IV normal saline: a medical habit
April 1, 2018 7:43 PM Subscribe
“Primarily a treatment for dehydration, normal saline is given without a second thought for a variety of conditions, from vomiting to fast heart rates to lightheadedness.
For such a ubiquitous treatment, you'd probably expect that saline has been thoroughly studied and refined. As it turns out, that was never really the case at all. Now there's a rethinking about whether saline is really the best way to go.” - Why Did Sterile Salt Water Become The IV Fluid Of Choice?
For all the emphasis on evidenced based practice in medicine we do an amazing amount just because its the way we always have.
I recently moved from only doing EMS to working in a Hospital, and had always thought the non-evidenced based EMS stuff was primarily because of the way EMS developed (reliance on backboarding for far too long after it was known to not be helpful for example) -- turns out the hospital is full of hard to break traditions as well.
posted by charles148 at 8:08 PM on April 1, 2018 [14 favorites]
I recently moved from only doing EMS to working in a Hospital, and had always thought the non-evidenced based EMS stuff was primarily because of the way EMS developed (reliance on backboarding for far too long after it was known to not be helpful for example) -- turns out the hospital is full of hard to break traditions as well.
posted by charles148 at 8:08 PM on April 1, 2018 [14 favorites]
Wait, I still see backboards being used to take people off the ice/field for sports injuries all the time -- what's the deets about them not being helpful?
posted by tavella at 8:21 PM on April 1, 2018 [2 favorites]
posted by tavella at 8:21 PM on April 1, 2018 [2 favorites]
Yes backboards are use to extricate people, but for many years it was common to transport people on hard backboards to the emergency department, believing that this kept the spine from moving. Turns out you cause more back problems this way.
posted by charles148 at 8:38 PM on April 1, 2018 [9 favorites]
posted by charles148 at 8:38 PM on April 1, 2018 [9 favorites]
Casual reading in /r/medicine (sorry no direct link that I could come up with, but that community really is decent enough to peruse casually) led me to believe that saline wasn't actually as commonly utilized as a default thing in other countries as it is in the US. So, my immediate default answer to the question 'Why?" immediately assumed that it was just another something the hospital could charge you for and/or make a higher profit margin on than other options. The fact that I went straight there with the logic speaks volumes as to my respect for medical practices here and now.
posted by RolandOfEld at 8:38 PM on April 1, 2018 [22 favorites]
posted by RolandOfEld at 8:38 PM on April 1, 2018 [22 favorites]
Well, shoot
I've probably had as many bags of normal saline as I've had hot dinners (OK, so I like cold dinners), and my endocrinologist has been glancing askance at a few of my kidney-related labs lately.
I usually base the ER-vs.-Urgent Care decision on "will I likely need an IV for this?" because that's the one big thing our Urgent Care doesn't do.
It sounds like changing the formula of normal saline would be a fairly simple thing to do, and not at a huge extra cost. Unless they would have to dump the existing stock instead of letting it run out or something. Or unless it would leave them liable for lawsuits from people who believed their illness was due to the old formula.
But yeah, without IV rehydration I wouldn't be here to tell the tale.
posted by The Underpants Monster at 8:51 PM on April 1, 2018 [10 favorites]
I've probably had as many bags of normal saline as I've had hot dinners (OK, so I like cold dinners), and my endocrinologist has been glancing askance at a few of my kidney-related labs lately.
I usually base the ER-vs.-Urgent Care decision on "will I likely need an IV for this?" because that's the one big thing our Urgent Care doesn't do.
It sounds like changing the formula of normal saline would be a fairly simple thing to do, and not at a huge extra cost. Unless they would have to dump the existing stock instead of letting it run out or something. Or unless it would leave them liable for lawsuits from people who believed their illness was due to the old formula.
But yeah, without IV rehydration I wouldn't be here to tell the tale.
posted by The Underpants Monster at 8:51 PM on April 1, 2018 [10 favorites]
Lots of "dumb" things aren't very obvious except in hindsight. For example it was well known that after a heart attack patients had a significant chance of dying within the next year due to heart arrhythmia... so obviously, in the 1980s these drugs were widely prescribed to control arrhythmia following a heart attack, because to not do so, would be negligent, right? These drugs had already been on the market for 20 years and been used successfully to treat arrhythmia in that time. Imagine how you would pitch the study to the prospective patients - hey, there's a good chance you'll die of arrhythmia after a heart attack, but we now want to study it just to be sure, so we'll put half the patients on placebos and see what happens.... want in?
