Transcript PostMarathonIVFluids

Intravenous Fluids PostMarathon: When and Why?
Scott W. Pyne, M.D.
United States Naval Academy
Annapolis, Maryland
•I have no affiliation or financial interest in any organization(s) that
may have a direct interest in the subject matter of my presentation.
•The opinions or assertions contained within this document
should not be construed as official or reflecting the views of the
United States Navy or the Department of Defense.
Objectives
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Discuss developing a protocol for IV use
How to make the appropriate diagnosis
Role of electrolyte measurement
Risks and benefits of the procedure
Revisit treatment protocols
Can we explain USA’s use of IV fluids?
Pre-Marathon Experience
• Temple University School of Medicine
– Philadelphia, Pennsylvania
• Family Medicine Training
– Jacksonville, Florida
• Family Medicine Physician
– Naples, Italy
• Primary Care Sports Medicine Fellowship
– San Diego, California
• Primary Care Sports Medicine
– Marine Corps Base, Quantico, Virginia
Marine Corps Marathon
1999-2003
United States Naval Academy
2003-present
No IV Needed
Marine Corps Marathon pre-1999
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Caring clinicians
Treated runners like Marines
Few treatment protocols
Liberal intravenous fluids for post-exercise
collapse
• Universal good outcomes
Look to the Literature
• Comprehensive review for MCM in 1999
• Little marathon specific literature
– Ultramarathons
– Ironman Triathlons
• Apply distance event data
• Laboratory research clinical correlations
• Compare marathon experience to Marine
Corps training and American Football
Medical and Physiological
Considerations in Triathlons
• US triathlons 19821986 (>6000 athletes)
• Dehydration is most
frequent medical
encounter
• 27% hyponatremic
• IV Fluid
recommendations
Hiller DW, et al: The American Journal of Sports Medicine Vol 15 (2) 1987.
Intravenous Fluid Effect on
Recovery After Running a
Marathon
• 2.5 l of 2.5%
glucose/0.45% NaCl
solution
• 100 ml 0.9% NaCl
Solution
• No significant influence
on:
– Rate of total recovery
– Number of days with pain,
stiffness, appetite, sleep or
fatigue
Polak AA, et al: British Journal of Sports Medicine 1993; 27(3):205-8.
1991 Rotterdam Marathon
Clinical and Biochemical
Characteristics of Collapsed
Ultramarathon Runners
• Only 15 % collapsing
during the event had
readily identifiable
medical diagnoses
• States of dehydration
were comparable in
controls and EAC
victims.
Holtzhausen LM, et al: Medicine and Science in Sports and Exercise 26, 1994.
The Prevalence and Significance of
Post-Exercise Hypotension in
Ultramarathon Runners
• Level of dehydration was unrelated to the
degree of postural hypotension.
• EAC should initially be treated with pelvic
and lower limb elevation, not IV
rehydration.
Holtzhausen LM, Noakes TD, et al: Medicine and Science in Sports and Exercise
1995;27(12):1595-1601.
Collapsed Ultraendurance Athlete:
Proposed Mechanisms and an
Approach to Management
• Who needs an IV?
– unconscious
– suspected heat stroke, hyponatremia,
hypoglycemia
– physical exam c/w dehydration
– persistent emesis
– persistent tachycardia and hypotension when
lying supine with legs and pelvis elevated >10
to 15 minutes
Holtzhausen LM, Noakes TD: Clinical Journal of Sports Medicine 1997;7:292-301.
A Guide to Treating Ironman
Triathletes at the Finish Line
• Treatment by
necessity is most
often initiated in the
absence of a
diagnosis.
• All persons who
collapse after
exercise do not have
dehydration-induced
hyperthermia
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).
A Guideline to Treating Ironman
Triathletes at the Finish Line
• “The administration of IV fluids should not
be an automatic first response.”
• Indications for IV fluids:
– Significant dehydration causing
cardiovascular instability
– Cannot be effectively orally hydrated
– Unconscious with serum sodium >130mmol/L
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8)
Elevate the Feet and Pelvis
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).
Hyponatremia in Distance Athletes
Pulling the IV on the “Dehydration Myth”
• Moderate dehydration is not hazardous
• Diagnose, then treat
• Too much fluid can hurt – oral and IV
Noakes TD: Physician and Sports Medicine 2000;28(9).
Intravenous versus oral rehydration
during a brief period: responses to
subsequent exercise in heat.
• No discernable advantage of IV over oral
• Oral hydration:
– Lower body temperatures
– Improved performance
– Decreased thirst
– Lower perceived exertion with subsequent
exercise
Casa DJ, et al: Med Sci Sports Exerc 2000;32(1):124-133.
Letters to the Editor
• Interesting points of
discussion
• Lab data vs. clinical
data
• Dangers of giving IVs
to patients whose
sodium
concentrations are
unknown
The Physician and Sports Medicine 2001;29(7).
IV for Exercise Associated Muscle
Cramps
• Dramatic improvement
with normal saline
– American Journal of Sports
Medicine 1999;27(5)
response to letter to the
editor
• Severe cramping usually
subsides after 2-3 hours
and 2-3 L of normal
saline.
– Eichner RE Curbing
muscle cramps: more than
oranges and bananas
GSSI 2002
Serum electrolytes and hydration
status are not associated with
exercise associated muscle
cramping (EAMC) in distance
runners
• Small but statistically significant
differences in serum sodium and
magnesium are too small to be clinically
significant.
• An alternate hypothesis to explain EAMC
must be sought.
Schwellnus, et al. Br J Sports Med. 2004;38;488-491.
