Heat stroke, Plasmalyte

Household6

Household6

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I'm not the greatest at chem yet, and I don't work with Plasmalyte. I am curious about it's applications, it's something the 68Ws are carrying and testing out now during trainups.

The critical heat casualty on post was given PL by Army medics per the instructor's orders instead of LRS. PTs heat stroke (dehydration?) turned into wicked bad rhabdomyolysis. After 3 days in the ICU he's off propofol, has pain reflexes, still intubated, and has regained some/most of his kidney and liver function, color is back to his feet, swelling is going down. He's looking at a month in the hospital, probably another week in the ICU

Here's what I THINK I MIGHT know about PL: Sodium gluconate isn't metabolized the greatest. Sodium gluconate doesn't work the way PL meant it to. They intended it to be metabolized with production of bicarbonate to level out the lactic acid in the blood. Instead most of the sodium gluconate is excreted in the kidneys without being metabolized at all. My medical director mentioned once that it can even act as a diuretic in some cases, but that's all the information I could get from out of him in the 20 seconds I see him.

So here's my questions:
In heat stroke does the temperature of the IV fluid need to be considered before therapy begins? I'm assuming that it would have been >110 since it was in a rucksack, it's always hot when it's in a pack.

Does sodium gluconate consistently metabolize into a bicarbonate?
Does does the temperature of the bag make a difference in how sodium gluconate metabolizes?
Does anything make a difference in how the sodium gluconate metabolizes?

Is it possible that PL might not be the best choice of fluid for a heat stroke pt who likely was also dehydrated.

TIA,
 
Out here on base we carry chillers with saline cooled to 1-2 degrees Celsius and it has excellent effects with bringing the temperature down. I can't imagine that any type of medication or fluids at high temperatures would be good for the heat patients. I would think that they would also need normal saline as the patient would be dehydrated also.
 
Interesting questions, Household. @Nova1300 might be the best one to ask.

I don't use Plasmalyte in my practice right now, so I'm not all that up on it. What I do remember is that its primary intended use is in severe metabolic acidosis (since gluconate has an alkalinyzing effect) and that it contains physiologic concentrations of all the electrolytes.

Generally speaking, there seems to be no consensus in the research and much disagreement between the experts on which IVF is best used in which situation. So physicians and facilities make policies and decisions on what to use based largely on anecdotal experience and personal preference.

I doubt the temp of the fluid when it is infused has much influence on anything. Obviously a 110 degree IVF isn't going to help cool a heat stroke patient, but generally, truly massive volumes of any IVF have to be infused before they have any influence on the patients body temp.

http://www.rxlist.com/script/main/mobileart-rx.asp?drug=plasma-lyte-a&monotype=rx-cp&monopage=10

http://www.derangedphysiology.com/m...ic-fate-lactate-acetate-citrate-and-gluconate
 
Remi said:
Interesting questions, Household. @Nova1300 might be the best one to ask.

I don't use Plasmalyte in my practice right now, so I'm not all that up on it. What I do remember is that its primary intended use is in severe metabolic acidosis (since gluconate has an alkalinyzing effect) and that it contains physiologic concentrations of all the electrolytes.

Generally speaking, there seems to be no consensus in the research and much disagreement between the experts on which IVF is best used in which situation. So physicians and facilities make policies and decisions on what to use based largely on anecdotal experience and personal preference.

I doubt the temp of the fluid when it is infused has much influence on anything. Obviously a 110 degree IVF isn't going to help cool a heat stroke patient, but generally, truly massive volumes of any IVF have to be infused before they have any influence on the patients body temp.

http://www.rxlist.com/script/main/mobileart-rx.asp?drug=plasma-lyte-a&monotype=rx-cp&monopage=10

http://www.derangedphysiology.com/main/core-topics-intensive-care/manipulation-fluids-and-electrolytes/Chapter 4.1.4/metabolic-fate-lactate-acetate-citrate-and-gluconate
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I've seen patients with 105 degrees and above cool down pretty rapidly with just one liter of NS rapid bolus and ice sheets. Granted this is with patients who have heat injuries from excessive physical activity.
 
luke_31 said:
I've seen patients with 105 degrees and above cool down pretty rapidly with just one liter of NS rapid bolus and ice sheets. Granted this is with patients who have heat injuries from excessive physical activity.
Click to expand...

Most body heat is lost by convection and ice sheets will accelerate that process dramatically. No doubt that ice-cold saline contributes to cooling, but one liter of IVF is a very small fraction of the mass of a normal-sized adult, so by itself it doesn't have a dramatic effect. The effect is even less when the IVF is room temp rather than iced or heated.
 
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Please keep things civil and relatively snark free, thanks!
 
If I were being more heavy-handed, I'd have done much more.
 
Remi said:
Most body heat is lost by convection and ice sheets will accelerate that process dramatically. No doubt that ice-cold saline contributes to cooling, but one liter of IVF is a very small fraction of the mass of a normal-sized adult, so by itself it doesn't have a dramatic effect. The effect is even less when the IVF is room temp rather than iced or heated.
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This is a tough concept to teach. Your answer is spot on. I have these discussions all the time with my students about warming (or cooling) surgical patients. It drives me crazy to see someone warming IV fluids (pointless) and not using a forced-air warming blanket. From a physics standpoint, it is impossible to actually warm a patient with IV fluids unless you use hot fluid which actually cooks RBC's which is not really helpful. Similarly, using cold IV fluid MIGHT help A LITTLE, but the real cooling effect is from surface cooling. If you need to cool your patient (or warm them) keep doing whatever it is you're doing continuously.
 
teedubbyaw said:
For calling Remi smart? Oh my, I'm so bad.
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No, it's that it's difficult to impossible to gauge someone's "tone" over the internet. Your comment could be taken in an unintended manner, in particular, in a derogatory/mocking way toward Remi.
 
Thanks for derailing the thread.

(Did you pick up on that tone?)
 
I have to admit, I have never used the stuff. In theory, it looks great. But in animal studies, it has not impressed me.

If I had a patient in rhabdo and all I had was warm plasmalyte, I would use it and cool with other methods.

The medical director's concern is that the gluconate is actually excreted unchanged in the urine and can act as an osmotic diuretic. Again, this effect is small and likely clinically irrelevant.

I suppose these things must be studied in order for progress to occur. But I have to admit, the fluid debates irk me. And until there are some landmark trials showing a real difference, I use the cheap stuff.

This ain't bourbon. It's iv fluid.
 
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