Anyone have good resource for fluid resuscitation?

[e_is_hv]

Hey All,

sorry to bother you, but I just can not seem to find a good resource for learning fluid resucitation. TO notes does an ok job I guess, but our lectures have been poor, and I get very quick explanations from residents - nothing concrete. Anyone know of a particularly good resource? Papers or books are fine - I'll take anything.

Many thanks!

[ploughboy]

Originally Posted by e_is_hv

Hey All,

sorry to bother you, but I just can not seem to find a good resource for learning fluid resucitation. TO notes does an ok job I guess, but our lectures have been poor, and I get very quick explanations from residents - nothing concrete. Anyone know of a particularly good resource? Papers or books are fine - I'll take anything.

Many thanks!

Stick in a foley, give 'em a few litres of fluid, watch the lactate trend and see what happens. If they start to sound wet, back off and bipap prn. I'm guessing that's the sort of explanation you've gotten from residents, and you've just gotten it again!

The original Rivers trial is N Engl J Med 2001;345:1368-1377 Then read the results of the Feast Trial just published in N Engl J Med 2011; 364:2483-249 and cry yourself to sleep in dispair thinking: Even though these were two very different patient populations, how can both studies be right?

For fun you might also want to look at the FACTT trial N Engl J Med 2006; 354:2564-2575.

[leviathan]

That's a really interesting study plough. I guess as you said, they are two very different populations. For one the kids were probably all anemic from the malaria. Getting further hemodiluted from fluid boluses is probably not so good for oxygen delivery in a shock setting. But of course if you're not perfusing at all then it doesn't matter what your Hgb level is...

I've also wanted to find a good guide for choosing the proper fluid type in maintenance, like when to use 1/2NS vs D51/2NS vs NS vs LR etc.

[A-Stark]

Well, to boil it down as follows...

Shock is bad. Shock means hypoperfusion.
Hypotension means shock.
Shock does not necessarily mean hypotension.
For hypotension give fluid. And then more fluid. If that fluid doesn't work, give more fluid and/or packed red cells. And if that still doesn't work give pressers and/or inotropes.
Ventilate as needed.
If there's too much fluid, use diuresis. Or dialysis if the kidneys don't work.

Oh, and treat the cause.

[leviathan]

Originally Posted by A-Stark

Well, to boil it down as follows...

Shock is bad. Shock means hypoperfusion.
Hypotension means shock.
Shock does not necessarily mean hypotension.
For hypotension give fluid. And then more fluid. If that fluid doesn't work, give more fluid and/or packed red cells. And if that still doesn't work give pressers and/or inotropes.
Ventilate as needed.
If there's too much fluid, use diuresis. Or dialysis if the kidneys don't work.

Oh, and treat the cause.

http://survivingsepsis.org/ for a good algorithm to follow. This is all for sepsis though and OP didn't specify what kind of context he was referring to fluid resuscitation. For example if it's a trauma, you want to do the exact opposite and minimize how much fluid you give, just giving enough to keep MAP adequate to perfuse the vital organs (permissive hypotension) to maximize hemostasis and reduce bleeding. And avoid giving anything besides blood as much as possible. If you predict you will be giving massive transfusions then you try to give 1:1:1 for PRBCs : plasma : platelets.

[ploughboy]

Originally Posted by leviathan

http://survivingsepsis.org/ for a good algorithm to follow. This is all for sepsis though and OP didn't specify what kind of context he was referring to fluid resuscitation. For example if it's a trauma, you want to do the exact opposite and minimize how much fluid you give, just giving enough to keep MAP adequate to perfuse the vital organs (permissive hypotension) to maximize hemostasis and reduce bleeding. And avoid giving anything besides blood as much as possible. If you predict you will be giving massive transfusions then you try to give 1:1:1 for PRBCs : plasma : platelets.

The papers coming out of America's recent imperial misadventures etc are on my "to read" list, but what I've heard from my trauma/icu staff is that the evidence supporting 1:1:1 transfusion has a potentially huge survivor bias embedded in it. Although there are "massive transfusion" protocols at the sites where I work, the actual components of a resuscitation still seem to depend very much on who is talking the loudest during the resuscitation. What are you finding where you work?

pb

PS - not picking on you or being argumentative, just tossing ideas out there...

[ploughboy]

Originally Posted by leviathan

That's a really interesting study plough. I guess as you said, they are two very different populations. For one the kids were probably all anemic from the malaria. Getting further hemodiluted from fluid boluses is probably not so good for oxygen delivery in a shock setting. But of course if you're not perfusing at all then it doesn't matter what your Hgb level is...

I dunno...across all groups only about 1/3 of the patients had a Hgb < 50 (I don't know how many had a Hgb 50-70). And to play the Devil's Advocate: the Blobbogram in Figure 3 shows that even in the malaria negative children, no bolus was better, although the limits come perilously close to crossing the 1.00 line. I'm no statistician and I really don't get off on clin epi but I would think that if this was all due to malaria then the non-malarial group would have been statistically different than the malaria kids.

I dunno. All I know is that among the folks I hang out with a lot of people are saying "WTF?" when they talk about this study, not because of how the study was run (which appears solid) but because of the results.

[leviathan]

Originally Posted by ploughboy

I dunno...across all groups only about 1/3 of the patients had a Hgb < 50 (I don't know how many had a Hgb 50-70). And to play the Devil's Advocate: the Blobbogram in Figure 3 shows that even in the malaria negative children, no bolus was better, although the limits come perilously close to crossing the 1.00 line. I'm no statistician and I really don't get off on clin epi but I would think that if this was all due to malaria then the non-malarial group would have been statistically different than the malaria kids.

I dunno. All I know is that among the folks I hang out with a lot of people are saying "WTF?" when they talk about this study, not because of how the study was run (which appears solid) but because of the results.

Yeah, I wonder if they could study this in all-comer pediatric shock patients in North America, to see outcomes of bolus vs. maintenance fluids? It probably wouldn't get by an ethics review board though because people would say exactly that "WTF?" when you tried to propose it.