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Intravenous Fluids Post-Marathon: When and Why?

Intravenous Fluids Post-Marathon: When and Why?. Scott W. Pyne, M.D. United States Naval Academy Annapolis, Maryland. I have no affiliation or financial interest in any organization(s) that may have a direct interest in the subject matter of my presentation.

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Intravenous Fluids Post-Marathon: When and Why?

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  1. Intravenous Fluids Post-Marathon: When and Why? Scott W. Pyne, M.D. United States Naval Academy Annapolis, Maryland

  2. I have no affiliation or financial interest in any organization(s) that may have a direct interest in the subject matter of my presentation. • The opinions or assertions contained within this document should not be construed as official or reflecting the views of the United States Navy or the Department of Defense.

  3. Objectives • Discuss developing a protocol for IV use • How to make the appropriate diagnosis • Role of electrolyte measurement • Risks and benefits of the procedure • Revisit treatment protocols • Can we explain USA’s use of IV fluids?

  4. Pre-Marathon Experience • Temple University School of Medicine • Philadelphia, Pennsylvania • Family Medicine Training • Jacksonville, Florida • Family Medicine Physician • Naples, Italy • Primary Care Sports Medicine Fellowship • San Diego, California • Primary Care Sports Medicine • Marine Corps Base, Quantico, Virginia

  5. Marine Corps Marathon 1999-2003

  6. United States Naval Academy 2003-present

  7. No IV Needed

  8. Marine Corps Marathon pre-1999 • Caring clinicians • Treated runners like Marines • Few treatment protocols • Liberal intravenous fluids for post-exercise collapse • Universal good outcomes

  9. Look to the Literature • Comprehensive review for MCM in 1999 • Little marathon specific literature • Ultramarathons • Ironman Triathlons • Apply distance event data • Laboratory research clinical correlations • Compare marathon experience to Marine Corps training and American Football

  10. Medical and Physiological Considerations in Triathlons • US triathlons 1982-1986 (>6000 athletes) • Dehydration is most frequent medical encounter • 27% hyponatremic • IV Fluid recommendations Hiller DW, et al: The American Journal of Sports Medicine Vol 15 (2) 1987.

  11. Intravenous Fluid Effect on Recovery After Running a Marathon • 2.5 l of 2.5% glucose/0.45% NaCl solution • 100 ml 0.9% NaCl Solution • No significant influence on: • Rate of total recovery • Number of days with pain, stiffness, appetite, sleep or fatigue Polak AA, et al: British Journal of Sports Medicine 1993; 27(3):205-8. 1991 Rotterdam Marathon

  12. Clinical and Biochemical Characteristics of Collapsed Ultramarathon Runners • Only 15 % collapsing during the event had readily identifiable medical diagnoses • States of dehydration were comparable in controls and EAC victims. Holtzhausen LM, et al: Medicine and Science in Sports and Exercise 26, 1994.

  13. The Prevalence and Significance of Post-Exercise Hypotension in Ultramarathon Runners • Level of dehydration was unrelated to the degree of postural hypotension. • EAC should initially be treated with pelvic and lower limb elevation, not IV rehydration. Holtzhausen LM, Noakes TD, et al: Medicine and Science in Sports and Exercise 1995;27(12):1595-1601.

  14. Collapsed Ultraendurance Athlete: Proposed Mechanisms and an Approach to Management • Who needs an IV? • unconscious • suspected heat stroke, hyponatremia, hypoglycemia • physical exam c/w dehydration • persistent emesis • persistent tachycardia and hypotension when lying supine with legs and pelvis elevated >10 to 15 minutes Holtzhausen LM, Noakes TD: Clinical Journal of Sports Medicine 1997;7:292-301.

  15. A Guide to Treating Ironman Triathletes at the Finish Line • Treatment by necessity is most often initiated in the absence of a diagnosis. • All persons who collapse after exercise do not have dehydration-induced hyperthermia Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).

  16. A Guideline to Treating Ironman Triathletes at the Finish Line • “The administration of IV fluids should not be an automatic first response.” • Indications for IV fluids: • Significant dehydration causing cardiovascular instability • Cannot be effectively orally hydrated • Unconscious with serum sodium >130mmol/L Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8)

  17. Elevate the Feet and Pelvis Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).

  18. Hyponatremia in Distance AthletesPulling the IV on the “Dehydration Myth” • Moderate dehydration is not hazardous • Diagnose, then treat • Too much fluid can hurt – oral and IV Noakes TD: Physician and Sports Medicine 2000;28(9).

  19. Intravenous versus oral rehydration during a brief period: responses to subsequent exercise in heat. • No discernable advantage of IV over oral • Oral hydration: • Lower body temperatures • Improved performance • Decreased thirst • Lower perceived exertion with subsequent exercise Casa DJ, et al: Med Sci Sports Exerc 2000;32(1):124-133.

  20. Letters to the Editor • Interesting points of discussion • Lab data vs. clinical data • Dangers of giving IVs to patients whose sodium concentrations are unknown The Physician and Sports Medicine 2001;29(7).

  21. IV for Exercise Associated Muscle Cramps • Dramatic improvement with normal saline • American Journal of Sports Medicine 1999;27(5) response to letter to the editor • Severe cramping usually subsides after 2-3 hours and 2-3 L of normal saline. • Eichner RE Curbing muscle cramps: more than oranges and bananas GSSI 2002

  22. Serum electrolytes and hydration status are not associated with exercise associated muscle cramping (EAMC) in distance runners • Small but statistically significant differences in serum sodium and magnesium are too small to be clinically significant. • An alternate hypothesis to explain EAMC must be sought. Schwellnus, et al. Br J Sports Med. 2004;38;488-491.

