Re: [Sepsis Groups] NSS vs Albumin (UNCLASSIFIED)

[Thomas Morris]

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" 
<lee.can...@us.army.mil> 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." <gkra...@utmb.edu> 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
>georgekra...@gmail.com
>
>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: gkra...@utmb.edu
>http://www.utmb.edu/rrl/
>
>
>G
>
>
>
>
>
>From: 
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<peggy.siene...@hcahealthcare.com<mailto:peggy.siene...@hcahealthcare.com(javascript:main.compose()>>
>Date: Wednesday, April 17, 2013 12:39 PM
>To: 
"alecia.katza...@readinghealth.org<mailto:alecia.katza...@readinghealth.org(javascript:main.compose()>" 
<alecia.katza...@readinghealth.org<mailto:alecia.katza...@readinghealth.org(javascript:main.compose()>>, 
"sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org(javascript:main.compose()>" 
<sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.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: 
sepsisgroups-boun...@lists.sepsisgroups.org<mailto:sepsisgroups-boun...@lists.sepsisgroups.org(javascript:main.compose()> 
[mailto:sepsisgroups-boun...@lists.sepsisgroups.org](javascript:main.compose() 
On Behalf Of Katzaman, Alecia
>Sent: Monday, April 15, 2013 3:10 PM
>To: 
'sepsisgroups@lists.sepsisgroups.org<mailto:'sepsisgroups@lists.sepsisgroups.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
>
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