June 11, 2020

Background: In end-stage renal disease (ESRD) patients on hemodialysis (HD), infection is the second most common cause of mortality after cardiovascular disease (Sarnik 2000). Because of the systemic inflammation and increased capillary permeability, septic patients are at significant risk for fluid imbalances and frequently require large volumes of crystalloids. The Surviving Sepsis Campaign guidelines provide a strong recommendation with low quality of evidence for administering a 30mL/kg fluid bolus within 3 hours of recognition of sepsis-induced hypoperfusion (Rhodes 2016). Further fluid administration should be guided by hemodynamic assessment (bedside echocardiography, passive leg-raise, etc.). In the general population, this early administration of fluids to patients with hypotension or sepsis-induced hypoperfusion has been associated with improved outcomes. However, there is significant confusion regarding the effects of a large 30mL/kg bolus on ESRD patients due to a lack of studies. While these patients may appear, volume overloaded on physical exam, they may be intravascularly volume deplete. Physicians may be hesitant to administer a large fluid bolus in ESRD patients because of the risk of precipitating cardiogenic shock, pulmonary edema, and respiratory failure. In fact, multiple studies show that patients who have ESRD are less likely to receive the full 30mL/kg fluid bolus compared to non-ESRD patients (Lowe 2018, Truong 2019, Dagher 2015). Furthermore, some studies show equivalent outcomes between ESRD patients who receive the full bolus and those who do not. We will review two studies that examined this topic.

April 8, 2020

Take Home Points
  1. Hyperthyroidism can present along a spectrum from the minimally symptomatic to severely decompensated and presentation can vary with age
  2. If there are a lot of interconnecting systems complaints consider obtaibning a TSH, t3 and t4 
  3. Once you’ve diagnosed hyperthyroidism, dont anchor on it. Look for what might have caused it especially in those with comorbidities
  4. If the patient is stable and reliable you can discharge them home with Atenolol. Make sure to have the patient follow up with their PCP or Endocrinologist. If, however, you feel uncomfortable doing that or the patient needs more social support, call your endocrinologist on call and get their recommendations.

January 29, 2020

Take Home Points

  • When compared to 0.9% saline, lactated ringers is a more balanced solution and more closely resembles our serum.
  • SALT ED and SMART trials show normal saline may increase the occurrence of major adverse kidney events in comparison to a balanced solution like LR. For large volume resuscitations, LR is a better choice.
  • Certain medications cannot be run with LR in the same IV line. Ampicillin, Carbapenems, Phenytoin, Potassium Phosphate, Nicardipine
  • Ceftriaxone and LR should never be running at the same time in children less than 28 days old.

December 5, 2019

Background: Saline (0.9% sodium chloride) has historically been one of the most common intravenous fluids administered in critically ill adults.  However, the supraphysiologic chloride concentration can cause hyperchloremia, metabolic acidosis, renal vasoconstriction and alter immune function.  There is nothing normal about normal saline. Balanced crystalloids (i.e. lactated Ringer’s solution, Plasma-Lyte A, etc) contain electrolyte compositions that are closer to physiologic levels.  Recently, the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) [2] compared balanced crystalloids to saline among critically ill adults and found that balanced crystalloids decreased the composite outcome of death, new renal replacement therapy, or persistent renal dysfunction (This composite outcome was primarily driven by mortality benefit).  Interestingly, in the subgroup analyses of septic patients, balanced crystalloids seemed to have its biggest benefit in MAKE30 compared to saline.

October 10, 2019

Background: Serial lactate measurements is a common core measure that we follow in septic shock resuscitation. A number of readers have written in enquiring about whether resuscitation with lactated ringers instead of 0.9% saline would lead to increases in serum lactate.   It’s a great question, and one that I am not sure I had a solid answer for before reviewing this topic.  LR contains 28 mmol/L of sodium lactate and, on the surface, it seems reasonable to think that infusion of LR would lead to lactate increases. This could potentially confound the interpretation of serial serum lactate measurements.
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