Spoiler: they did the study in 1987 but halted it early because so many patients on the drugs were dying compared to the placebo... 8% of patients on the drugs died within a year compared to 3% taking the placebo. Apparently it was routine to be prescribed these drugs after a heart attack, so in the 80s, say 500,000 heart attacks per year in North America and maybe 1/4 of them were treated with the drug, with excess deaths of 5%, that's 6,000 excess deaths per year...
posted by xdvesper at 9:05 PM on April 1, 2018 [20 favorites]
Spoiler: they did the study in 1987 but halted it early because so many patients on the drugs were dying compared to the placebo... 8% of patients on the drugs died within a year compared to 3% taking the placebo. Apparently it was routine to be prescribed these drugs after a heart attack, so in the 80s, say 500,000 heart attacks per year in North America and maybe 1/4 of them were treated with the drug, with excess deaths of 5%, that's 6,000 excess deaths per year...
posted by xdvesper at 9:05 PM on April 1, 2018 [20 favorites]
I think this is awesome. I love it when we get to see the very moment that a scientific field makes a small, but important shift in the way “it’s always been done”.
We look back at the field of medicine 150 years ago and shudder at how relatively primitive it seems to us now. But that change came as an accumulation of thousands of little advances and innovations, just like this one.
Can you imagine what we assume is medically helpful today, that we will be rejecting 150 years from now?
posted by darkstar at 9:09 PM on April 1, 2018 [11 favorites]
We look back at the field of medicine 150 years ago and shudder at how relatively primitive it seems to us now. But that change came as an accumulation of thousands of little advances and innovations, just like this one.
Can you imagine what we assume is medically helpful today, that we will be rejecting 150 years from now?
posted by darkstar at 9:09 PM on April 1, 2018 [11 favorites]
I hope that this actually results in change though. It seems like even money that it won't.
posted by bleep at 9:11 PM on April 1, 2018 [4 favorites]
posted by bleep at 9:11 PM on April 1, 2018 [4 favorites]
Well, what are we supposed to use instead?
posted by sexyrobot at 9:17 PM on April 1, 2018 [6 favorites]
posted by sexyrobot at 9:17 PM on April 1, 2018 [6 favorites]
All the Hamburger references made me wonder if I should take this article seriously, but I saw it was dated March 31, so I guess it is real. I remember watching John Gage give patients lactated Ringers in his ambulance back in the 1970s. I even remember asking my father (who had a PhD in physiology) what lactated Ringers was. He gave me an explanation that mostly went over my pre-teen head at the time, but fast forward a few decades, and LR is the standard fluid in our OR, and has been for some time. There are certainly situations that call for other IV fluids, but 0.9% NaCl is the exception rather than the rule.
(And don’t get me started on Mass General given their efforts to claim the discovery of anesthesia. Especially right after Doctors Day.)
posted by TedW at 9:25 PM on April 1, 2018 [7 favorites]
(And don’t get me started on Mass General given their efforts to claim the discovery of anesthesia. Especially right after Doctors Day.)
posted by TedW at 9:25 PM on April 1, 2018 [7 favorites]
Probably related, the US is experiencing saline shortages.
posted by Quonab at 9:27 PM on April 1, 2018 [7 favorites]
posted by Quonab at 9:27 PM on April 1, 2018 [7 favorites]
Lactated Ringer's has been the default IV fluid of choice at every hospital in which I've worked since becoming a nurse in 2006. The only time I give normal saline is in conjunction with a blood transfusion or as an amnioinfusion.
posted by jesourie at 9:30 PM on April 1, 2018 [9 favorites]
posted by jesourie at 9:30 PM on April 1, 2018 [9 favorites]
This is just one article y’all, I would caution against overgenereralising based on this especially when it comes to your own care. An interesting data point but hardly the final word.
posted by supercrayon at 9:33 PM on April 1, 2018 [2 favorites]
posted by supercrayon at 9:33 PM on April 1, 2018 [2 favorites]
This is a great opportunity for someone in Big Pharma to patent a general purpose isotonic solution. Then they can charge $1000 a bag for it ($2500 if you’re paying out of pocket)
posted by spacewrench at 9:34 PM on April 1, 2018 [2 favorites]
posted by spacewrench at 9:34 PM on April 1, 2018 [2 favorites]
Via IMDB:
[opening credits, 6th season. These credits were also incorrectly used on some earlier DVD releases and syndication]
Dispatcher: Fifty-One, informant reports toxic chemicals are stored in tanker. Use caution.
Dr. Kelly Brackett: Squad Fifty-One, this is Rampart - can you send me some EKG?
John Gage: 10-4; transmitting EKG - we're sending you a strip, vitals to follow. Pulse is 160, the - victim is in extreme pain, Rampart.
Paramedic Roy DeSoto: Patient is in V-fib! Rampart, we have lost the victim's pulse! Beginning CPR! We're defibrillating victim, Rampart! Rampart, we've defibrillated victim; he's in sinus rhythm.
