The Great(est) Fluid Debate

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Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.

The greatest fluid debate
@DogICUma
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@JAMyburgh

The greatest fluid debate
@srrezaie
@DogICUma
@toddrice_ICU
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The greatest fluid chat
@DogICUma
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45 year old diabetic
male
Severe generalised
abdominal pain
Vomiting
Rigors
Calls an ambulance

High heart rate
– 140bpm
High fever
– 39°C
Low blood pressure
– 78/40

Septic shock
Abdominal source

Fluids first
vs.
Fluids + pressors
vs.
Pressors first

An echo is mandatory
vs.
An echo is generally helpful
vs.
An echo is generally unhelpful

Balanced crystalloid
vs.
0.9% Saline
vs.
Colloid

8L +ve & 8kg heavier
On mod. dose noradrenaline
Intravascularly deplete

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Sepsis is a common presentation in the prehospital and retrieval environment, with most cases having a respiratory, urinary or soft tissue origin. However the best practice for identifying and management sepsis in the prehospital environment remains unclear. Despite sepsis having been a priority for in hospital guidelines and protocols for decades now, relatively little attention has been paid to prehospital sepsis management. Traditional teaching is that early antibiotics in sepsis save lives, however trials examining this are observational and confounded by outdated ICU care. An appropriately sensitive and specific tool for the prehospital identification of sepsis remains elusive. NEWS2 is common and lactate-modified QSOFA emerging (although prehospital lactate measurement remains difficult). The role of prehospital antibiotics, and the most appropriate one are also unclear. Most ambulance services that carry antibiotics use ceftriaxone. The retrieval environment is similar, with sepsis probably being the single commonest reason to call a retrieval service. For more head to our podcast page #CodaPodcast

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Catheterization of the bladder involves introducing a latex or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable patients. Because bladder catheterization carries the risk of UTI, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence. Types of Catheterization. Intermittent and indwelling retention catheterizations are the two forms of catheter insertion INTERMITTENT CATHETERIZATION introduce a straight single-use catheter long enough to drain the bladder (5 to 10 minutes When the bladder is empty, you immediately withdraw the catheter. COMPLICATION- increases risk of trauma and infection. INDICATION- It is common for people with spinal cord injury or other neurological problems such as multiple sclerosis to perform self– intermittent catheterization up to every 4 hours daily for months or years. UTI rate is lower than for patients with long-term indwelling catheters. INDWELLING CATHETERIZATION- remains in place for a longer period, until a patient is able to void voluntarily or continuous accurate urine measurements are no longer needed The straight single-use catheter has a single lumen with a small opening about 1.3 cm ( 1 2 inch) from the tip. . Urine drains from the tip, through the lumen, and to a receptacle. An indwelling Foley catheter has a small inflatable balloon that encircles the catheter just above the tip. When inflated the balloon rests against the bladder outlet to anchor the catheter in place. The indwelling retention catheter often has two or three lumens within the body of the catheter . One lumen drains urine through the catheter to a collecting tube. A second lumen carries sterile water to and from the balloon when it is inflated or deflated. A third (optional) lumen is sometimes used to instill fluids or medications into the bladder. It is easy to determine the number of lumens by the number of drainage and injection ports at the end of the catheter A second type of intermittent catheter has a curved tip A Coudé catheter is used on male patients who may have enlarged prostates that partly obstruct the urethra. It is less traumatic during insertion because it is stiffer and easier to control than the straight-tip catheter Plastic catheters are suitable only for intermittent use because of their inflexibility Latex catheters are recommended for use up to 3 weeks. Be aware of allergies. Pure silicon or Teflon catheters are best suited for long-term use (2 to 3 months) because of less encrustation at the urethral meatus Balloon sizes range from 3 mL (pediatric) to large postoperative volumes (75 mL). In adults the 5-mL and 30-mL sizes are the most common: The 5-mL size allows for optimal drainage, whereas the 30-mL size is used after pros

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The connection between genetics and kidney disease lies in the role of inherited genetic factors that can increase the risk of developing various kidney diseases. Certain kidney diseases, such as Polycystic Kidney Disease (PKD) and Alport Syndrome, have a clear genetic component where mutations in specific genes contribute to the development of these conditions. Understanding these genetic basis is vital for assessing the risk of kidney disease in individuals with family history and for advancing personalized medicine approaches in prevention, diagnosis and treatment. Genetic testing plays a significant role in identifying these predispositions and guiding healthcare strategies.

