Ashtangha Yoga or the eight limbs of Yoga-

“Should I give them more fluid?”

Extremely common question during AKI referrals from junior docs.

⛔️ Fluid management is tricky, often misunderstood, & can cause huge iatrogenic harm ⛔️

We try to convey important principles in THREAD 👇

#tipsfornewdocs #medtwitter #tweetorial

Currently too often patients with high creatinine are given too much IV fluid, driven by an AKI ➡️ fluid reflex

We’ve seen 7 litres be given in one shift.

Medics & surgeons, juniors & seniors, it seems everyone loves to reach for extra IV fluid (especially if urine output poor)

Why does huge volume IV fluid ‘resuscitation’ consistently occur?

Lots of reasons, including FALSE beliefs:
🛑 IV fluid always “treats AKI”
🛑 Hypotension = hypovolaemia
🛑 Lactate >2 means fluid deficiency
🛑 Septic patients are very hypovolaemic

The rule with IV fluids and AKI is to remember this 5 word phrase:

💥 💥 Aim for euvolaemia, then stop💥 💥

Fluid status is like Goldilocks - hypovolaemia is bad for the kidneys BUT excess volume is also harmful for renal function and will cause other complications too.

It is easy to say “target euvolaemia” - but we agree it is more difficult to do!

Fluid status assessment is certainly made harder by a belief that we must only rely on a snapshot assessment of examination features which are NOT specific / sensitive / reliable to elicit like.…

The #RELAx trial has been published today in @JAMA. It was coordinated by Anna Algera. This thread is to explain the rationale, what we did, the findings and the meaning.
The rationale of #RELAx is based on the following

First, there is NO adequate evidence on the level of PEEP in non-ARDS patients. Most of the studies are old, conducted in post-surgical patients (short-term ventilation), and were not powered to detect differences in patient-centered

Second, despite the absence of evidence, the levels of PEEP used in non-ARDS patients increased over years, from 5 to 7/8 cmH2O, probably as a reflection of studies and practice in ARDS

Third, one IPDM showed that higher levels of PEEP could benefit more severe ARDS patients. However, opposite trends (higher mortality and longer ventilation) were found in mild ARDS with higher PEEP (despite not powered to be statistically

Fourth, most of the weaning protocols include PEEP ≤ 5 cmH2O as a criterion for readiness to wean. Theoretically, a standardized liberal strategy of higher PEEP could delay weaning in some

@73inlancs @janethooton_ @ErinInTheMorn @fifi_EY 1/ The 🏴󠁧󠁢󠁥󠁮󠁧󠁿 government decided pediatric gender care in England would be a monopoly contract (a Labour minister, in 2008), despite all other NHS patients officially being entitled to a choice of providers, & second opinions on diagnoses & treatment, & gave it to GIDS, which has…

@janethooton_ @ErinInTheMorn @fifi_EY 2/…always advocated that trans minors & their families must have no alternative source of care, & subsequent Tory ministers have personally put their signature on renewals of it, and even personally rejected proposals for improvement that have been put forward by NHS England…

@janethooton_ @ErinInTheMorn @fifi_EY 3/…as a result of wider & public consultation. They & their civil servants listen only to GIDS on trans minors - it was GIDS advised against <18s being allowed #GenderRecognition in 2004, & since, on the basis that no one under 18 can be certain of their gender identity, just…

@janethooton_ @ErinInTheMorn @fifi_EY 4/…as many other staff at their trust wrote⬇️ to the press in 2002 (when the first instigator of this case, psychoanalyst Susan Evans was on staff too) that no trans people should be allowed that recognition but needed

@janethooton_ @ErinInTheMorn @fifi_EY 5/…to "cure" us instead. Yet GIDS proved incapable of defending its super-conservative protocol in court - no doubt because GIDS has always expected challenges to be from patients seeking care more like that elsewhere, arrogantly ignoring that services in countries where the…

Here is a tweetorial from our latest publication in @Annals_Oncology about longitudinal tracking of esophageal adenocarcinoma. #OesophagealCancer #EsophagealCancer https://t.co/QWvrzBXmK7 1/8

We sequenced 245 plasma samples from 97 patients with oesophageal adenocarcinoma using a 77 gene pan-cancer ctDNA panel. 2/8

Variants derived from previously characterised driver oesophageal adenocarcinoma genes had a significantly higher VAF than variants from other genes, indicating selection. 3/8

Peripheral blood cell samples were also sequenced for 78/97 patients. CHIP mutations were identified in 23% of cases, longitudinal tracking of CHIP variants suggested these variants were dynamic over time. 4/8

We found patients that were ctDNA positive post-surgery had a significantly poorer survival than ctDNA negative patients, and the elimination of CHIP variants improved the positive predictive value. 5/8

breaking my social media fast, which may or may not exist anymore, to share something i found really really helpful from today's therapy sesh. i figured out why i (we?) have so much trouble celebrating our wins

so ive been in therapy for 100 years. still anxious, but im pretty sure i was born that way so i'll stay that way. still depressed too, which i thought id be cured of by now. aa few sessions ago we talked about what i think a return to health 'should' look like

initially i figured itd look like being the person i was before i got depressed. energetic, not needing pep talks to do shit like go outside, cooking everyday, working out at least 30 mins at least 3 days a week, calling my mom everyday, etc.

that session i realized that im a completely different person than i was before i got depressed. also the world has changed a lot & things are just done differently now. not allowing for those things had me reaching for shit that was impossible.

so i make some concessions but say that i *still* want to be able to do some things that i dont want to do. like i cant just sit on the couch and never move in the name of accepting who i am, which is A Bitch Who Don't Like To Move. i still want to be able to eve if i dont want