Joe Early: Administer two amps sodium bicarb and insert an airway. Start an IV, Fifty-One - lactated Ringer's.
Dixie McCall: Squad Fifty-One, continue monitoring vitals and transport immediately.
John Gage: We're on our way, Rampart!
(Just in case anyone thought I was confabulating)
posted by TedW at 9:35 PM on April 1, 2018 [8 favorites]
[opening credits, 6th season. These credits were also incorrectly used on some earlier DVD releases and syndication]
Dispatcher: Fifty-One, informant reports toxic chemicals are stored in tanker. Use caution.
Dr. Kelly Brackett: Squad Fifty-One, this is Rampart - can you send me some EKG?
John Gage: 10-4; transmitting EKG - we're sending you a strip, vitals to follow. Pulse is 160, the - victim is in extreme pain, Rampart.
Paramedic Roy DeSoto: Patient is in V-fib! Rampart, we have lost the victim's pulse! Beginning CPR! We're defibrillating victim, Rampart! Rampart, we've defibrillated victim; he's in sinus rhythm.
Joe Early: Administer two amps sodium bicarb and insert an airway. Start an IV, Fifty-One - lactated Ringer's.
Dixie McCall: Squad Fifty-One, continue monitoring vitals and transport immediately.
John Gage: We're on our way, Rampart!
(Just in case anyone thought I was confabulating)
posted by TedW at 9:35 PM on April 1, 2018 [8 favorites]
This is a great opportunity for someone in Big Pharma to patent a general purpose isotonic solution. Then they can charge $1000 a bag for it ($2500 if you’re paying out of pocket)
Plasmalyte
posted by TedW at 9:44 PM on April 1, 2018
Plasmalyte
posted by TedW at 9:44 PM on April 1, 2018
(I have to add that Plasma-Lyte is about $15.00 a bag, vs $1.50 for most other IV fluids [pre-hurricane], so draw conclusions as appropriate.)
posted by TedW at 9:51 PM on April 1, 2018 [2 favorites]
posted by TedW at 9:51 PM on April 1, 2018 [2 favorites]
The page you linked doesn’t say anything about patents...perhaps the Aussies haven’t gotten the hang of fleecing the ailing and infirm yet. In any event, I think there’s still room for an isotonic solution that can be Shkreli’d. Can’t leave money on the table! (With apologies to supercrayon for the derail.)
posted by spacewrench at 10:03 PM on April 1, 2018 [2 favorites]
posted by spacewrench at 10:03 PM on April 1, 2018 [2 favorites]
Thanks for throwing me down a Randolph Mantooth rabbit hole, people.
posted by Samizdata at 10:26 PM on April 1, 2018 [9 favorites]
posted by Samizdata at 10:26 PM on April 1, 2018 [9 favorites]
The majority of hospital care in Australia is provided in public hospitals, the economica of which are dictated by the need to provide cost efficient care to the population with no charge for service. I have been trained in that environment, so my biases for cost efficiency in order to maximise the public health dollar will be evident.
The harms, so to speak, of normal saline are not going to be evenly distributed across the population who receive it. Most people who get a litre of IV fluid are, I posit, probably pretty healthy in the scheme of sick people, ie they have relatively preserved kidney function and no significant organ dysfunction. Most people in hospital are not Healthy, but they're not in ICU with multi organ dysfunction. If your kidneys are functioning, they can probably handle the acid / chloride load of 0.9% sodium chloride.
I rate it... 70% beatup.
posted by chiquitita at 11:10 PM on April 1, 2018 [4 favorites]
The harms, so to speak, of normal saline are not going to be evenly distributed across the population who receive it. Most people who get a litre of IV fluid are, I posit, probably pretty healthy in the scheme of sick people, ie they have relatively preserved kidney function and no significant organ dysfunction. Most people in hospital are not Healthy, but they're not in ICU with multi organ dysfunction. If your kidneys are functioning, they can probably handle the acid / chloride load of 0.9% sodium chloride.
I rate it... 70% beatup.
posted by chiquitita at 11:10 PM on April 1, 2018 [4 favorites]
If your kidneys are functioning, they can probably handle the acid / chloride load of 0.9% sodium chloride.
And heck, even if they aren’t. The .9% sodium chloride is what’s used to prime the lines for hemodialysis for patients with kidney failure. We take in at least half a liter of it that way, sometimes more, three days a week.
posted by mochapickle at 11:47 PM on April 1, 2018 [3 favorites]
And heck, even if they aren’t. The .9% sodium chloride is what’s used to prime the lines for hemodialysis for patients with kidney failure. We take in at least half a liter of it that way, sometimes more, three days a week.
posted by mochapickle at 11:47 PM on April 1, 2018 [3 favorites]
Joe Early: Administer two amps sodium bicarb and insert an airway. Start an IV, Fifty-One - lactated Ringer's....
