Transcript PostMarathonIVFluids
Intravenous Fluids Post Marathon: 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
• 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 • 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 1982 1986 (>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)
• 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 – Discomfort – Tissue injury – Bleeding – Infection – Embolization • Benefits – Treat identifiable conditions – Lessen the strain on emergency and hospital services – Training – 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 $12.18
– 18ga angiocath $ 1.94
– IV tubing $ 1.35
– Misc supplies – Total $ 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 – Thailand 3.3% – China – United Kingdom 5.6% 8% – South Africa – Canada – United States 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.