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Botulism has been used as a weapon of terror in the past. During World War II, the infamous Unit 731, the Japanese biological warfare group, fed cultures of Clostridium botulinum to prisoners during the Japanese occupation of Manchuria, killing them. It was suspected that Germany had weaponized botulism as well, and several other countries were suspected to have done research into the use of botulism as a weapon. More recently, between 1990 and 1995, aerosols were dispersed on at least three occasions by the Japanese cult Aum Shinrikyo, who would later go on to release sarin gas in the Tokyo subway, to disastrous effect. These releases of botulism failed for various reasons, but the ease with which Aum Shinrikyo was able to culture Clostridium botulinum from the soil is one reason that this toxin would make an excellent bioweapon.

Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.

Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.

Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.

Lactation Mraining Management Session-2-Comm-Building-Conf.ppt

Lactation Mraining Management Session-2-Comm-Building-Conf.ppt

Lactation Mraining Management Session-2-Comm-Building-Conf.ppt

Medidas Medical Center INC

Today’s healthcare leaders are seeking technology solutions to optimize efficiencies and improve patient care. However, without effective change management and strategies in place, healthcare leaders struggle to strategically improve patient flow, space, to strategically improve patient flow, space, and schedule management, and implement daily huddles. The role of technology in supporting operational efficiency and change management initiatives is inevitable. During this webinar, attendees will learn how to optimize Ambulatory Operational Efficiencies and Change Management. Attendees will also learn about the importance of visual management boards in enhancing clinic performance and insights into effective change management approaches.

Unlock the Secrets to Optimizing Ambulatory Operations Efficiency and Change ...

Unlock the Secrets to Optimizing Ambulatory Operations Efficiency and Change ...

Unlock the Secrets to Optimizing Ambulatory Operations Efficiency and Change ...

Health Catalyst

Session-17-KANGAROO-MOTHER-CARE_final-blue.pptx

Session-17-KANGAROO-MOTHER-CARE_final-blue.pptx

Session-17-KANGAROO-MOTHER-CARE_final-blue.pptx

Medidas Medical Center INC

A month-long celebration of the POSHAN Abhiyan mission places special attention on Severe Acute Malnourished (SAM) children. It is an umbrella scheme covering the Integrated Child Development Services (ICDS) (Anganwadi Services, Poshan Abhiyan, Scheme For Adolescent Girls, National Creche Scheme). Poshan 2.0 will include three significant initiatives within its purview: Anganwadi Services, the Scheme for Adolescent Girls, and Poshan Abhiyaan. Moreover, Poshan 2.0 will concentrate on Maternal Nutrition, Infant and Young Child Feeding Norms, Treatment of MAM/SAM, and Wellness through AYUSH.

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POSHAN ABHIYAAN-Poshan 2.0 will concentrate on Maternal Nutrition, Infant and...

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Technology transfer documentation and strategies