  23. Evaluation and Treatment of Marathon Associated Hyponatremia • On-site sodium analysis • Exercise Associated Hyponatremia (EAH) Concensus Panel. 2005. Clin J Sports Med. 2005;15:208-213. • 3% NaCl solution utilized in the field treatment symptomatic hyponatremia • Ayus C, Rarieff A, Moritz M. Treatment of marathon associated hyponatremia. N Engl J Med. 2005;353(4):427-428.

  24. What did we learn? • Most collapsed runners do not have dehydration-induced hyperthermia • Diagnosis before treatment • There are indications for IV fluids • Too much fluid can hurt • Exercise associated muscle cramping etiology is unclear • But IV saline appears to help in some situations • Measure sodium and field treatment

  25. Ask for IV Guideline Help • Compared notes with others • American Medical Athletic Association • International Marathon Medical Directors Association • American College of Sports Medicine • Endurance Athlete Medicine and Science • American Medical Society of Sports Medicine • Develop intravenous guideline

  26. Survey of Experts • Do you give IV fluids after marathons? • What do you use to determine if an athlete receives IV fluids? • What types of IV fluid do you use? • Do you measure serum electrolytes? • Is there anything else that might be helpful?

  27. Survey Results (10 responses) • 10/10 are prepared to give IV fluids • 8/10 have IV fluid protocols • 10/10 have 0.9% NaCl solution • 9/10 have 3% NaCl solution • 8/10 always measure Na prior to IV • 1/10 measure depending upon presentation • 1/10 never measured Na

  28. Survey Comments • “I am quite liberal with their appropriate use.” • “If they need fluids and cannot tolerate oral we give IV.” • “We have guidelines, but I cannot guarantee that they are always followed.” • “The criteria was ‘ya want an IV?’” • “One of our major goals is to prevent ER transfer”

  29. Comments Continued • “There is no need to measure a serum sodium on every patient that you give IV fluids to.” • “Not checking serum sodium is malpractice” • We did not give one IV infusion after two recent Ironman races. • “The assault on IVs may be a gathering storm.”

  30. Benefits Treat identifiable conditions Lessen the strain on emergency and hospital services Training IV Risk and Benefit • Risks • Discomfort • Tissue injury • Bleeding • Infection • Embolization • Worsening electrolyte imbalances • Utilize resources

  31. Financial Costs of IV treatment • Average Cost for IV fluids at Ironman events is around $10,000. • My costs: • 1 liter 0.9% NaCl $12.18 • 18ga angiocath $ 1.94 • IV tubing $ 1.35 • Misc supplies $ 2.00 • Total $17.47 plus people to do it. Mayers LB, Noakes TD. A Guide to treating ironman triathletes at the finish line. Phys Sports Med. 2000;28(8).

  32. Challenges Addressing IV Fluids • High expectation from system • Education • Importance of making a diagnosis • Clinical guideline development • Clinician position on the medical team • Clinical supervision • Measurement of electrolytes

  33. Treatment Expectations • Runners are educated • Previous experience in other medical tents • Expectations of the medical system

  34. Patient Expectations • Unmet expectations were especially more likely in younger patients. • Patients with unmet expectations were less satisfied and reported less symptom improvement. • Reasonable patient expectations need to be considered and unreasonable ones need to be denied with a full and compassionate discussion. Bell RA, et al. J Gen Intern Med 2002;17:817-824.

  35. Medical System Expectations • Patient desires were similar in Michigan and Ontario, but expectations were higher in Michigan. • Michigan physicians gave greater estimates of patient expectations than Ontario physicians. Zemencuk JK, et al. J Gen Intern Med 1998;13:273-276.

  36. Expectation Correlation? • Total expenditure on health as a percentage of the Gross Domestic Product in 2006 World Health Report • Thailand 3.3% • China 5.6% • United Kingdom 8% • South Africa 8.4% • Canada 9.8% • United States 15.6% • European Commission relates that there is no direct correlation between the level of expenditure and overall healthcare performance.

  37. Medical Tent Expectations • Parallel that of office visits • IV requests • Request everything available • Similar treatment as previous events • Perception that more is better • Badge of honor

  38. Glorification of Playing with Pain • Chicago Bears Dick Butkus • American Football leave field and return to win the game. • Lance Armstrong’s ability to control the Central Governor. • Contrast to World Cup

  39. Education • Patients • Requires a universal effort • Has been successful clinically • Clinicians • Make the diagnosis • Does a protocol exist? • If so, how closely is it followed? • Are IVs a medical leadership priority? • Importance of measuring sodium

  40. Beware of the Rogue Clinician

  41. Why do we want to give IV? • Treat an appropriate diagnosis • Believe it is the right thing to do • Want to help and do not know how • Show we are doing something

  42. Recommendations for IV Fluids • Significant dehydration causing cardiovascular instability • Cannot be effectively orally hydrated • Unconscious with serum sodium >130mmol/L • Symptomatic Exercise-Associated Hyponatremia with 3% NaCl • Consider for resistant exercise associated muscle cramping • Recommend Sodium assessment prior to IV

  43. Conclusions • “First, do no harm” • Diagnose first, treat second • Have clear indications for interventions that you do and do not perform.

  44. I hope you enjoyed the ride! swpyne@annapolis.med.navy.mil

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