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Journal Club

Journal Club. 7/13/2018. Clinical Case. 37 year old male with a no signif pmhx, presents with 2 days of rapidly increasing leg pain/swelling/redness, subjective fever/chills. He believes his symptoms started after a bite, but had not witness any insects/snakes.

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Journal Club

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  1. Journal Club 7/13/2018

  2. Clinical Case 37 year old male with a no signif pmhx, presents with 2 days of rapidly increasing leg pain/swelling/redness, subjective fever/chills. He believes his symptoms started after a bite, but had not witness any insects/snakes. • Tmax 100.8, BP 140/100, HR 130, RR 22, SpO2 99% RA • EXT: Rt leg swollen and firm below knee, mod tenderness to touch, no discoloration, diminished sensation in foot, diminished toe movements; posterior aspect with cellulitis to mid thigh • WBC 17K, Hb 14, Plt 275, Na 136, CO2 30, BUN 21, Cr 0.9, Glu 114 • ALT 328, AST 899, ALKP 64, TBili 0.8 • Lactic Acid 5.4 • UDS (+) Meth • US no DVT • Received fluid resuscitation 3L NS, blood cx and started on Vanco and Zosyn by ED

  3. In ED • Consult plastic surgery • MRI leg • IMPRESSION: Findings suggestive of myositis with severe edema andenlargement of the soleus muscle. Mild patchy edema but no significantenlargement of the gastrocnemius muscles.Cellulitis about the lower leg proximal to distal with fluid thicknessgreatest over the lateral aspect of the distal soleus muscle up to 3 mm.Fluid surrounding the distal soleus muscle near the ankle.No significant enhancement of the fascia and there is intact arterialenhancement within the muscles and in the tibial peroneal arteries.No definite air within the right lower leg but tiny amount of air air maybe better excluded with plain films or CT.

  4. Additional studies • CK 1675 • Lactic acid initially decreased 5.4->1.8, then rose to 3.7 despite LR 150ml/hr • Patient taken to the OR - Right lower extremity fasciotomies: • The fascia was opened and a significant amount of [greyish] bulging muscle became exposed. After exposure, the muscle started to pink up. There was no significant purulence. Blunt dissection was carried around the superficial compartment into the deep compartment and this was also released. A similar procedure was performed on the medial side, releasing the compartment on that side. Cultures were taken, although no purulence or drainage was noted.

  5. Hospital Stay • Hospital day #2 • Afebrile, stable vitals • WBC down to 11k • CK increased to >20’000 • Reperfusion of affected muscle • Improved with aggressive hydration, preserved renal functio • Received Cefazolin for 3 days, discontinued when final cultures were negative • Final diagnosis:Sepsis, RLE compartment syndrome, rhabdomyolysis, meth abuse • Cause - uncertain • Scorpion/insect bite? • Focal myositis from meth? • Continued wound care, received skin graft and discharged on 7/6 (6/15-7/6)

  6. Choice of IV Fluids for Volume Resuscitation

  7. Fun Facts • Sydney Ringer (1835-1910) - British clinician, known for his teaching and research activities at the University College, London • Noted that isolated perfused heart contracted longer with addition of small amounts of calcium, potassium and other solutes to then-standard 0.75% saline - now known as Ringer’s Solution • Discovery of benefit from calcium was incidental, when London tap was used instead of distilled water. London tap water happens to have almost exact Ca++ concentration as the blood! • Lactate was added later by American pediatrician Alexis Hartman in 1930 as a buffer - Lactated Ringer’s (AKA Hartman’s solution)

  8. Fluid resuscitation in Hypovolemic/Septic Shock • Start EARLY! (within 1 hour) • Give adequate VOLUME! (30ml/kg, 2-3L) • REASSESS! after initial fluid resuscitation • Saline versus Albumin Fluid Evaluation (SAFE) trial - no benefit, much higher cost • Saline vs Pentastarch/HES - increased mortality and need for RRT with dextrans • Saline vs Balanced solutions (LR/HS/Pedialyte)Hypothesis: • Lower occurrence of hyperchloremic acidosis • Less Na load on kidneys • Correction of metabolic acidosis

  9. SMART-MED/SMART-SURG Trial>15’000 adults admitted to ICU, randomized to NS vs LR • Lower incidence of death or RRT at 30 days (15.4 vs 14.3%) • Higher benefit in patients with sepsis (29% vs 25%) SALT-ED Trial>13’000 non-ICU patients, also randomized to NS vs LR • Modest decrease in death or RRT at 30 days (5.6% vs 4.7%) • No difference in hospital-free days NEJM, March 1st, 2018

  10. Uptodate Summary The choice between balanced solutions and normal saline is individualized and informed by factors including patient chemistries, estimated volume of resuscitation, potential adverse effect of the solution used (eg, hyponatremia [Ringer's lactate] and hyperchloremic acidosis [normal saline] as well as institutional and physician preference. The clinician should have a low threshold to re-evaluate the type of fluid administered depending on the patient's response and development of adverse effects. The rationale for this recommendation is based upon the lack of an ideal standard crystalloid resuscitation solution, data from randomized trials that is conflicting but may suggest potential benefit from balanced crystalloids in those in whom large volumes of fluids are administered (eg, >2 liters)

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