(Just in case anyone thought I was confabulating)
Oh, no. When I saw the 'useless' thing, I immediately thought of all the people who got programmed watching Emergency.
posted by mikelieman at 11:53 PM on April 1, 2018
(Just in case anyone thought I was confabulating)
Oh, no. When I saw the 'useless' thing, I immediately thought of all the people who got programmed watching Emergency.
posted by mikelieman at 11:53 PM on April 1, 2018
Well if you're on haemodialysis, that is your kidney.
posted by chiquitita at 11:55 PM on April 1, 2018 [2 favorites]
posted by chiquitita at 11:55 PM on April 1, 2018 [2 favorites]
About half of that amount is post treatment, though, and not immediately cleared by the machine. And many patients with low bp receive additional saline as well at the end of treatment to raise their bp back up. So it would be 2-3 days between receiving the fluid and the patient's next treatment.
posted by mochapickle at 12:09 AM on April 2, 2018 [1 favorite]
posted by mochapickle at 12:09 AM on April 2, 2018 [1 favorite]
jesourie this may be a state difference or maybe a department difference, but every ED I've worked in has used saline as the norm, with the occasional physician (usually younger) opting for LR. I'm in the same state as TedW, but in very a very different situation (adult ED vs peds OR).
As for the study... I guess I'm a little underwhelmed? Here's a link to the damn paper. I think it makes a pretty good case for NS being harder on the kidneys than LR, but falls short of being definitive about stage 2 or greater AKI.
There's a lot of non-significant values for clinical outcomes in the study along with some pretty meh CIs for the ORs of even the significant values. Of note is a companion paper which had the same study design, but followed non-ICU admitted patients. Even its primary outcome measure (hospital-free days after discharge) found no significant difference. So I'm inclined to agree with chiquita that, in non-ICU populations, the difference between getting a bag of NS vs LR is probably not worth mentioning.
I would like to see further studies which are more narrowly focused, especially those looking at outcome measures where kidney function and hyperchloremia/acidosis are more significant factors, such as with renal patients or DKA cases. Their definition of "major adverse kidney event" is pretty broad, encompassing everything from death to dialysis to a 200% increase in creatinine from baseline lab. So it would be good to see further studies that focus in on the differences on renal effects between NS and LR. I'd particularly like to see a focus on conditions, like sepsis, where massive fluid boluses are the standard.
Also, I'd like to see a better picture of the clinical effect of LR vs NS before opting to see one as unconditionally superior to the other. LR is slightly hypotonic (compared to the slightly hypertonic NS), so I'd be interested in trials of increasing intravascular volume with regards to cardiac function between the two. LR also might not be the magic bullet the article makes it out to be, given that it is hyponatremic relative to plasma, so it would be interesting to see how changes in sodium levels affect clinical outcomes just as the hyperchloremic values of NS affect outcomes. But overall, I'm equivocal on whether this would affect anything about my current practice of hanging a liter of NS on my non-critical patients.
posted by Panjandrum at 12:28 AM on April 2, 2018 [15 favorites]
As for the study... I guess I'm a little underwhelmed? Here's a link to the damn paper. I think it makes a pretty good case for NS being harder on the kidneys than LR, but falls short of being definitive about stage 2 or greater AKI.
There's a lot of non-significant values for clinical outcomes in the study along with some pretty meh CIs for the ORs of even the significant values. Of note is a companion paper which had the same study design, but followed non-ICU admitted patients. Even its primary outcome measure (hospital-free days after discharge) found no significant difference. So I'm inclined to agree with chiquita that, in non-ICU populations, the difference between getting a bag of NS vs LR is probably not worth mentioning.
I would like to see further studies which are more narrowly focused, especially those looking at outcome measures where kidney function and hyperchloremia/acidosis are more significant factors, such as with renal patients or DKA cases. Their definition of "major adverse kidney event" is pretty broad, encompassing everything from death to dialysis to a 200% increase in creatinine from baseline lab. So it would be good to see further studies that focus in on the differences on renal effects between NS and LR. I'd particularly like to see a focus on conditions, like sepsis, where massive fluid boluses are the standard.
