From Mathew Bargas MD Wolfson Children’s Hospital
I really enjoyed reading your comments about elevated CO2 in the OR (CO2 is good for you). There are 2 other things that I have observed. 1. Many recent trainees and graduates are afraid to let any patient breath spontaneously without ventilator assistance out of fear that the patient is going to move. That's never made sense to me. 2. At the end of the case, many of them will hyperventilate the patient to speed up the removal of residual volatile agent. Then the patient becomes apneic, and takes forever to start breathing again. PS This line of thinking became prevalent in the past 10-15 years.
From Don Tyler MD
I was finally able to get Narcan to keep in my car, but it was not easy. I went to two different pharmacies, and they didn’t have it right away, needed paperwork, etc. So I gave up. My son volunteers at a clinic, and they get shipments in every once in a while, and he got me some. Should SPA give out nasal Narcan at our upcoming meeting?
From Ethan L Sanford, MD UT Southwestern and Children's Medical Center, Dallas, TX
I am a confessed zealot for both isotonic and balanced salt solutions. I agree with the PAAD group that hypotonic solutions should be reserved for specific populations. I see it more often used when children have been overloaded with abNormal Saline. I've been surprised throughout training and as a junior faculty at the resistance to adoption of balanced solutions. While a PICU fellow, a push to have plasmalyte readily available in the omnicell helped transition practice in our unit, but elsewhere in the hospital normal saline and even half NS continue to be common. Kids coming from the floor almost always have D5NS running and a high chloride on the AM labs. I'm guessing this is true in many places.
To me, the use of isotonic, balanced IV fluids seems intuitive...replace the volume and solute lost/needed with similar volume and solute. I find it ironic that NS is the standard and, therefore, the research/QI community have to prove the benefit of more physiologically sensical choices. I would suggest the opposite should be true; NS supporters should have to prove the benefit of this choice. NS may be preferable in certain clinical circumstances such as 1) hypochloremia due to contraction alkalosis (often with diuretic), 2) benefit of higher sodium on cerebral perfusion for children with neurologic pathology, and 3) renal failure (though the acid/base benefits with balanced solutions likely still outweigh the potassium risk and I regularly utilize balanced solutions for renal transplant cases). However, we may improve the metabolic profiles of our patients if balanced solutions were the default and NS utilized only when needed.
More prevalent barriers to balanced solutions include: it's too expensive, problems with compatibility, "we would have to get that from pharmacy", and "we don't use that here". I would contend 1) the absolute cost difference between solutions is minimal (often in the range of 2-10 dollars), 2) most compatibility issues are due to calcium in LR. Utilizing plasmalyte/normosol or simply flushing the line, holding the maint fluid for the infusion, then flushing and restarting the infusion, 3) QI efforts to have pharmacy stock fluids is simple, convincing nurses and physicians to actually use the new fluid choice takes more time, 4) education and experience most often alleviate initial fears of change in practice.
From Bob Spear MD, retired
Thanks for your most-interesting post on risks of hyponatremia. Most trainees are unaware of Na content in commonly ingested/infused substances. Breastmilk contains 6-8meq/L (1/20 NS!) of Na. Common formulas have 10meq/L, 1/15th NS. The late Jim Keating was a the “intensivist” at St. Louis Children’s in the 70s and 80s in the pre-intensivist era, trained in GI, and possessed encyclopediac knowledge of all things pediatric…including sodium. He published a paper about water-intoxication in children, showing how little reserve infants have, especially if the usual maternal-infant dyad (his words) is disturbed. He noticed that cases were clustered toward the end of the calendar months and identified the culprit; poor mothers ran out of formula towards the end of the month and diluted the formula with more water to make it last until they received either government assistance or money from their job(s). He changed public policy by having infant formula availability independent of financial means.
I remember an infant in the early 1980s who presented with dehydration and altered mental status. The Na was 165, but the usual moderate metabolic acidosis associated with hypernatremic dehydration was not present; the serum bicarbonate was 40 meq/L (nl 20-25 meq/L). The mother was feeding the child a standard formula. Dr. Keating suggested that we go back and ask the mother if she was giving the child baking soda. Indeed, the mother was dipping the nipple of the bottle every few minutes into baking soda, a not uncommon home-remedy for colic. Finally, Jim was an inpatient teacher if we used imprecise language. He was not fond of doing “sodium checks” (what is that exactly, a new breakfast cereal?) When one us mentioned that the serum Na was 130 meq/L and we were going to “repeat it again”, he shook his head dismissively saying, “that’s a redundancy that goes on forever”.
I agree wholeheartedly that dilute IV solutions have little place in most ill, hospitalized children.
Some thoughts on Fritz Berry
I received a couple of heartfelt responses from several readers (Aubrey Maze, Lynne Maxwell, Jim Viney, Peggy McNaull, to name a few) on the loss of our friend and colleague, Fritz Berry MD.
From Charlie Cote MD
I was in the Navy when I met first met Fritz as our visiting professor He gave a great talk on difficult airways and I still have copies of some slides that he generously gave to me! Also I was on my first panel and quite nervous and he calmed me down and told me I knew more about the topic than anyone in the audience Then he said if I stumbled he would help out Sure enough I answered a question and grabbed the microphone and said “What I think Charlie is trying to say is xxx. Then Burt Epstein who was another panelist took the microphone and said “No I think he is saying…..” they both made me feel welcomed into our small academic community I never forgot their kindness.
From Myron
When I was first coming up, because of his refresher course lectures and presence at national meetings, Fritz was the face of pediatric anesthesia to the membership of the ASA and beyond. Unfortunately, there are many of you who never had the privilege of knowing and interacting with him so I thought this would be a good opportunity, maybe my last, of sharing something about him that very much defined him and will probably not be mentioned in his “official” obituary.
I’ve already told you the story about how Fritz saved the day when SPA was formed. What many of you may not know, Fritz was a passionate court room and public advocate for physician anesthesiologists who were being sued for malpractice AND he was fearless in calling out publicly and by name paid experts (or gunslingers as he called them) anesthesiologists who would whore themselves with absolute falsehoods about standards of care for plaintiff attorneys in court. He was incredibly erudite and a terrific teacher who could speak and educate juries about anesthesia and because of his stature, often “saved the day”. At that time and even today, no one publicly names and shames experts who lie in court. Indeed, he called for the loss of Board certification and ASA membership for these “experts”.
I distinctly remember sitting in the audience at an ASA meeting when he called out several “experts” by name, including my former department chair, who, Fritz claimed flat out lied under oath about “standards of care”. In fact, he read their testimony to the audience. He saw me in the audience and called me to come to the microphone and explain if the expert testimony was in fact how we practiced at Hopkins and if I agreed with the testimony. I couldn’t and it was a drop the microphone moment.