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Post by katevaughn on Jan 30, 2017 12:57:22 GMT -5
This month's journal club is presented by Ben Waldbaum. He chose a very important article that is applicable to our daily practice concerning fluid management. Enjoy! Click here for the article. Recently the APSF questioned traditional fluid resuscitation and this article is a foundational article for why providers need to rethink how fluids are administered. This article explains why fluid boluses can be harmful. Understanding the article also helps one understand why administration of IV fluids via an IV pump is preferred as it's effect on the Jv are COP the least and why that is preferred. The goal is euvolemia at all times, avoiding peaks and valleys and the resulting destruction at the cellular level. With so many people now doing ERAS fluid management, it is important to understand why this method of fluid management works. 1.) Based on your understanding of this article, do you think it would be helpful to introduce fluid maintenance and resuscitation guidelines for a broader spectrum of OR cases? 2.) Of all the changes the ERAS protocol introduced, do you think the highest yield change with the anesthetic management that led to the decrease in length of stay could be better fluid management? Why or Why not?
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Post by katevaughn on Jan 30, 2017 13:26:25 GMT -5
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Post by abenson on Feb 20, 2017 8:15:49 GMT -5
This is a fascinating article. I haven't really thought about some of these concepts at a cellular level since school. I think it is an excellent idea to stop and think about our practice and why we do the things with do especially when new research is presented. Fluid maintenance and resuscitation is one of the first topics we learn about in our basic anesthesia class. It is drilled in and we completed problems after problems calculating fluids. I do think we probably give too much fluid and deliver it in a way that could be harmful according to this article.
With respect to the ERAS protocol, I am not sure how successful we have been with our fluid management metrics. We have tried to use technology to help guide us with fluid management but encountered difficulty. When we used metavision we were able to capture the fluid data more easily but it wasn't perfect as we looked for patients who received more than 3L and less than 3L. With the initiation of EPIC we have experienced a set back with capturing data but are working on it. I know at other hospitals who have implemented the ERAS protocols, the fluid management plays a huge part and they run the patients dry. Each of the components of the ERAS protocol are important and I don't think we can single out an individual initiative to say this is why the length of stay has decreased.
Great article, Ben. Thanks for submitting it!
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Post by Ben Waldbaum on Feb 20, 2017 16:21:02 GMT -5
1.) Personally I've long thought that patient's are over fluid resuscitated in the OR. Who wakes up in the morning and drinks 1 to 1.5 liters of fluid? Or if 2 liters of fluid was dumped on the floor in the OR, how long would it take to evaporate, a day, 2 days, a week? This article also explains why constant hydration through an alaris pump is better than bolusing and then clamping the fluids, even if the total at the end is the same. Because of the tendency to over resuscitate and the tendency to open and clamp fluids, I think it would be beneficial to encourage wider use of alaris pumps for a larger variety of cases. I guess not quite a protocol, just encouragement of restraint.
2.) I agree with Andy that it is impossible to conclude that the fluid resuscitation protocol in the ERAS protocol we use is the "factor" for the decreased length of stay. Based on other institutions, it definitely seems like fluid restriction has been beneficial. Hence, also why the APSF wants anesthesia providers to challenge traditional fluid resuscitation algorithms.
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kty67
New Member
Posts: 22
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Post by kty67 on Feb 21, 2017 8:59:41 GMT -5
1. Great article, I think we already have fluid maintenance and resuscitation guidelines for a broader spectrum of OR cases. And we can tailor fluids to some specific cases. As we already do for flaps. 2 As for ERAS cases I don't do them a lot enough. But I think the fluid resuscitation protocol in the ERAS protocol we use is one of the components to decrease length of stay. I personally like the idea to use IV pumps for fluids if you can find them in OR. We hardly can find pumps for drugs that have to be going through them.
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Post by faraclarke on Feb 21, 2017 14:29:34 GMT -5
1. I think it will be beneficial to re-examine fluid resuscitation guidelines, however, I think it would be challenging to encompass a universal protocol that equally benefits all patients. Other non-biological factors must be considered as well such as time in preop while NPO and only on KVO IVF fluids (especially for late cases and cases of short duration). In addition, other factors that providers often consider are case related (limiting fluids for a prostatectomy prior to anastomosis then blousing later), whether or not the patient has a Foley, and history in which a standard fluid guideline may be detrimental (renal or heart failure). Though it may be beneficial, one challenge is that guidelines that would result in a more "appropriate" fluid administration would have to consider many differing non-patient-related factors.