Also, I'd like to see a better picture of the clinical effect of LR vs NS before opting to see one as unconditionally superior to the other. LR is slightly hypotonic (compared to the slightly hypertonic NS), so I'd be interested in trials of increasing intravascular volume with regards to cardiac function between the two. LR also might not be the magic bullet the article makes it out to be, given that it is hyponatremic relative to plasma, so it would be interesting to see how changes in sodium levels affect clinical outcomes just as the hyperchloremic values of NS affect outcomes. But overall, I'm equivocal on whether this would affect anything about my current practice of hanging a liter of NS on my non-critical patients.
posted by Panjandrum at 12:28 AM on April 2, 2018 [15 favorites]
Oh, and I wonder about IV compatibility of NS vs LR regarding meds. I'm at home so I don't have Micromedex to check the common drugs I give, but I don't imagine there would be a huge difference (outside of transfusions)
posted by Panjandrum at 12:37 AM on April 2, 2018 [2 favorites]
posted by Panjandrum at 12:37 AM on April 2, 2018 [2 favorites]
Assuming I was conscious, what luck would I have asking that I be hooked up to Ringer's instead of normal saline?
xdvesper, what are the "these drugs" that you refer to being given to heart-attack patients?
posted by Kirth Gerson at 1:06 AM on April 2, 2018 [2 favorites]
xdvesper, what are the "these drugs" that you refer to being given to heart-attack patients?
posted by Kirth Gerson at 1:06 AM on April 2, 2018 [2 favorites]
Oh, and I wonder about IV compatibility of NS vs LR regarding meds.
The big one that comes to mind is Zosyn, which is not compatible with LR.
posted by dephlogisticated at 1:50 AM on April 2, 2018 [2 favorites]
The big one that comes to mind is Zosyn, which is not compatible with LR.
posted by dephlogisticated at 1:50 AM on April 2, 2018 [2 favorites]
Plus there are some people you don't want to be giving extra potassium or calcium to full stop!
For the first time in my life I looked up the product info for CSL (ie Ringer's) - it's contraindicated for patients on ACE inhibitors or ARBs, which is EVERY MEDICAL WARD PATIENT.
INTERACTIONS WITH OTHER MEDICINES
The Hartmann’s IV and Modified Hartmann’s IV Infusion should not be administered simultaneously with blood preparations (eg. citrate anticoagulated/ preserved blood) through the same administration set, because of a possibility of the likelihood of coagulation.
Concomitant administration with ceftriaxone is not recommended through the same infusion line (see Contraindications and Precautions) due to the risk of fatal ceftriaxone-calcium salt precipitation.
Administration of calcium may increase the effects of digitalis and lead to serious or fatal cardiac arrhythmias. Therefore larger volumes or faster infusion rates should be used with caution in patients treated with digitalis glycosides.
Caution is advised when administering Hartmann’s IV and Modified Hartmann’s IV Infusion to patients treated with thiazide diuretics or vitamin D as these can increase the risk of hypercalcaemia.
Caution is advised when administering Hartmann’s IV and Modified Hartmann’s IV Infusion to patients treated with medicines that may increase the risk of sodium and fluid retention such as carbenoxolone and corticosteroids (see Precautions).
Hartmann’s IV and Modified Hartmann’s IV Infusion may interfere with the elimination of medicines for which renal elimination is pH dependent. Renal clearance of acidic drugs such as salicylates, barbiturates and lithium may be increased. The renal clearance of alkaline medicines such as sympathomimetics (eg. pseudoephedrine), dexamphetamine sulphate and fenfluramine hydrochloride may be decreased.
These products should not be administered concomitantly with potassium sparing diuretics (amiloride, spironolactone, triamterene), angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARAs) or the immunosuppressants tacrolimus and cyclosporin. Simultaneous administration of these drugs can result in severe hyperkalaemia, particularly in patients with severe renal insufficiency.
Like, I get modern medicine is not perfect, but seriously there is no scam to withhold the magic IV fluid.
posted by chiquitita at 2:54 AM on April 2, 2018 [10 favorites]
For the first time in my life I looked up the product info for CSL (ie Ringer's) - it's contraindicated for patients on ACE inhibitors or ARBs, which is EVERY MEDICAL WARD PATIENT.
INTERACTIONS WITH OTHER MEDICINES
The Hartmann’s IV and Modified Hartmann’s IV Infusion should not be administered simultaneously with blood preparations (eg. citrate anticoagulated/ preserved blood) through the same administration set, because of a possibility of the likelihood of coagulation.
Concomitant administration with ceftriaxone is not recommended through the same infusion line (see Contraindications and Precautions) due to the risk of fatal ceftriaxone-calcium salt precipitation.
Administration of calcium may increase the effects of digitalis and lead to serious or fatal cardiac arrhythmias. Therefore larger volumes or faster infusion rates should be used with caution in patients treated with digitalis glycosides.
Caution is advised when administering Hartmann’s IV and Modified Hartmann’s IV Infusion to patients treated with thiazide diuretics or vitamin D as these can increase the risk of hypercalcaemia.
Caution is advised when administering Hartmann’s IV and Modified Hartmann’s IV Infusion to patients treated with medicines that may increase the risk of sodium and fluid retention such as carbenoxolone and corticosteroids (see Precautions).
