More harm than good

[Just Plain Ruff]

I've been sitting here thinking something and I'm going to ask the collective for their thoughts (the collective is EMTCity)

I've been watching at various ER's across the country and also in my own practice and place of employment.

I see these cardiac arrests come into the ED with Fluids running wide open, often with at least one bag of fluid already infused and a 2nd bag hanging.

These codes of course come in all shapes and sizes of patients.

We've already realized that using multiple medications on patients often provides a detriment based on the medications all working on different actions or different parts of the body and by staying in the circulation this hodgepodge of medicines post code can be problematic to say the least.

I have seen multiple code saves or even codes in progress with the IV's running full bore and flowing into the body often times with pressure infusers going especially if the access is an IO device.

My question is this - are we helping or hindering patient outcomes when we do things like this?

[Aeromedic]

Thanks for getting me to think long and hard about something... **smoke billowing from ears**

I'm looking at it like this: (I have no definitive answer, but maybe my thought process will spark somebody else)

Large fluid infusions can serve 2 purposes: Volume expansion and Electrolyte Balance (less with Saline more with Ringers).

From a Volume point of view:

Pros: More stuff to push around. Slight thinning effect allowing for the very remote possibility of a return of VERY slight perfusion beyond a blockage (I can't emphasize very remote and very slight enough... but everything counts when you're dead).

Cons: Dilution of RBC's decreasing the amount of o2 carried in blood per ml as well as risk of pulmonary edema.

Electrolytes:

Pros: More solution to dilute harmful enzymes from tissue infarct. Rapid infusion would carry meds more rapidly than a slow infusion/small volume flush compensating for the decreased return from CPR.

Cons: Dilutes meds beyond what a simple flush and TKO or slow infuse would do. Risk of creating further electrolyte imbalances through dilution.

This is my thinking so far.

[chbare]

You should look toward the evidence. The AHA has a journal known as circulation. In this journal, the delivery of IV fluids in a cardiac arrest is addressed. Unfortunately, there is a distinct lack of evidence regarding this question, with a few rather inconclusive animal studies. Currently, I believe AHA says the delivery of fluids in normovolemic arrest patients is an indeterminate intervention.

Personally, I like to limit fluid delivery as there is no evidence that giving fluids is helpful. If something is not helpful or in this case, we do not know, then I believe the conservative approach should be warranted.

Take care,

chbare.

[Just Plain Ruff]

You should look toward the evidence. The AHA has a journal known as circulation. In this journal, the delivery of IV fluids in a cardiac arrest is addressed. Unfortunately, there is a distinct lack of evidence regarding this question, with a few rather inconclusive animal studies. Currently, I believe AHA says the delivery of fluids in normovolemic arrest patients is an indeterminate intervention.

Personally, I like to limit fluid delivery as there is no evidence that giving fluids is helpful. If something is not helpful or in this case, we do not know, then I believe the conservative approach should be warranted.

Take care,

chbare.

I agree CH but I've always been curious as to the efficacy of large amounts of fluid given to Arrest patients. I've always thought it in the end made for a more difficult recovery and have attempted to limit my fluids in cardiac arrest only to the amount required to flush the medications and also to keep the vein open.

I've always wondered how many patients we throw into chf or pulmonary edema post code and am dismayed at the amount of evidence based studies that look at this.

[BushyFromOz]

we give 2L of fluid all the time to patients with electrolyte derrangement or significant RBC dilution, i don't see why this would be any different. I think if you are going to be using adrenaline you need to have something as a carrier to spread it around the vasculature or it just gets metabolised i the plasma without constricting anything.

Also, ROSC management here after a downtime of more than 15 mins gets 2 L of rapid cold normal saline, and we now have survival to discharge rates of 24% in melbourne, so why change a recipe that's obviously is working?

[armymedic571]

I've been sitting here thinking something and I'm going to ask the collective for their thoughts (the collective is EMTCity)

I've been watching at various ER's across the country and also in my own practice and place of employment.

I see these cardiac arrests come into the ED with Fluids running wide open, often with at least one bag of fluid already infused and a 2nd bag hanging.

These codes of course come in all shapes and sizes of patients.

We've already realized that using multiple medications on patients often provides a detriment based on the medications all working on different actions or different parts of the body and by staying in the circulation this hodgepodge of medicines post code can be problematic to say the least.

I have seen multiple code saves or even codes in progress with the IV's running full bore and flowing into the body often times with pressure infusers going especially if the access is an IO device.

My question is this - are we helping or hindering patient outcomes when we do things like this?

I think the first question is, "Why are we still transporting so many cardiac arrests?"............. OK, OK sorry, just had to get that out.

I think the question is legitimate, but are we missing something. As CH said, studies show that normotensive patient have been inconclusive, but I think it is more a questions of fluid in and fluid out.

Are we giving the fluid so fast that the body cannot process it, causing pulmonary edema? OR Does the patient have extended History of some type of renal problem which does not allow for quick excretion of that fluid. I's & O's? I might be off track, but that where I am headed.

we give 2L of fluid all the time to patients with electrolyte derrangement or significant RBC dilution, i don't see why this would be any different. I think if you are going to be using adrenaline you need to have something as a carrier to spread it around the vasculature or it just gets metabolised i the plasma without constricting anything.

Also, ROSC management here after a downtime of more than 15 mins gets 2 L of rapid cold normal saline, and we now have survival to discharge rates of 24% in melbourne, so why change a recipe that's obviously is working?

Bushy, I get what you are saying, but what is really the winning part of that formula. The fact that you are giving the patient 2 Liters of fluid, or the fact that you are giving cold fluid. Which is lowering the patients core body temperature, which in turn is slowing down the patients metabolism?........I say in any "Artic Protocol" as it is referred to in my neck of the woods, it would be because we are lowering the CBT. It just happens to take 2 liters of cold saline to do that.

Once again, I could be headed the wrong way with this, but........any thoughts?

Thanks.

J

(Edited for spelling)

Edited July 5, 2010 by armymedic571

[BushyFromOz]

Bushy, I get what you are saying, but what is really the winning part of that formula. The fact that you are giving the patient 2 Liters of fluid, or the fact that you are giving cold fluid. Which is lowering the patients core body temperature, which in turn is slowing down the patients metabolism?........I say in any "Artic Protocol" as it is referred to in my neck of the woods, it would be because we are lowering the CBT. It just happens to take 2 liters of cold saline to do that.

(Edited for spelling)

no idea...... but the recipe is still good, and the survival rate is world class.

I guess i wasn't clear in what i was typing... what i meant was that clearly there is a major benefit in giving fluid during arrests and ROSC management (i think if you talk about arrests you have to talk about ROSC as well). I think sometimes we overstate 2L of fluid in haemodilution and electrolyte imbalance in this case, dead is deadm it can only improve. fluid overload and APO while not exactly awesome is a risk we will take to get that 1 in 4 chance of going back home to your family we have here.

[chbare]

However, we are talking about different concepts and cannot make a valid comparison. Giving cooled fluids as part of a hypothermic protocol is much different than room temp or warmed fluids as part of a "classical" resuscitation attempt.

The physiology of therapeutic hypothermia is much more complicated than the traditional "metabolism" concept. You in fact appear to have significant changes in membrane permeability, proteins, ion channel function, reperfusion oxidative changes, the inflammatory process and perhaps a whole lot we do not understand.

Take care,

chbare.

Edit: "reperfusion"

Edited July 6, 2010 by chbare

[BushyFromOz]

YEah, i think i'm over thinking this as good fluid v's bad fluid

[armymedic571]

Fair enough.......perhaps I was trying to over simplifiy the process......