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From: B. Harris)
Subject: Re: The Ringer's solution and my father's death
Date: 29 Apr 1998 07:06:04 GMT

In <> (James S
Cowan) writes:

>As the the main point of this issue....get a patient through an ER who
>is hypotensive and nine times out of ten we punch em with
>fluids...just pick a type. Without benifit of a Swan you don't know
>what the patient's fluid balance is anyway and you have to have blood
>pressure or it's all irrelevant. I can't count the number of patient's
>I have received into an ICU in pulmonary edema who were fluid
>overloaded in ER because that and the vasopressors where the only
>options until we could get everything online to see where we were.
>Oh yes....and it's quite possible for a patient to need vascular
>volume and still show outward symptoms of pulmonary edema
>Jim Cowan RRT
>Ventilator Care Coordinator

    Worse, it's quite possible, and even quite common, for a patient to
need vascular volume and BE in pulmonary edema.  The lung capillaries
(as well as others elsewhere) leak or have leaked.  Because they're
fried by shock lung or trauma or infection or whatever; or because
there's no plasma oncotic pressure (no plasma proteins or hemoglobin or
other colloid).  And there's no way to get that water out of there
alveoli presently but keep the transcapillary pressures low.  Which
generally means get the plasma proteins and hematocrit UP (way higher
`crit than they used to), grit your teeth, and diurese off all that
water they gave for fluid resuscitation, just as you describe.  If the
heart won't take those low filling pressures, that patient's not going
to survive anyway.

   Once upon a time they gave lots of "artificial plasma expanders" as
colloid fluid in resuscitation, but I believe they have now decided
it's generally a waste of time-- these things (glucose polymers like
the dextrans and Hespan) leak out almost as fast as crystalloids (and
eventually EVERYTHING leaks out but RBCs), and they cause side effects.
And they are really expensive, which means your HMO is going to want to
see the SCIENCE before they pay for anything more complicated than

    Coming down the road are some interesting things: like a
resuscitation solution that uses for colloid a starch that stays in
capillaries much better.  And shocked lungs full of edema fluid can be
cleaned out if filled up with oxygenated fluorocarbon twice as dense as
water.   But you won't see this in the modern ICU yet.  Indeed, if the
FDA-mediated research-slowing and the HMO-mediated cost-cutting
continue, you may not ever see this stuff at all.  But I'm here to tell
you it works great on dogs <g>.

                                       Steve Harris, M.D.

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