Where do you look for edema?

We by custom look for pitting edema over the ankles. To look at the ankles can kill the patient. No pitting, no edema, right?  No saline overload, correct?  WRONG PLACE!!  Edema collects over the trochanters in a hospitalized patient, not over the ankles!

Look at the elbows!   Pinch over the trochanters!    Slim ankles may hide 40 lbs over the trochanters--give a fatal false sense of security!

 

evidence for 25% albumin use

Bill, Bcc:leakers,fluid management

Thanks for your thoughtful reply.

In my view, 25% albumin helps.  Why?  The effect of 100 cc of 25% albumin given in a vein, IV, it increases serum concentration of albumin.  It only adds 100 cc to the body's load.  25% gets rid of edema.  It shifts distribution, in a direction desired, reduces interstitial volume and increases plasma volume, which increases renal flow.    

As evidence:  Lasix alone did not increase urine volume. It did not raise sodium above existing < 5 meq/100 urine.  In that particular patient Lasix had no effect.  I noted low urine sodium which I took as indirect evidence of low renal blood flow probably due to squeeze and low volume in vessels.  I searched for the quickest way to fill vessels, for a substance that stayed in vessels.  Packed red cells!. I repeated Lasik after PRBC.   PRBC plus Lasix had the desired effect.  Urine volume doubled and the kidney began to release sodium.  Urine became salty--rising from <5 meq (almost distilled water) to 60 meq/100 cc urine.  Renal blood flow had improved after PRBC.  The body shed some deadly salt.

As alternatives, to increase blood volume 25% albumin and Hetastarch solutions should help.  I repeated trial with them.  They both worked to increase Lasix effect.  I favor 25% albumin because with added small volume it pulls juice from where juice is not wanted, edema, into where juice (volume) is desired, circulating volume.

Weight gain in patients is deadly.  Saline overload is the source.  Overload dilutes albumin.  25% albumin seems effective in treating overload.  Prevention is better.

Wreck!!!

   I lost control of the car on a remote canyon road in Eastern Oregon.  Ruth, 84, suffered Fx sternum, ribs on both sides, C5 and right lower leg.


My hobby of fighting saline overload (the intended subject of this blog from May '10) suddenly took on sharp practical turn.  I hope to share some lessons I  have and others have  learned as of this 11 days after the wreck (stable, not intubated)        http://www.caringbridge.org/visit/ruthbascom  is a link and information source for well-wishers I will try to keep these "posts" on the saline blog scientific and informative.  I welcome your comments as we learn to use this frightening and new means of teaching so that all injured get as good care as Ruth.

Benefit from 25% albumin

Bill,

I greatly appreciate your replies---often they are the only ones.  As usual, I have some comments.    JUB

John, I don't know how to respond as a blogger; I'm just responding as I would to your e-mail. I hope you get it.

But, in a fluid-overloaded case with evident generalized edema and a 10+% weight gain, the entire extracellular space, plasma and interstitial, is volumetrically expanded. Adding 25% albumin first only tends to expand the plasma space further; tends to increase congestion and interstitial edema. In any event, it tends to increase edema of the bowel wall and thus intra-abdominal pressure. In my opinion, the "squeeze" this puts on the kidneys, is really on the renal veins, the renal outflow, reducing urine volume. Renal blood flow is exquisitely sensitive to elevations in renal vein pressure. 

Of course this kind of case probably needs CRRT or dialysis. But stopping the IV and giving a good-sized dose of furosamide ought to be tried first. BILL

You are a careful observer and wide reader, but........

....Plasma volume is high???  I know of no direct evidence but experience tells me, in an edematous patient, plasma volume (PV) is LOW; interstitial volume is HIGH.  Patient sheds salt better after PV increase. 

Serum albumin is low in an edematous patient, albumin being diluted by saline.  That results in poor performance of the return of interstitial fluid into venous capillaries, normally a robust flow.  Return of interstitial fluid to vessels is dependent on albumin, its oncotic effects.  Oncotic effect depends on higher concentration of albumin in plasma than in intersitial fluid.  

 As evidence of benefit of 25%, after 25% or PRBC injection I have seen toes become warm (a crude measure of adequate vascular fill).    A increase in urine volume and rise in concentration in urine Na followed--evidence of improved renal function and of a dump of edema into toilet.  Also Lasix becomes effective.        

