Find out whether balanced solutions beat saline in the ICU (fluid wars revisited), how sleep affects weight loss and calorie intake, whether or not Vitamin D can prevent autoimmune disease, new guidelines for pneumonia and hepatitis B (HBV) vaccination, and the utility of ultrasound to measure JVP! Time to fill your plate with a fresh stack of hotcakes! Drs. Paul Williams (@PaulNWilliamz), Rahul Ganatra (@rbganatra), Nora Taranto (@NoraTaranto), and Matt Watto (@doctorwatto) catch us up on recent practice-changing articles and guidelines!
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Deep dives on practice-changing articles.
Finfer S et al; PLUS Study Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022 Jan 18. doi: 10.1056/NEJMoa2114464. Epub ahead of print. PMID: 35041780.
Question: Are more “balanced” fluids (fluids with more physiologic concentrations of various electrolytes) better than normal saline (0.9%)? The fluid wars have persisted in multiple spaces over the last decade, with the most recent pendulum in critical care seeming to swing more to the side of balanced crystalloids like lactated ringers or plasma-lyte over normal saline out of concern about increasing kidney injury and even all-cause mortality in patients maintained on normal saline (SMART trial 2018 being the most recent of these, though it was open-label), and no difference in other trials (SPLIT trial 2015). The BaSICS trial (2021) did not find a difference in mortality, need for renal replacement, or AKI (see NephJC discussion here).
Comparison: The PLUS trial was a double-blind, randomized controlled trial in critically ill adults that compared Plasma-Lyte 148 (a balanced multi-electrolyte solution) with normal saline. The primary outcome was death from any cause at 90 days, with secondary outcomes as the initiation of new renal-replacement therapy and increase in Creatinine. Patients were excluded if they had received previous fluid resuscitation (>500 mL), had life expectancy under 90 days, or were at risk of cerebral edema. Once outside the ICU, any type of fluid could be administered.
Results and Thoughts: This was overall a negative trial. The study was performed down under, in Australia and New Zealand and followed 5037 patients, with half in each group, who received a median of 3.5-4L fluids in both groups over six days. Death within 90 days of randomization occurred in 21.8% of the balanced solution group and 22% of the saline group, a difference that did not reach statistical significance (difference -.15%, 95%, CI -3.6 to 3.3, p 0.9). For secondary outcomes: new RRT occurred in 12.7% vs 12.9% of individuals in the balanced versus saline groups, respectively (also not statistically significant), and there were not clinically relevant differences in serum creatinine between the two. No differences in adverse events. A potential source of bias is the fact that 50% of patients did receive 500 mL or more of saline in the balanced fluids group, which could have attenuated any real benefit of balanced fluids. Notably, a new systematic review (Jan 2022 NEJM Evidence), including this trial data, and suggests that there’s a high probability that, on average, balanced crystalloids reduce mortality.
Bottom Line: Overall, this study did not find evidence of a benefit of Plasma Lyte over normal saline on all-cause mortality at 90 days.
A brief discussion of recent articles, medical news, guidelines
Tasali E et al. Effect of Sleep Extension on Objectively Assessed Energy Intake Among Adults With Overweight in Real-life Settings: A Randomized Clinical Trial. JAMA Intern Med. 2022 Feb 7. doi: 10.1001/jamainternmed.2021.8098. Epub ahead of print. PMID: 35129580.
Summary: What are the effects of a sleep extension intervention on energy intake, energy expenditure, and body weight in persons with overweight who habitually curtail their sleep duration? Obviously, I am (Paul) motivated by pure selfishness, and we have covered in some detail the problems of insufficient sleep. However, even though the measurement techniques were bananas, the intervention was achievable. Eighty-one patients were randomized to a personalized sleep hygiene counseling session or instructed to continue their habitual sleep patterns after two weeks of their usual sleeping habits. Sleep duration was assessed by actigraphy, total energy expenditures were measured by the doubly labeled water method, and energy stores were calculated using weights and composition changes by dual-energy xray absorptiometry.
Bottom line: Sleep duration was increased by 1.2 hours per night in the extension group, who also consumed less energy (~270 Kcals/day) and had an average weight loss of 0.48 kg from their baseline. Participants in the control group had an average 0.39 kg weight gain.
Paul’s thoughts: I wonder how much of the change in weight and energy intake was due more to the counseling than the physiologic impact of sleep (e.g.,”Don’t eat right before bed”). It was a small study done over a short period. So to me, this suggests counseling on sleep hygiene may be part of the toolkit when doing weight loss counseling.
Further reading: Medscape coverage 2/1/2022
Hahn J, et al. Vitamin D and marine omega 3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial. BMJ. 2022 Jan 26;376:e066452. doi: 10.1136/bmj-2021-066452. PMID: 35082139; PMCID: PMC8791065.
Question: Does daily vitamin D supplementation, with or without omega 3 supplementation, prevent the development of new autoimmune diseases among community-dwelling older adults?
Comparison: Because this was a 2×2 factorial trial, there were four comparison groups: people randomized to daily vitamin D supplementation + placebo, daily omega 3 fatty acid supplementation + placebo, both vitamin D and the omega 3 together, or neither treatment (and both placebos).
Results: Among 25,000 patients over a median of 5 years of follow-up, patients randomized to vitamin D, with or without omega 3s, experienced about a 20% relative reduction in the incidence of self-reported new autoimmune diseases of any kind.
This was a technically positive study, but consider these two sources of chance and bias in applying these results:
Wang L et al. Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous Congestion. Ann Intern Med. 2021 Dec 28. doi: 10.7326/M21-2781. Epub ahead of print. PMID: 34958600.
Summary: POCUS uJVP was easily obtainable, reproducible, and accurately predicted CVP (quantitative uJVP had AUC 0.84 and qualitative uJVP was 94.6% specific for elevated CVP. Single-center, prospective observational study of 100 adult patients with heart failure comparing central venous pressure estimates with handheld POCUS (by two cardiology fellows, one cardiology attending) vs right heart catheterization. JVP was visualized in the transverse, NOT longitudinal orientation.
Bottom line: Perform a quantitative, reclined uJVP (measure with the patient lying at 30-45 degrees) or a qualitative (visualized or not) uJVP with the patient seated upright (feet on floor or legs extended in bed) as part of the volume status exam for heart failure…not to be interpreted in isolation.
See video from Annals site (top right of page)
Disco Elysium (Videogame)
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Listeners will review recent practice-changing articles and medical news.
After listening to this episode listeners will…
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Taranto NP, Ganatra RB, Williams PN, Watto MF. “#325 Hotcakes: Fluid Wars revisited, Sleep & Weight Loss, Vitamin D, Pneumonia and HBV Vaccine Updates”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 7, 2022.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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Thank you for your podcast. As a board-certified internist who now stranded in the home country; fluid management is really a struggle. For the 1st time in my life I see so many different solutions options for my patient. During my residency training in NY and later geriatric medicine fellowships, I am only familiar with saline, half saline, lactated ringer … Maybe I need some update on fluid management?
Thank you so much for listening! We will continue to update this topic in the future!
I answered question #1 correctly, but it said that I answered it incorrectly. I answered give one dose of PCV 20, and it said that I answered incorrectly. There must be something wrong with how the website is interpreting answers for question #1. I still earned my CME by answering the otner two question correctly. I just wanted you guys to know that there was a problem. Thank you.
Thank you so much for letting us know! Glad you earned your credit!