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.