2. I think there are multiple factors when it comes to the ERAS protocol and fluid administration can not be singled out as the greatest factor in length-of-stay. I do think that it would be beneficial to use IV pumps for non-ERAS cases, as they give a more precise amount of fluids and can decrease the incidence of accidental excessive fluid administration.
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Post by emedina1 on Feb 21, 2017 14:35:27 GMT -5
I had practice almost 40 years, i am still in search of the best guideline for fluid management. I practice with how pt respond to my management interns of their vital signs and blood works. this is a great article.
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Post by BrittneyKeating on Feb 26, 2017 21:36:12 GMT -5
Thanks so much for posting this great article! It was really thought provoking and will have me thinking more critically about my fluid choices and method of administration. One point made in this article that I found very interesting is the vast difference in the volume of EGL found in patients with diabetes or acute hyperglycemia. I wonder what other comorbid disease states that may be common amongst our patient population, might be associated with such a great difference in volume of EGL.
1.) I do not think that fluid maintenance and resuscitation guidelines for a broader spectrum of OR cases is necessarily indicated. I think this could cause harm to patients as providers may be tempted to follow the guideline when not clinically indicated or specific procedure related factors or patient related factors may call for a different regimen than the guideline may suggest. However, I do think that there should be more discussion within our department about the impact that fluid administration and choice of fluid (i.e. cystalloid versus colloid) has on patient outcomes. This article is a great beginning to that discussion, as it is provides clear clinical application and offers a new way of understanding the impact of our current practices.
2.) Like most of posts on this thread have suggested, I think that the changes made to anesthetic practice as a result of the ERAS protocol are too complex to suggest that better fluid management is the highest yield change within anesthetic management that has led to decreased length of stay. Various patient related factors, such as comorbidities, may make it very challenging to assess which change to our anesthetic management has the greatest yield amongst the surgical patient population under ERAS protocol.
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nanci
Junior Member
Posts: 57
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Post by nanci on Feb 27, 2017 12:01:06 GMT -5
1) I think it would be helpful if we know where we are under the Starling curve- and if that takes us into a broader spectrum of OR cases then it may be beneficial. For some of the smaller cases I'm not sure it would be indicated.
2) Doing a variety of ERAS cases I can see the benefit of fluid restriction- but our current methods of going about that may/may not be the best. Hopefully with increase in education and better methods to monitor and track results we can see if better fluid management would be helpful. But, with our ERAS protocols, there are a lot of treatments and plan that we perform, not just fluid management, so it would be difficult to say that fluid management is the most important or provides the highest yield to decrease in length of stay. I've not seen any ERAS articles to support that either.
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Post by Meginnis on Feb 28, 2017 0:55:15 GMT -5
1) I think that a guideline for fluid maintenance and resuscitation could be another resource that may be helpful. Not all practitioners are familiar with longer cases and a guide that provides ranges based on hemodynamics may be helpful. 2) There are to many aspects to ERAS to isolate fluid management as the highest yield that has led to a decrease in length in stay but I do believe that it is beneficial. I also think using the IV pumps to better manage quantity is the way to go
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Post by jhadley on Feb 28, 2017 10:23:03 GMT -5
This article was an excellent review of physiology I haven't considered in awhile! I especially appreciated the explanation of how administering large boluses of ISS can actually be harming out patients.
1. I do not think it is necessary to institute guidelines for all cases but I certainly think it would be helpful to know the typical fluid requirements for larger cases where it is harder to manage fluid resuscitation. In an ideal scenario part of our CUSP discussion would include feedback from our surgical colleagues regarding which patients are coming out of the OR overresuscitated vs. underresuscitated etc. so that we can better manage our patients.
2. I also believe it is impossible to determine what is the highest yield improvement in management foe ERAS patients.
One thought on running fluids on the Alaris pump; I often am doing cases where I don't have access to the IV and I like to be able to physically see the IV is free flowing. I can't tell you how many times in the ICU when the alaris was running without alarms into an infiltrated IV.
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Post by emedina1 on Feb 27, 2019 16:41:41 GMT -5
I agree with all my co-league who made a comment about this article. This phenomenon if not addressed sooner or later will have an impact on our organization in the department. There are a few activities that I am aware within the department that is geared towards. this end. The wellness program is certainly help to this end
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