Common Bad Effects of Weight Gain--Edited

Self evident is a patient's struggles to survive when 40 pounds of edema loads an ICU patient .  He can't even bend his arms!  A ventilator struggles to push aside edema fluid.

Emergency Room started "normal" saline IV.  A swelled abdomen squeezed kidneys, slowing blood flow--a strong signal to retain salt and water.  Urine output falls.  Speed the IV.  Abdomen grows tighter--speed the IV!  A viscous cycle is started.

Instead raise serum albumin by giving 25%--moves fluids from edema to vessels.  25% moves fluid from where excess intercellular fluid clogs the system instead 25% moves fluid into vessels where fluid is needed.  Important point!  You want proof?  Check urine Na on a random spec from the catheter of an edematous patient--Na almost absent.  Check after 25% albumin. Urine Na will rise.  Higher urine Na is a sign to you that kidneys release Na, and edema, because of better renal blood flow.

Saline caused colostomy complications?

We thought if all went well we would be able to restart her chemotherapy treatments in about three weeks.  Well, sometimes surgical procedures do not work out as planned and
that was the case with X.  The bowel stoma was under a bit of tension
and pulled away from the skin and back into the deeper layer of the
subcutaneous tissue so it made it difficult to apply the bag and prevent leakage.


I read the above and wonder if "Normal" or Ringer's hung as "routine" operative IV collected in the abdomen, pushed the wall out, made tension and etc, etc.  See Brandstrup who controlled complications in colon cases by care with saline.

IV salt loads

That occasional hospitalized patients gain 20 to 40 pounds and cannot get rid  of it, remains a mystery.  A London doctor in 1700 noted sick void 1/11 of the solids that healthy adults do.  Hospital patients get 20 salt tablets in each IV.  Body holds one liter to dilute that salt.

What is low sodium? Another look.

A patient had "low sodium"  He was treated by adding dietary salt--despite Hx of cardiac problems and edema from recent surgery.

Was it really low sodium?  Yes, in salt concentration.  Serum Na was 124.  

Was it really low sodium?  No, in salt content.   Edema had added 14 Kg.  Each Kg held 124 meq or 10 gm.  His salt supply was high by 10X14 gm = 140 gm!  Since the normal salt content is about 140 gm in vascular plus interstitial spaces,  He had doubled his salt content.  Why add salt?

Better give 25% albumin to shift saline from hurtful, squeezing edema.  Albumin pulls edema into vessels where it is needed to improve renal blood flow.  Better blood flow releases salt to the toilet, releases squeeze.  Harvests salt from content to improve concentration.

Edema hinders rehab

A patient complained, post knee replacement, "My leg was so heavy I could not lift it to do rehab."  Abdominal complications resulted in multiple IVs.  Of course of Normal Saline or Ringers!  Yet the source of the edema, 20 salt tablets injected with each IV, was never suspected!

good other source on ARDS

http://pascalesthoughts.blogspot.com/2010/05/journal-club-is-saline-toxic.html         Consult this site for evidence that weight gain is a serious problem.  I am working the site toward simple and safe measures to test for and treat the weight gain in ARDS.

WEIGHT GAIN IN ARDS IS OOZE

Unlike the unlimited faucet water to a soaker hose, blood forced through capillaries has a limited supply.  The ooze of fluid out of vessels must be replaced with a fluid that stays in vessels to keep blood pressure up and vessels full.  The constant ooze might otherwise empty the arteries.  The body demands a return of pooled fluid to the heart.

DIAGNOSIS ARDS?

Look at ARDSUSA.ORG.  If you have questions, ask.  I'll try to be helpful.

Salt is Common Rx--- but makes trouble

You feel confused, right?  For you would like to understand why I am excited about salt, correct?  Last post I said "salt is best treatment" but it often leads to death.  If I can make this clear to you, patients and colleagues will be grateful.        Grandson Paul, if you read this, what can I do for you in exchange for you posting a comment for me on this, my salt blog, as we struggle to make Blogger useful.

SALT IS KEY

Puffy after days in hospital?  Check weight gain.  Best of current treatment adds salt.  Salt is key 1% of weight gain.  That 1% forces the body to hold on to 100X as much water to dilute the saltiness.  More at this site on hazard.