Hartmann’s IV and Modified Hartmann’s IV Infusion may interfere with the elimination of medicines for which renal elimination is pH dependent. Renal clearance of acidic drugs such as salicylates, barbiturates and lithium may be increased. The renal clearance of alkaline medicines such as sympathomimetics (eg. pseudoephedrine), dexamphetamine sulphate and fenfluramine hydrochloride may be decreased.
These products should not be administered concomitantly with potassium sparing diuretics (amiloride, spironolactone, triamterene), angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARAs) or the immunosuppressants tacrolimus and cyclosporin. Simultaneous administration of these drugs can result in severe hyperkalaemia, particularly in patients with severe renal insufficiency.
Like, I get modern medicine is not perfect, but seriously there is no scam to withhold the magic IV fluid.
posted by chiquitita at 2:54 AM on April 2, 2018 [10 favorites]
Haha, that gave me Randy Mantooth flashbacks as well, but I used to work with him. Randy days were always painful....
posted by nevercalm at 3:58 AM on April 2, 2018 [2 favorites]
posted by nevercalm at 3:58 AM on April 2, 2018 [2 favorites]
Well, what are we supposed to use instead?
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2, 2018 [15 favorites]
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2, 2018 [15 favorites]
Remind me of this article, The cult of the Swan-Ganz catheter.
posted by ssmug at 5:02 AM on April 2, 2018 [2 favorites]
posted by ssmug at 5:02 AM on April 2, 2018 [2 favorites]
Can you imagine what we assume is medically helpful today, that we will be rejecting 150 years from now?
I expect that future people will view chemotherapy the same way we view leeches.
posted by Jacqueline at 5:04 AM on April 2, 2018 [2 favorites]
I expect that future people will view chemotherapy the same way we view leeches.
posted by Jacqueline at 5:04 AM on April 2, 2018 [2 favorites]
Well, what are we supposed to use instead?
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2
eponyproppriate
posted by halation at 5:47 AM on April 2, 2018 [3 favorites]
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2
eponyproppriate
posted by halation at 5:47 AM on April 2, 2018 [3 favorites]
Jacqueline I doubt that. Perhaps more like we view certain "heroic" toxin treatments that were used back when. Or amputations done with no anesthetic and then plunged into pitch to stop the bleeding.
Thing is, unlike leeches, chemotherapy really does work. But we also know that it works because poisoning a person's body and relying on the fact that cancer cells are more susceptible to the poison is really fucking stupid and harmful. We just don't have a better way of dealing with it yet.
It's harmful, but has actual, measurable, scientifically provable, benefits. While leeches didn't.
I do think they'll look back in horror at chemotherapy (and radiation therapy, and so on). Not because they were mere superstition but because they are genuinely horrible and the only reason we use them is because there's no alternative that works.
With any luck we'll be dealing in micrometer scale bots soon and that'll be vastly better.
posted by sotonohito at 6:04 AM on April 2, 2018 [7 favorites]
Thing is, unlike leeches, chemotherapy really does work. But we also know that it works because poisoning a person's body and relying on the fact that cancer cells are more susceptible to the poison is really fucking stupid and harmful. We just don't have a better way of dealing with it yet.
It's harmful, but has actual, measurable, scientifically provable, benefits. While leeches didn't.
I do think they'll look back in horror at chemotherapy (and radiation therapy, and so on). Not because they were mere superstition but because they are genuinely horrible and the only reason we use them is because there's no alternative that works.
With any luck we'll be dealing in micrometer scale bots soon and that'll be vastly better.
posted by sotonohito at 6:04 AM on April 2, 2018 [7 favorites]
But leeches DO work. They're great for an excess of sanguinic humour, you know, subcutaneous haemotoma.
posted by seanmpuckett at 6:19 AM on April 2, 2018 [11 favorites]
posted by seanmpuckett at 6:19 AM on April 2, 2018 [11 favorites]
When my dad was dying of cancer, and we were caring for him at home, for some reason I had to buy two bags of saline solution for the nurse to IV him, playing out of pocket. The charge was $200, for two bags of saline solution. Seemed like a lot. But what was I supposed to do, haggle?
posted by jabah at 6:40 AM on April 2, 2018 [2 favorites]
posted by jabah at 6:40 AM on April 2, 2018 [2 favorites]
It's harmful, but has actual, measurable, scientifically provable, benefits. While leeches didn't.
"The saliva of leech contains numerous biologically active substances, which have antiinflammatory as well as anesthetic properties..."
Systematic review, Clin J Pain: "moderate to strong evidence" for efficacy of medicinal leech therapy in knee arthritis.
OTOH, recent work of John Ioannidis exploring the myriad grave methodological and statistical concerns with many of the empirical studies that constitute what's popularly accepted as "actual, measurable, scientific proof" (although many of those concerns doubless apply to the leech studies, as well!)
