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)
“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
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)
Lots of reasons, including FALSE beliefs:
🛑 IV fluid always “treats AKI”
🛑 Hypotension = hypovolaemia
🛑 Lactate >2 means fluid deficiency
🛑 Septic patients are very hypovolaemic
💥 💥 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.
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.…
🔹 Bibasal crackles - highly nonspecific in older patients!
🔹 Dry skin
🔹Tachycardia
🔹 x and y descent of the JVP wave…..
Even postural BP drop, one of the better performing signs for hypovolaemia, still has a wide differential diagnosis.
And unfortunately the blood tests can be misleading too - for example check out our previous post about other causes of raised urea 👇 https://t.co/CSiRRnMi1a
Quick learning: think isolated high urea = \u201cdehydration\u201d?
— Buku Renal (@BukuRenal) September 17, 2020
Some other differentials:
\u2757\ufe0fGI bleeding
\u2757\ufe0f\u2019apparent hypovolaemia\u2019 in CCF (when the kidney sees low perfusion pressure)
\u2705 corticosteroids
\u2705 high protein intake
Not all \u2b06\ufe0furea needs IV fluid!#medtwitter #tipsfornewdocs
1️⃣ Has there been volume loss?
2️⃣ Has there been decreased intake?
If the answer is “not really” to both of these, then think carefully about what you think more fluid will accomplish.
When phoned as renal reg on-call on day 2-3 we’re usually not thinking “easy hypovolaemic AKI” but are concerned something is being missed.
Three common things:
1. AKI is part of sepsis / hypotension / MOF badness: patient needs ICU & vasopressors, not more IV fluid
3. AKI is an additional signal that palliative care may be appropriate (remember stage 3 AKI has terrible 42% mortality at 30 days in patients >75 years)
If the patient has a great story for hypovolaemia but their creatinine is rising/stuck, then they often have a degree of acute tubular necrosis (ATN).
Let us show you something (it’s not as boring as it appears!)
Appreciate that there is actual histological change - this needs TIME to recover
✳️ Just as injured cells in stroke or MI don’t magically heal with IV saline, neither does ATN ✳️
✅ Remember low urine output is a warning you have less margin for error before causing hypervolaemia - again, shake off the reflex just to ⬆️fluid rate
Not really - there’s different risk:benefit in different scenarios
👉 in tumour lysis, myeloma or rhabdo for example we do try to target higher urine outputs
BUT when patient is well-filled & not peeing much, we’re re-thinking rather than ploughing on.
YES - and it’s not just the obvious pulmonary oedema badness.
Excess fluid ➡️ high venous pressure ➡️ decreased perfusion pressure for heart, brain, liver (& kidneys!!)
Patients with excess volume have:
🛑 longer AKI
🛑 higher mortality
Avoidable dialysis for ⬆️volume continues because of myth that the hugely complex pathophysiology of AKI is easily remedied by IV salty water (pic from Ostermann et al)
🛑 “I can’t give fluid for their AKI because they are already overloaded” makes no sense 🛑
And why:
🛑 “I’ll keep giving IV fluids until their oxygen sats drop” is just bonkers 🛑
✅ Prescribe IV fluid with the care you would warfarin
✅ Achieve euvolaemia, then sit on your hands
✅ If urine output or BP stays low think “Is a different approach needed here?” rather than autoreaching for more IV fluid
✅ Break your AKI ➡️ fluid reflex
Would love to hear views on how you approach teaching ward junior docs @NephroGuy @icmteaching
More from Health
1/
Remember woman who tuk multiple @SriSriTattva products 4 range of problems frm diabetes 2 gas 2 liver disease & developed liver failure, listed for liver transplant?
Here is original thread:
https://t.co/PXxI1Slyv2
23 samples, Analysis results
#MedTwitter #livertwitter
2/
Before I go into results, I must say this was overwhelming. There was SO MUCH the lab identified, impossible to put everything here. So I made a summary. At the end of this thread, I have linked a full analysis described in Excel format. Some results were VERY concerning
3/
How did we analyse?
Here R links 2 methods
They R high end, done under strict protocols
Frm Ministry of Forest, Environment, Climate / NABL approvd Lab
ICP-OES https://t.co/O1CLhqVQAu
GC MSMS https://t.co/zRJoXyWQIr
FTIR https://t.co/goAembQ08p
Here is list V analysed 👇
4/
Sample names written on top (each column).
