Episode 51 — Resuscitating and Deresuscitating With Hypertonic Saline, With Sean Barnett
Highlights
- Do I Need More Than 300 Amels Per Day?
Summary:
Bolis is kind of the whole, know, how much benefit did i get out of it, and for how long to them? I'm sure we've all had that of you give a guy a bolits o 500, whatever it is, and their blood pressures get better. But within 30 minutes, the blood pressures are dropping down again. Now, any bolist can do that, and especially with the hypertonic. It just kind of sits with the other crystalloids. Of ye, it could be so transient that your knocking notice much improvement other than, you know, 30 minutes to an hour in my experience. And ii, mean, i do use this quite a bit
Transcript:
Speaker 1
Oh, that is a very good questionand i'm glad you prased it that way, because it let me say, yes, it is, you know, potentially transient, but also, yes, there is potentially something that you did to the body over all that might help and improve that. So first of all, as far as transient goes, yes, any fluid that we give as a bolis is kind of the whole, know, how much benefit did i get out of it, and for how long to them? I'm sure we've all had that of you give a guy a bolits o 500, whatever it is, and their blood pressures get better. But you know, within 30 minutes, the blood pressures are dropping down again, and you'r like, i can't do this every 30 minutes, like that's not a sustained enough impact. Now, any bolist can do that, and especially with the hypertonic. It just kind of sits with the other crystalloids. Of ye, it could be so transient that your knocking notice much improvement other than, you know, 30 minutes to an hour in my experience. And ii, mean, i do use this quite a bit when i can, when i canknow, convince these icy utines that i'm talking to you, that i'm not crazy, i promise. It actually is pretty pronounced that you're going to get at least a one to two hour type of benefit out of it, potentially more than that. And i will cav out this by saying, i've never needed to use more than 300 amels in an entire day for any of the purposes that i've used it for. So when it comes back to or did end your second part of that question, or did you change something in the patient, kind of fundamentally, that would fix many of these problematic processes? And in my opinion, this is where it gets a little bit into the physiology side of things, you did. Because what controls your blood vessels, permeability, basically how leaky you are, is angiotenson too. So your angiotenson too is not just a vaso constrictor. It is, it absolutely is, but it is also what controls how leaky your blood vessels are. (Time 0:16:31)
- What Controls Your Blood Vases?
Summary:
High rat states are high capillary leak states. That's why our nephrotic centrom patients are the ones that swell up like a balloon, because they are so hi rassed and just leak all of this fluid out. So when it comes back to or did end your second part of that question, or did you change something in the patient, kind of fundamentally, that would fix many of these problematic processes? And in my opinion, this is where it gets a little bit into the physiology side of things, you did. Because what controls your blood vessels, permeability, basically how leaky you are, is angiotenson too.
Transcript:
Speaker 1
So when it comes back to or did end your second part of that question, or did you change something in the patient, kind of fundamentally, that would fix many of these problematic processes? And in my opinion, this is where it gets a little bit into the physiology side of things, you did. Because what controls your blood vessels, permeability, basically how leaky you are, is angiotenson too. So your angiotenson too is not just a vaso constrictor. It is, it absolutely is, but it is also what controls how leaky your blood vessels are. So high rat states are high capillary leak states. That's why our nephrotic centrom patients are the ones that swell up like, like a balloon, because they are so hi rassed that they just leak all of this fluid out. Now, first of all, when you give a bolus of three %, even 100 ml, that is the most potent renon inhibitor that we have in all of hospital, or all of medicine, or even all of physiology. So when you do that, you're basically, again, shutting off renin. That is going to significantly decrease the overall ras system. Kind of at the cascade that you are fundamentally changing how leaky their blood vessels are. (Time 0:17:53)
- Hypertonic Solution
Summary:
Colloids combined with a hypertonic solution far out perform crystalloids on their own. And they do even ow perform hypertonic solutions on their own, specifically relating to the length of impact. You wouldn't expect to see the same benefit from just using a a colloid solution that is hyperosmolar, like a 25 % albumen.
Transcript:
Speaker 1
And this is what i think has been the most interesting about all published literature on colloids versus crystalloids, and then, of course, when we do have those couple of studies, collods combined with a hypertonic solutions, colloids combined with a hypertonic solution far out perform crystalloids on their own and colloids on their own. And they do even ow perform hypertonic solutions on their own, specifically relating to the length of impact. So, you know, a hundred amels of three % plus a hundred amels of five % albumen, well, i can almost guarantee that's going to get somebody a significant blood pressure boot and it's probably going to last, you know, in the four to six hour range as te post of the one to two hour range, because you are combining them, if that makes tem and you wouldn't expect to see the same benefit from just using a a colloid solution that is hyperosmolar, like a 25 % albumen. So unfortunately, no, we have not seen that type of thing matched up in any of the literature, and haven't seen that personally as well. Plus, the other thing you have to worry about is, 25 % albumen is actually nephrotoxic, where that can actually damage the kidneys themselves. (Time 0:20:38)
- Don't Give It As Infusion
Summary:
You wouldn't recommend administering this as an infusion. You would like to see the bowluses, even if they're relatively small, boluses. And especially if you're giving it with the three perer, with the furosemine. I always just say, make sure the hypertonic has started running before you give the bolis o lasic. That kind of synagistic effect hits the kidneys at the exact same time is that it gives you more of a ok, now i'm going to watch and see if the patients respond.