Evaluation and Treatment of
Marathon Associated
Hyponatremia
• On-site sodium analysis
– Exercise Associated Hyponatremia (EAH)
Concensus Panel. 2005. Clin J Sports Med.
2005;15:208-213.
• 3% NaCl solution utilized in the field
treatment symptomatic hyponatremia
– Ayus C, Rarieff A, Moritz M. Treatment of
marathon associated hyponatremia. N Engl J
Med. 2005;353(4):427-428.
What did we learn?
• Most collapsed runners do not have
dehydration-induced hyperthermia
• Diagnosis before treatment
• There are indications for IV fluids
• Too much fluid can hurt
• Exercise associated muscle cramping etiology is
unclear
– But IV saline appears to help in some situations
• Measure sodium and field treatment
Ask for IV Guideline Help
• Compared notes with others
• American Medical Athletic
Association
• International Marathon Medical
Directors Association
• American College of Sports
Medicine
– Endurance Athlete Medicine
and Science
• American Medical Society of
Sports Medicine
• Develop intravenous guideline
Survey of Experts
• Do you give IV fluids after marathons?
• What do you use to determine if an athlete
receives IV fluids?
• What types of IV fluid do you use?
• Do you measure serum electrolytes?
• Is there anything else that might be
helpful?
Survey Results (10 responses)
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10/10 are prepared to give IV fluids
8/10 have IV fluid protocols
10/10 have 0.9% NaCl solution
9/10 have 3% NaCl solution
8/10 always measure Na prior to IV
– 1/10 measure depending upon presentation
– 1/10 never measured Na
Survey Comments
• “I am quite liberal with
their appropriate use.”
• “If they need fluids
and cannot tolerate
oral we give IV.”
• “We have guidelines,
but I cannot
guarantee that they
are always followed.”
• “The criteria was ‘ya
want an IV?’”
• “One of our major
goals is to prevent ER
transfer”
Comments Continued
• “There is no need to measure a serum
sodium on every patient that you give IV
fluids to.”
• “Not checking serum sodium is
malpractice”
• We did not give one IV infusion after two
recent Ironman races.
• “The assault on IVs may be a gathering
storm.”
IV Risk and Benefit
• Risks
• Benefits
– Treat identifiable
– Discomfort
conditions
– Tissue injury
– Lessen the strain on
– Bleeding
emergency and
hospital services
– Infection
– Training
– Embolization
– Worsening electrolyte imbalances
– Utilize resources
Financial Costs of IV treatment
• Average Cost for IV fluids at Ironman
events is around $10,000.
Mayers LB, Noakes TD. A Guide to treating ironman triathletes at the
finish line. Phys Sports Med. 2000;28(8).
• My costs:
– 1 liter 0.9% NaCl
– 18ga angiocath
– IV tubing
– Misc supplies
– Total
$12.18
$ 1.94
$ 1.35
$ 2.00
$17.47 plus people to do it.
Challenges Addressing IV Fluids
• High expectation from system
• Education
– Importance of making a diagnosis
– Clinical guideline development
– Clinician position on the medical team
• Clinical supervision
• Measurement of electrolytes
Treatment Expectations
• Runners are
educated
• Previous experience
in other medical tents
• Expectations of the
medical system
Patient Expectations
• Unmet expectations were especially more
likely in younger patients.
• Patients with unmet expectations were
less satisfied and reported less symptom
improvement.
• Reasonable patient expectations need to
be considered and unreasonable ones
need to be denied with a full and
compassionate discussion.
Bell RA, et al. J Gen Intern Med 2002;17:817-824.
Medical System Expectations
• Patient desires were similar in Michigan
and Ontario, but expectations were higher
in Michigan.
• Michigan physicians gave greater
estimates of patient expectations than
Ontario physicians.
Zemencuk JK, et al. J Gen Intern Med 1998;13:273-276.
Expectation Correlation?
• Total expenditure on health as a percentage of
the Gross Domestic Product in 2006 World
Health Report
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–
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–
–
–
Thailand
China
United Kingdom
South Africa
Canada
United States
3.3%
5.6%
8%
8.4%
9.8%
15.6%
• European Commission relates that there is no
direct correlation between the level of
expenditure and overall healthcare performance.
Medical Tent Expectations
• Parallel that of office
visits
• IV requests
• Request everything
available
• Similar treatment as
previous events
• Perception that more
is better
• Badge of honor
Glorification of Playing with Pain
• Chicago Bears Dick
Butkus
• American Football
leave field and return
to win the game.
• Lance Armstrong’s
ability to control the
Central Governor.
• Contrast to World
Cup
Education
• Patients
– Requires a universal effort
– Has been successful clinically
• Clinicians
– Make the diagnosis
– Does a protocol exist?
• If so, how closely is it followed?
– Are IVs a medical leadership priority?
– Importance of measuring sodium
Beware of the Rogue Clinician
Why do we want to give IV?
• Treat an appropriate
diagnosis
• Believe it is the right
thing to do
• Want to help and do
not know how
• Show we are doing
something
Recommendations for IV Fluids
• Significant dehydration causing cardiovascular
instability
• Cannot be effectively orally hydrated
• Unconscious with serum sodium >130mmol/L
• Symptomatic Exercise-Associated Hyponatremia
with 3% NaCl
• Consider for resistant exercise associated
muscle cramping
• Recommend Sodium assessment prior to IV
Conclusions
• “First, do no harm”
• Diagnose first, treat
second
• Have clear indications
for interventions that
you do and do not
perform.
I hope you enjoyed the ride!
[email protected]