First 5 samples: C what we identified in #Ayurveda #medicines
Antibiotics
Steroids (anabolic/synthetic)
#NARCOTICS - LSD, Morphine
Blood thinners (possible reason Y bleeding tests were off the roof in the patient)
Heavy metals!
5/
Next 5 samples (total 10 now)
Mercury is clear winner. Almost all samples
See controlled substances - Butyrolactones https://t.co/CPz0FwPEOm, methylamine https://t.co/OZnXY7U9UQ
Alcohols, industrial solvents
Rare metals - cobalt, lithium
Again lots of blood thinners
#Ayush
Remember woman who tuk multiple @SriSriTattva products 4 range of problems frm diabetes 2 gas 2 liver disease & developed liver failure, listed for liver transplant?
Here is original thread:
https://t.co/PXxI1Slyv2
23 samples, Analysis results
#MedTwitter #livertwitter
Middle-aged woman wit jaundice (bilirubin 34), liver failure. Liver #Transplant this week.
— (Cyriac) Abby Philips (@drabbyphilips) December 7, 2020
\U0001f633Cause\U0001f447#Ayurveda #medicines total 23\U0001f616 by @SriSriTattva & @SriSri 3-6 mnth 4 sugar, pressure, #COVID19 #ImmuneBoosters, #memory, #liver tonic.
Sent 4 analysis.#livertwitter #MedTwitter pic.twitter.com/uz3FCiVJ3f
2/
Before I go into results, I must say this was overwhelming. There was SO MUCH the lab identified, impossible to put everything here. So I made a summary. At the end of this thread, I have linked a full analysis described in Excel format. Some results were VERY concerning
3/
How did we analyse?
Here R links 2 methods
They R high end, done under strict protocols
Frm Ministry of Forest, Environment, Climate / NABL approvd Lab
ICP-OES https://t.co/O1CLhqVQAu
GC MSMS https://t.co/zRJoXyWQIr
FTIR https://t.co/goAembQ08p
Here is list V analysed 👇
4/
Sample names written on top (each column).
First 5 samples: C what we identified in #Ayurveda #medicines
Antibiotics
Steroids (anabolic/synthetic)
#NARCOTICS - LSD, Morphine
Blood thinners (possible reason Y bleeding tests were off the roof in the patient)
Heavy metals!
5/
Next 5 samples (total 10 now)
Mercury is clear winner. Almost all samples
See controlled substances - Butyrolactones https://t.co/CPz0FwPEOm, methylamine https://t.co/OZnXY7U9UQ
Alcohols, industrial solvents
Rare metals - cobalt, lithium
Again lots of blood thinners
#Ayush
I applaud the #EUCancerPlan *BUT* caution: putting #meat 🥩 (a nourishing, evolutionary food) in the same box as 🚬 to solve a contemporary health challenge, would be basing policy on assumptions rather than robust data.
#FollowTheScience yes, but not just part of it!
THREAD👇
1/ Granted, some studies have pointed to ASSOCIATIONS of HIGH intake of red & processed meats with (slightly!) increased colorectal cancer incidence. Also, @WHO/IARC is often mentioned in support (usually hyperbolically so).
But, let’s have a closer look at all this! 🔍
2/ First, meat being “associated” with cancer is very different from stating that meat CAUSES cancer.
Unwarranted use of causal language is widespread in nutritional sciences, posing a systemic problem & undermining credibility.
3/ That’s because observational data are CONFOUNDED (even after statistical adjustment).
Healthy user bias is a major problem. Healthy middle classes are TOLD to eat less red meat (due to historical rather than rational reasons, cf link). So, they
4/ What’s captured here is sociology, not physiology.
Health-focused Westerners eat less red meat, whereas those who don’t adhere to dietary advice tend to have unhealthier lifestyles.
That tells us very little about meat AS SUCH being responsible for disease.
#FollowTheScience yes, but not just part of it!
THREAD👇
\U0001f534LIVE \U0001f4c5Today \u23f012:00 CET
— EU_HEALTH - #EUCancerPlan (@EU_Health) February 3, 2021
We are presenting today the #EUCancerPlan as part of a strong \U0001f1ea\U0001f1fa#HealthUnion
Follow the presentation live here: https://t.co/Cr8ATvzNkg#WorldCancerDay pic.twitter.com/zdByuklWV6
1/ Granted, some studies have pointed to ASSOCIATIONS of HIGH intake of red & processed meats with (slightly!) increased colorectal cancer incidence. Also, @WHO/IARC is often mentioned in support (usually hyperbolically so).