There has never been a worse time to feel smug about the truth and clarity of our current Scientifically Verified knowledge, as compared with that of the benighted leech-gatherers of old.
posted by Bardolph at 6:58 AM on April 2, 2018 [8 favorites]
"The saliva of leech contains numerous biologically active substances, which have antiinflammatory as well as anesthetic properties..."
Systematic review, Clin J Pain: "moderate to strong evidence" for efficacy of medicinal leech therapy in knee arthritis.
OTOH, recent work of John Ioannidis exploring the myriad grave methodological and statistical concerns with many of the empirical studies that constitute what's popularly accepted as "actual, measurable, scientific proof" (although many of those concerns doubless apply to the leech studies, as well!)
There has never been a worse time to feel smug about the truth and clarity of our current Scientifically Verified knowledge, as compared with that of the benighted leech-gatherers of old.
posted by Bardolph at 6:58 AM on April 2, 2018 [8 favorites]
Well, what are we supposed to use instead?
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2
Yeah, but the 16 year, or the 12 year?
posted by 40 Watt at 7:01 AM on April 2, 2018 [2 favorites]
Lagavulin.
posted by Mr. Bad Example at 4:53 AM on April 2
Yeah, but the 16 year, or the 12 year?
posted by 40 Watt at 7:01 AM on April 2, 2018 [2 favorites]
And IVs may not be necessary in many cases either: Are IV Bags Necessary to Rehydrate Patients?
"IV fluids are a perfect example of our tendency to spend more and subject patients to invasive approaches when less invasive measures would suffice. We’ve long known that in patients who can tolerate oral fluids (i.e. they aren’t vomiting or otherwise excreting more liquid than they consume), IV fluids offer no advantage in rehydrating patients with dehydration.
IV fluids are a perfect example of our tendency to spend more and subject patients to invasive approaches when less invasive measures would suffice.
In fact, in many cases, IV fluids are actually worse than oral fluids for treating dehydration, because so many medical providers unthinkingly order sodium chloride solutions (aka “normal saline”) that contain no glucose and, unlike our natural physiology, are highly acidic."
posted by Mr.Know-it-some at 7:39 AM on April 2, 2018 [3 favorites]
"IV fluids are a perfect example of our tendency to spend more and subject patients to invasive approaches when less invasive measures would suffice. We’ve long known that in patients who can tolerate oral fluids (i.e. they aren’t vomiting or otherwise excreting more liquid than they consume), IV fluids offer no advantage in rehydrating patients with dehydration.
IV fluids are a perfect example of our tendency to spend more and subject patients to invasive approaches when less invasive measures would suffice.
In fact, in many cases, IV fluids are actually worse than oral fluids for treating dehydration, because so many medical providers unthinkingly order sodium chloride solutions (aka “normal saline”) that contain no glucose and, unlike our natural physiology, are highly acidic."
posted by Mr.Know-it-some at 7:39 AM on April 2, 2018 [3 favorites]
Just another doctor here to say that this resident is grossly oversimplifying things. There’s definitely a culture of “this is how we always do it” — for instance, surgeons almost always use LR at my institution while internists almost always use saline. But saline being hypertonic is an intravascular volume expander which is kinda what you want when organs are shutting down while LR tends to provide more fluid to the interstitium which is kinda what you want after surgery. But the thing about saline is that you are often adding lots of other stuff to it like glucose or insulin or correcting particular electrolyte deficiencies or actively managing the acid/base situation by adding bicarbonate. And all of the calculations and equations we are taught about how fast to correct volume deficits and electrolyte imbalances assume you’re using normal saline of half normal saline or whatever. I’m not saying ones better than the other and, as with many other things in medicine, it would be nice to have clear applicable research to guide us, but this is not such a simple change to say “let’s just start using LR tomorrow.”
And of course there’s no way that research is going to happen in the US unless it leads to Purdue’s new $7,000 a liter Normotek Infusion System with proprietary catheter and infusion pump.
posted by Slarty Bartfast at 7:50 AM on April 2, 2018 [21 favorites]
And of course there’s no way that research is going to happen in the US unless it leads to Purdue’s new $7,000 a liter Normotek Infusion System with proprietary catheter and infusion pump.
posted by Slarty Bartfast at 7:50 AM on April 2, 2018 [21 favorites]
Yeah, but the 16 year, or the 12 year?
Your insurance will only cover the 12.
posted by Mr. Bad Example at 10:30 AM on April 2, 2018 [7 favorites]
Your insurance will only cover the 12.
posted by Mr. Bad Example at 10:30 AM on April 2, 2018 [7 favorites]
Mr.Know-it-some ,I really appreciate that article on IV vs oral rehydration. Thank you!