Transcript:
Speaker 2
And you wouldn't recommend administering this as an infusion. You would like to see the bowluses, even if they're relatively small, boluses.
Speaker 1
Correct. Correct. And that's more of a bcause this is the other thing, as i mean, we know the nerve, the nervser or the a nerle, i see you uses it almost constantly. But they do give it as infusion. And i will say, their patients don't typically get overloaded. I think it's better to do it as a short burst, because then you as a bolis because then you see whatever impact you're going to have. And especially if you're giving it with the three perer, with the furosemine. Sorry, the benefit there is you give the hypertonic. I always just say, make sure the hypertonic has started running before you give the bolis o lasic. And that kind of synagistic effect hits the kidneys at the exact same time is that it gives you more of a ok, now i'm going to watch and see if the patients respond. And i would say, if this guy's urine output didn't increase with that, (Time 0:23:44)
- I'm assuming you said he's on fenal frin and vaso presson
Summary:
The first thing that i would start talking to them about is, ok, if you added the panetran, can we get him off the nor epi? So then the nor epy is just causing a lot of squeeze in both the systemac thascula resistance and the pulmonary vascular resistance. The ionotropic effect will well help. Now this is where i would not be surprised at all if the three % started to have even more benefits in this guy. And so what i would hope is we can decrease the after load, kind of what we're doing.
Transcript:
Speaker 1
Absolutely unso let's say he got 300 in the even with pretty bad injured kidneys, i would say, 300 m ls within that first hour, two hours, is believable. And so the first thing that i would say is, all right, i will work on diaresus in every way that i can. And in this guy, i would basically just say, let's put him on, you know, three %. Hundred m ls t eight hours with hundred, 60 millograms of ivy crills in my c six er t. Eight hours and ten. I would talk to them about, so if i can get his blood pressure a little bit better with my three %, what should we cut off with our vaso pressures? And so if he's hef rest and he's reduced ef and he actually has some rv strain, and rv, i guess, not failure, but ar vy strain as well, the first thing that i would start talking to them about is, ok, if you added the panetran, can we get him off the nor epi? So then the nor epy is just causing a lot of squeeze in both the systemac thascula resistance and the pulmonary vascular resistance to make it harder on his heart. And so, i mean, i'm assuming you said he's on, i think, fenal frin and vaso presson. And ye they want to do a little bit of fi to give him a little bit of extra squeeze, that's great. And so what i would hope is we can decrease the after load, kind of what we're doing. And of course, giving him a little it, the ionotropic effect will well help. Now this is where i would not be surprised at all if the three % started to have even more benefits in this guy. One of the other major benefits that you get from hypertonic solutions in general, but three % specifically, is you stimulate atrio, natratic pectide and nitric oxide. So your two most potent stimuli for a and p is stretch of the right atria and hypertonicity of the right atria. (Time 0:26:09)
- Dialysis Cassiter Is Right In His Cavotreal Junction
Summary:
This is like kind of a a foot stamping moment for anybody listening that you have a c rr t or any kind of dialysis patient with right heart failure. These are the patients who you have to watch like a hawk. And this is definitely one of the times where i would consider more of an infusion bas i suppose to just giving it is bolases, cause i will. absolutely.
Transcript:
Speaker 1
Yes, absolutely. And this is definitely one of the times where i would consider more of an infusion bas i suppose to just giving it is bolases, cause i will. And this is like kind of a a foot stamping moment for anybody listening that you have a c rr t or any kind of dialysis patient with right heart failure. These are the patients who you have to watch like a hawk. Because if you think about it, where that dialysis cassiter is is right in his, you know, r a r v, cavotreal junction, anything like that. When we are taking us, it is very important to think about where we are taking that from in a patient. So we are essentially robbing his preload wherever he is on that frank starling curve. As soon as we start pulling true us, we are taking it directly from his r v. So he, if he's preload dependent, like, you know, man y of these r v sailur guys are, that is one of the reasons that these patients are the scaries ones to dialyze or to do ser r t on, because they can't. This is, unfortunately, seen, this happend many, many times, where they're kind of doing ok, you know, maybe they're tolerating a negative ten to 15 an hour or something like that, then you try and bump em up to negative (Time 0:30:36)