But, let’s have a closer look at all this! 🔍
2/ First, meat being “associated” with cancer is very different from stating that meat CAUSES cancer.
Unwarranted use of causal language is widespread in nutritional sciences, posing a systemic problem & undermining credibility.
3/ That’s because observational data are CONFOUNDED (even after statistical adjustment).
Healthy user bias is a major problem. Healthy middle classes are TOLD to eat less red meat (due to historical rather than rational reasons, cf link). So, they
4/ What’s captured here is sociology, not physiology.
Health-focused Westerners eat less red meat, whereas those who don’t adhere to dietary advice tend to have unhealthier lifestyles.
That tells us very little about meat AS SUCH being responsible for disease.
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These 10 threads will teach you more than reading 100 books
Five billionaires share their top lessons on startups, life and entrepreneurship (1/10)
10 competitive advantages that will trump talent (2/10)
Some harsh truths you probably don’t want to hear (3/10)
10 significant lies you’re told about the world (4/10)
Five billionaires share their top lessons on startups, life and entrepreneurship (1/10)
I interviewed 5 billionaires this week
— GREG ISENBERG (@gregisenberg) January 23, 2021
I asked them to share their lessons learned on startups, life and entrepreneurship:
Here's what they told me:
10 competitive advantages that will trump talent (2/10)
To outperform, you need serious competitive advantages.
— Sahil Bloom (@SahilBloom) March 20, 2021
But contrary to what you have been told, most of them don't require talent.
10 competitive advantages that you can start developing today:
Some harsh truths you probably don’t want to hear (3/10)
I\u2019ve gotten a lot of bad advice in my career and I see even more of it here on Twitter.
— Nick Huber (@sweatystartup) January 3, 2021
Time for a stiff drink and some truth you probably dont want to hear.
\U0001f447\U0001f447
10 significant lies you’re told about the world (4/10)
THREAD: 10 significant lies you're told about the world.
— Julian Shapiro (@Julian) January 9, 2021
On startups, writing, and your career:
1/“What would need to be true for you to….X”
Why is this the most powerful question you can ask when attempting to reach an agreement with another human being or organization?
A thread, co-written by @deanmbrody:
2/ First, “X” could be lots of things. Examples: What would need to be true for you to
- “Feel it's in our best interest for me to be CMO"
- “Feel that we’re in a good place as a company”
- “Feel that we’re on the same page”
- “Feel that we both got what we wanted from this deal
3/ Normally, we aren’t that direct. Example from startup/VC land:
Founders leave VC meetings thinking that every VC will invest, but they rarely do.
Worse over, the founders don’t know what they need to do in order to be fundable.
4/ So why should you ask the magic Q?
To get clarity.
You want to know where you stand, and what it takes to get what you want in a way that also gets them what they want.
It also holds them (mentally) accountable once the thing they need becomes true.
5/ Staying in the context of soliciting investors, the question is “what would need to be true for you to want to invest (or partner with us on this journey, etc)?”
Multiple responses to this question are likely to deliver a positive result.
Why is this the most powerful question you can ask when attempting to reach an agreement with another human being or organization?
A thread, co-written by @deanmbrody:
Next level tactic when closing a sale, candidate, or investment:
— Erik Torenberg (@eriktorenberg) February 27, 2018
Ask: \u201cWhat needs to be true for you to be all in?\u201d
You'll usually get an explicit answer that you might not get otherwise. It also holds them accountable once the thing they need becomes true.
2/ First, “X” could be lots of things. Examples: What would need to be true for you to
- “Feel it's in our best interest for me to be CMO"
- “Feel that we’re in a good place as a company”
- “Feel that we’re on the same page”
- “Feel that we both got what we wanted from this deal
3/ Normally, we aren’t that direct. Example from startup/VC land:
Founders leave VC meetings thinking that every VC will invest, but they rarely do.
Worse over, the founders don’t know what they need to do in order to be fundable.
4/ So why should you ask the magic Q?
To get clarity.
You want to know where you stand, and what it takes to get what you want in a way that also gets them what they want.
It also holds them (mentally) accountable once the thing they need becomes true.
5/ Staying in the context of soliciting investors, the question is “what would need to be true for you to want to invest (or partner with us on this journey, etc)?”
Multiple responses to this question are likely to deliver a positive result.
