soap box on fluid therapy.

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I was typing out a an opinion about modern antibiotic theory when I was interrupted by somebody suggesting that large and rapid fluid boluses should be used in shock secondary to surgical emergencies such as hemorrhage from acute pancreatitis or of course penetrating trauma.

I don’t know where these people have been for the last 10 or so years, but I am sure many of us old people can remember the days of large bore IVs and machines infusing liters of fluid (I have seen 14 before blood was even available) until the person died and the blood looked more like artificial fruit juice. Consequently some brilliant minds did some research and came to the conclusion this should not be done unless the patient is “seriously hypovolemic.” The idea of permissive hypotension was reborn. I say reborn because it was part of WWI trench warfare and the was practiced by doctors on all sides according to accounts I have read on French surgery. But the “serious hypovolemic” recommendation is flawed to the core! If you have that much loss, water will not help at all.

We know all about hematocrit and hemoglobin levels, oxygen transportation, fluid balance, ischemia secondary to edema, capillary permeability, and even clinical references like ATLS that maintain severe hemorrhage is either transiently or not affected by crystalloid/colloid, fluid infusion at all!

So why do we keep doing this? Why does suggested practice directly conflict with everything we know about what should and does work?

The reason can only be we are not performing these treatments for patients. We are performing them for ourselves. To make us feel and look like we are doing something, because we are faced with the truth that if we cannot make resuscitation into an algorithm, most really cannot do it. So they would basically do nothing, especially in the emergent setting, waiting for somebody who could really help to show up or deliver the patient to them. It creates a false sense of making a difference. This is reinforced in the attempt to “normalize” a set of quantitative values to target numbers. It is foolishness at its best. I could go to a cadaver lab right now, plug every hole in the vascular, infuse fluid to a 120/80 bp, and use a chemical slurry with a Ph of 7.34, but that corpse will not come back to life.

What is wrong with admitting you just can’t do anything? What is wrong with not making things more complicated for the people who can?

This madness must stop. There have been more advances in the last 20 years in medicine than in the entire history of medicine prior. I just cannot reconcile how doctors go on practicing techniques with absolutely flawed theories, which seems to be nothing more than dogma passed on verbally and with no basis in fact other than “that is what we have always done.” Really? You have always done something that doesn’t work and your solution is to keep on doing it?

There really isn’t much hope for mankind. If our ancestors were this lazy and stupid, none of us would be here today.

Is there anyone who actually thinks about what they are doing anymore instead of just following the script?

I need a raise and a better job.

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