Critical Care: Student/Resident Case Report Poster - Critical Care V |

Combined Tonicity Fluids in Complex Critical Care Patients FREE TO VIEW

Ravi Doobay, MD; David Landsberg, MD
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SUNY Upstate, Syracuse, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):459A. doi:10.1016/j.chest.2016.08.472
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care V

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: The choice of fluids used in Critical Care medicine is a complex issue that can directly impact the survival of patients. There are multiple scenarios where one fluid may be indicated over another. The rapid evolution of neurocritical care and the practice of osmolar therapy via the use of hypertonic saline may present unique management challenges.

CASE PRESENTATION: A 48 year old male with a past medical history of mild cerebral palsy (CP) presented with slurring of speech and confusion. A Head CT revealed a left cerebellar ischemic stroke in evolution confirmed on MRI along with small brainstem infarcts. Emergent angiography revealed thrombosis of the left vertebral artery with excellent collateral circulation. Clot extraction was then judged to represent more risk than benefit. The patient was admitted to the ICU where systolic blood pressure was maintained between 140-180 mm Hg and 3% hypertonic saline was administered. He was clinically stable for the first two days of admission, however, aspiration remained a prominent problem ultimately resulting in pneumonia and profound septic shock. The creatinine rose from 1.3 to 7.2 in 2 days with profound acidosis and continuous renal replacement therapy was initiated. At this time his serum sodium was recorded at 165 mmol/L.

DISCUSSION: This scenario presented a very complex clinical conundrum where large volume crystalloid resuscitation was indicated as was dialysis but both resuscitation fluids and dialysate would be hypotonic to this patient’s serum invoking substantial risk of obstructive hydrocephalus and central pontine myelinolysis as potentially fatal side effects. Certainly sacrificing the central nervous system (CNS) in favor of overall perfusion would be as fruitless as not supporting perfusion to avoid detrimental CNS side effects. There are no formal recommendations to inform management of this scenario but the authors having been faced with this scenario before have arrived at a management schema which we have employed successfully in the past and again on this occasion. Both issues were addressed by administering 250 ml/hr of 0.9% saline concurrently with 50 ml/hr of 3% saline. To the dialysate we added 30cc of 23.4% saline per bag. Coupled with usual healthcare associated antibiotic therapy the patient was off triple pressors and had a serum sodium of 155 mmol/L after 36 hours of resuscitation. Obtundation gave way to response to voice and a neuro exam ultimately matching that of his pre-septic state.

CONCLUSIONS: In scenarios when intravascular repletion is needed with a high level sodium goal, regimens of high rate isotonic fluid in combination with lower rates of hypertonic saline can be used with good success and limit the chance of obstructive hydrocephalus and central pontine myelinolysis.

Reference #1: Dringer MN. The Evolution of the Clinical Use of Osmotic Therapy in the Treatment of Cerebral Edema. Acta Neurochir Suppl. 2016;121:3-6.

DISCLOSURE: The following authors have nothing to disclose: Ravi Doobay, David Landsberg

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