Technology transfer documentation and strategies

Technology transfer documentation and strategies

Giudeline: Adverse event CTCAE version 5.pdf

Giudeline: Adverse event CTCAE version 5.pdf

Giudeline: Adverse event CTCAE version 5.pdf

Dr. Afreen Nasir

Pulse Check Decisions - RRT and Code Blue Workshop

Pulse Check Decisions - RRT and Code Blue Workshop

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WORLD HEALTH ORGANIZATION WE CHAMPION HEALTH AND A BETTER FUTURE FOR ALL’ INTRODUCTION- WHO leads and champions global efforts to give everyone, everywhere, an equal chance to live a healthy life. HISTORY- founded in 1948, 7 April HEADQUARTERS- Geneva OFFICES- 6 semi autonomus regional and 150 fields offices DIRECTOR- Dr. Tedros Adhanam Ghebeyesus OBJECTIVES- Direction, co-ordination agencies Collaboration with local bodies Help the government in health services Proper technological assistance To attain highest possible level of health Prioritize and support health Formulate health policies Disease inspection and analysis Health education GOAL: To ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies and provide a further billion people with better health and well being ORGANIZATION: executive board, secretariat, world health assembly FUNCTION: FOR UNIVERSAL HEALTH Focus on PHCare Sustainable financing and protection Access to health products and medicines Training of health workforce and advice on labor policies Support people participation in National health policies Increasing monitoring, data and information FOR HEALTH EMERGENCIES Identification, mitigation and risk management Prevention and support of development of tools Detect and respond to acute health emergencies Support delivery of essential health services FOR HEALTH AND WELL BEING Address social determinants Promote intersectoral approach for health Prioritize health in all policies and healthy settings THROUGH WORK, ADDRESS Prevention of non- communicable disease Mental health promotion Climate change Antimicrobial resistance Elimination and eradication of communicable disease UNITED NATION FUND FOR POPULATION ACTIVITYINTRODUCTION- SEXUAL AND REPRODUCTIVE HEALTH AGENCY MISSION- To deliver a world where every pregnancy is wanted, every childbirth is safe, and every young person’s potential is fullfilled AIM- to improve reproductive and maternal health worldwide ESTABLISHED YEAR- 1969 (1974 in INDIA) HEADQUARTER- NEW YORK DIRECTOR- Dr. Natalia Kanem (2017) FUNCTION Develop national healthcare Increasing the access to birthcontrol Leading campaigns against child marriage Prevention of violence against gender Prevention of female genital mutiliation Treatment and prevention of STD and RTI MCH care HIV prevention and treatment IEC on sexuality and treatment of infertility and Abortion FOCUS area: Reproductive health Gender equality Population and development strategies Girl education Political participation for women FGM Child marriage UNITED NATION DEVELOPMENT PROGRAMME 1965 ESTABLISHED- 22 November. 1965 HEADQUARTER- New York HEAD- Achim steiner STRUCTURE- 170 member countries and territories INTRODUCTION- Advocates for change and connect countries to knowledge, experience and resources to help people bulid a better life for themselves Encourages Human right protection, women empowerment in all its programme

INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx

INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx

INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx

AnushriSrivastav

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Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.

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Technology transfer documentation and strategies

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The Great(est) Fluid Debate

1. The greatest fluid debate @DogICUma @toddrice_ICU @JAMyburgh

2. The greatest fluid debate @srrezaie @DogICUma @toddrice_ICU @JAMyburgh

3. The greatest fluid chat @DogICUma @toddrice_ICU @JAMyburgh

4. 45 year old diabetic male Severe generalised abdominal pain Vomiting Rigors Calls an ambulance

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6. High heart rate – 140bpm High fever – 39°C Low blood pressure – 78/40

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8. Septic shock Abdominal source

9. Fluids first vs. Fluids + pressors vs. Pressors first

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11. An echo is mandatory vs. An echo is generally helpful vs. An echo is generally unhelpful

12. Balanced crystalloid vs. 0.9% Saline vs. Colloid

13. 8L +ve & 8kg heavier On mod. dose noradrenaline Intravascularly deplete

14. @DogICUma @toddrice_ICU @JAMyburgh all icons: https://thenounproject.com

Editor's Notes

The title of this session is ‘the greatest fluid debate’ but we are all friends here and agree about everything all of the time so, it’s really more of a chat.
We hope you will get involved. Please send questions and comments to the Twitter moderator
We hope you will get involved.
Ambulance comes. Patient looks sick.
The sick patient arrives in hospital.
The provisional diagnosis here is septic shock with a primary abdominal source
“So, you might have noticed that this icon is called ‘saline drip’. I want to put that to one side for now. John / Todd – let’s start with a philosophical discussion. In general terms, tell us which camp you belong to and why?” Among other things, I think that this would be an opportunity to talk about the CENSER trial: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201806-1034OC & the REFRESH pilot RCT: https://link.springer.com/article/10.1007%2Fs00134-018-5433-0 There are also couple of recent retrospective studies that highlight the association between duration of hypotension and mortality that could be mentioned: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-018-0448-9 https://link.springer.com/article/10.1007%2Fs00134-018-5218-5 We could a twitter Poll or take some comments from Twitter here.
While the philosophical discussion is ongoing, the emergency physician swoops in with an ultrasound machine and says, “look, the patient is hypovolaemic and needs volume”. Todd/John – any thoughts or comments. “Vigorous empty ventricle from low SVR and from hypovolaemia look the same – my view is that this echo actually does not help much apart from confirming appearances are consistent with septic shock. Still don’t know whether this means we should give fluid.”
...and where do you stand on this spectrum. Twitter comments / questions? Twitter poll?
“So, let’s just say you decide to give a fluid bolus. Let’s talk about this. Todd, you go first...” Twitter comments? Live Twitter Poll?
Some time later the patient, who has been to the OR and had a gangrenous perforated appendix chopped out, is in the ICU. Using your expert clinical judgement you decide that the patient has a combination of total body fluid overload and intravascular depletion. Where do you stand on fluid boluses for this patient? Twitter comments? Live Twitter Poll? Once the time comes to take fluid away, where do you stand on diuretics? Twitter comments? Live Twitter Poll?