >>>m(javascript:main.compose()>> >>> >Date: Wednesday, April 17, 2013 12:39 PM >>> >To: >>>"[email protected]<mailto:Alecia.Katzaman@readinghealth. >>>org(javascript:main.compose()>" >>><[email protected]<mailto:Alecia.Katzaman@readinghealth. >>>org(javascript:main.compose()>>, >>>"[email protected]<mailto:[email protected] >>>ups.org(javascript:main.compose()>" >>><[email protected]<mailto:[email protected] >>>ups.org(javascript:main.compose()>> >>> >Subject: Re: [Sepsis Groups] NSS vs Albumin >>> > >>> >Usually we see NSS in ED and recently the Intensivists >>>started adding Albumin to continued need for NSS boluses. >>> > >>> >From: >>>[email protected]<mailto:sepsisgroups-bounces@ >>>lists.sepsisgroups.org(javascript:main.compose()> >>>[mailto:[email protected]](javascript:main.com >>>pose() >>>On Behalf Of Katzaman, Alecia >>> >Sent: Monday, April 15, 2013 3:10 PM >>> >To: >>>'[email protected]<mailto:'[email protected] >>>oups.org(javascript:main.compose()>' >>> >Subject: [Sepsis Groups] NSS vs Albumin >>> > >>> >What does everyone do in terms of fluid resuscitation >>>do you give NSS or Albumin? What do you do in the ED? DO >>>you have a limit of NSS that is given before Albumin is >>>given, or is provider specific? >>> > >>> >Alecia Katzaman, MSN, RN >>> >Emergency Department Quality Improvement Coordinator >>> > >>> >[Description: Description: RHLogo_Email] >>> > P.O. Box 16052 >>> > Reading, PA 19612-6052 >>> > >>> >>>>[email protected]<mailto:Alecia.Katzaman@readinghealth. >>>>org(javascript:main.compose()> >>> >www.readinghealth.org<http://www.readinghealth.org/> >>> >PHONE: 484-628-4810 >>> > >>> >Advancing Health. Transforming Lives. >>> > >>> > >>> >________________________________ >>> > >>> >----- Email Disclaimer ----- >>> >This email and any files transmitted with it are >>>confidential and are intended for the named recipient(s). >>>If you are not the intended recipient, you are hereby >>>notified that you have received this communication in >>>error and that any copying, disclosure, dissemination, >>>distribution or review of it or its contents is >>>prohibited. If you have received this email in error, >>>please notify the sender and immediately delete this >>>email from your system. >>> >--------------------------------------- >> UNCLASSIFIED _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