Also, I(ANAD) seem to recall reading a medical article recently that suggested that subcutaneous rehydration using a butterfly needle (as is done with our pets) is just as effective at rehydration as I.V. administration. So even when there is vomiting, for example, it's not specifically needed to administer I.V. to rehydrate unless there are other drugs that need to be I.V.
Setting a subQ butterfly needle is an awful lot less prone to problems for the layperson, especially when veins don't make it easy for you (i.e., taking care of an elderly parent at home, on medical direction) compared to running an I.V.
Though of course, in the hospital, I understand that many patients already have an IV line run because health care providers want easy access to the bloodstream to administer drugs, in which case the subQ route isn't an advantage.
posted by darkstar at 10:34 AM on April 2, 2018
Also, I(ANAD) seem to recall reading a medical article recently that suggested that subcutaneous rehydration using a butterfly needle (as is done with our pets) is just as effective at rehydration as I.V. administration. So even when there is vomiting, for example, it's not specifically needed to administer I.V. to rehydrate unless there are other drugs that need to be I.V.
Setting a subQ butterfly needle is an awful lot less prone to problems for the layperson, especially when veins don't make it easy for you (i.e., taking care of an elderly parent at home, on medical direction) compared to running an I.V.
Though of course, in the hospital, I understand that many patients already have an IV line run because health care providers want easy access to the bloodstream to administer drugs, in which case the subQ route isn't an advantage.
posted by darkstar at 10:34 AM on April 2, 2018
Metafilter: a Randolph Mantooth rabbit hole
posted by The Underpants Monster at 10:41 AM on April 2, 2018 [2 favorites]
posted by The Underpants Monster at 10:41 AM on April 2, 2018 [2 favorites]
piggy backing on Slarty Bartfast's comment, I sent this article to one of my medical relatives for comment, they came back with this:
"Pretty interesting. This has been a long term controversy
Another detail the author omits is the fact that for most people who receive more than one unit of normal saline will develop hypokalemia. So potassium chloride is added into subsequent units of saline. This contributes to the already excessive amount of chlorine in the solution. This is not only more rough on the kidneys but the patient tends to develop acidosis, so bicarbonate is added to the solution. You can’t starve people forever, so if they are not eating, this all gets switched to 5% dextrose and water which has no electrolytes in it whatsoever.
So then electrolytes have to be added back in., etc.
Starting with ringers lactate in the first place makes the entire thing much easier"
posted by Dr. Twist at 2:24 PM on April 2, 2018 [4 favorites]
"Pretty interesting. This has been a long term controversy
Another detail the author omits is the fact that for most people who receive more than one unit of normal saline will develop hypokalemia. So potassium chloride is added into subsequent units of saline. This contributes to the already excessive amount of chlorine in the solution. This is not only more rough on the kidneys but the patient tends to develop acidosis, so bicarbonate is added to the solution. You can’t starve people forever, so if they are not eating, this all gets switched to 5% dextrose and water which has no electrolytes in it whatsoever.
So then electrolytes have to be added back in., etc.
Starting with ringers lactate in the first place makes the entire thing much easier"
posted by Dr. Twist at 2:24 PM on April 2, 2018 [4 favorites]
> But we also know that it works because poisoning a person's body and relying on the fact that cancer cells are more susceptible to the poison is really fucking stupid and harmful. We just don't have a better way of dealing with it yet.
We had to bomb the village in order to save it.
posted by klarck at 3:18 PM on April 2, 2018
We had to bomb the village in order to save it.
posted by klarck at 3:18 PM on April 2, 2018
There has never been a worse time to feel smug about the truth and clarity of our current Scientifically Verified knowledge, as compared with that of the benighted leech-gatherers of old.
The research you cited is for using leaches is like the exact opposite of what "the leach gatherers of old" were doing.
posted by Dr. Twist at 8:33 PM on April 2, 2018 [1 favorite]
The research you cited is for using leaches is like the exact opposite of what "the leach gatherers of old" were doing.
posted by Dr. Twist at 8:33 PM on April 2, 2018 [1 favorite]
Probably related, the US is experiencing saline shortages.
Yeah, my gut response to this is "What a crazy random happenstance that we are looking in to this now!"
FYI, I don't know the industrial processes, but I'd guess that saline is cheaper to make than Ringer's. At least, the adjusted Ringer's I had to make BITD had to be pH'd by CO2 bubbling which is a PITA.
posted by maryr at 8:21 AM on April 6, 2018
Yeah, my gut response to this is "What a crazy random happenstance that we are looking in to this now!"
FYI, I don't know the industrial processes, but I'd guess that saline is cheaper to make than Ringer's. At least, the adjusted Ringer's I had to make BITD had to be pH'd by CO2 bubbling which is a PITA.
posted by maryr at 8:21 AM on April 6, 2018
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