I am a practicing general surgeon in South Korea, and I must say your videos are very educational and helpful.. I too am waiting for your video on maintenance fluids. Thank you!
Thank you Dr Strong, this is a second time i listen to this lecture. I am so glad to find your channel. I was looking for video to teach how to read EKG. which lead me to watch many video of you. I would be so out of date if i never ever ran into this video :) . I thank you once more.
+trisha mirza Sorry, UA-cam is not allowing me to reply directly to your comment... Lactate is discussed in detail in my video on the causes of an elevated anion gap metabolic acidosis, from about minute 4 through 15 (ua-cam.com/video/CmQOtP3pFus/v-deo.html). I don't have a video that specifically discusses haptoglobin, but the topic of anemia (which would include this) is on my list of topics to cover, but unfortunately, I can't offer any specific estimate of when I will get to it. Regarding dehydration, having a very elevated ratio of BUN to Cr is suggestive of it, as is having an elevated serum bicab (i.e. often listed on lab reports as "CO2"), high urine specific gravity, low urine fractional excretion of sodium, and having hylaline casts present on a urinalysis. But ultimately, a diagnosis of dehydration is best made from a combination of history and the physical exam.
Hello Dr. Strong, Normally during inspiration the decease in intra-thoracic pressure will cause an increase to blood flow to the right side of the heart and since more blood remains in the lungs during inspiration there is a small drop in systolic pressure (less than 10 mmHg unless we have a tamponade for example). So just to understand -everything mentioned in around minute 5:50 is because of the positive pressure of the ventilator in inspiration which is exactly the opposite to the negative pressure effect in physiological inspiration? Thanks for being the #1 online source for medicine and much more :)
My preceptor who is a trauma surgeon ripped into me yesterday because I asked why LR Instead or NS. I almost cried he was so mean. This was helpful! I won’t cry about this topic again. Rip year 3
I'm so sorry to hear that. On top of being a jerk, I bet he couldn't even provide you a correct answer. Clerkship preceptors are usually great, but there are definitely some bad apples who should not be working with students.
I'm an emergency as well as critical care specialist ,( double whammy,right?😅) And I saw ur video first time today and tmrw I am going to tell my students to see ur video before coming to my lectures.
Hi Eric, just watched the first 3 videos in the IV fluids playlist- thank you so much, they're great! At the end of the third video you mentioned a fourth video on maintenance fluids, have you ever uploaded it? I'm looking forward to watching it!
I think there may be a sensitivity/specificity angle to the CVP->fluid responsiveness issue. low CVP is sensitive, but not specific. So if CVP is low, we don't know whether pt will be fluid responsive. But if it's normal, we can feel confident they are adequately resuscitated (ie non-responsive). Still learning, but this is my impression.
Hello doctor Strong, you have no idea how much i appreciate the work you do, your videos are amazing, will be please tell us when will be the final video of this series released? thank you again.
Also as an FYI: since this video was made, there has been new evidence supporting LR over normal saline in some cases, check out SALT-ED trial and SMART trial.
Thank you Dr Strong , but what is cardiac index ? How to quick calculate? I didn’t hear well, you said cardiac output per ? How to get those quicker than old paradigm? I get that is this patient fluid responsiveness ?
The claims you make around minute 6 with regards to the effects of positive pressure on LV/RV preload and afterload were a little confusing. I consulted an older clinical review on the matter (www.ncbi.nlm.nih.gov/pmc/articles/PMC1414045/), which seems to disagree with some of your conclusions and has left me even more confused. Any chance you could shed some light on this? Thank you for your videos!
sir, when is the 4th video of the series coming out? Desperately need it :-) I am an intensivist in training, and I literally spent months reading and experimenting on hemodynamics and fluid choices... and I must say that this series serves as an excellent primer for students and a great revision tool for residents! eagerly waiting for the last video!
+Darshan Jani Thanks for the message. I have a small handful of videos I need to do in order to complete some unfinished series (last IVF video, one on pressors for shock series, COPD diagnosis/treatment, some mechanical ventilation topics, etc...). I'm hoping to tackle all of them before winter break, but unfortunately I can't guarantee it.
+Strong Medicine I understand sir! all the subscribers are indebted and we couldn't have demanded more from you :-) You are positively effecting thousands of professional life! Thank you and I wish you good luck!
Dear Dr Strong, can you please make a video about lactate, haptoglobin and their importances? Also, how can I understand dehydration from looking at the labs? Is it the concentration of creatinine and BUN? THANKS.
How is pulse pressure variation determined, given that it is so dynamic? Can it only be determined in catheterized patients? Thank you for the very helpful videos.
Came here as my father in law is in septic shock and the Dr's are saying his blood pressure is too low for them to give him anything. He's 82 and it seems like from the moment he went into hospital, there's been little to no urgency in his care.
Dear Dr. Strong, These videos have become part of my syllabus & I want to thank you for them. Q). In the above video, when you represent options of venous access and speed of infusion @17:25. Where would an intraosseous line fall in the hierarchy.? Kindest Regards Dr. O.G
Dr.Strong,love all your videos. Had a couple of doubts though, 1.How does Inspiration in Mechanical ventilation reduce LV afterload? 2. How does lactate in RL get converted to Bicarb and benefit acidosis while the same in shock worsens acidosis?
1. I discuss it in my video on the physiologic effects of mechanical ventilation, starting around 4:00: ua-cam.com/video/plcrzGTOBmw/v-deo.html Let me know if you still have questions after watching. 2. There's not really a single pretty pathway by which lactate from RL (or LR, depending on where you are practicing) gets converted to bicarb. However, the lactate in RL is predominanly in the form of sodium lactate (which is not an acid), rather than lactic acid.
I have an assignment to write on fluid therapy. Do you have all this in writing (hard copy)? would like to use this as a reference. very god information.
dear dr Strong thanks for another excellent lecture. Please explain further, in 7:12 You have said that difference between pulse pressure at the and of inspirium and expirium should be significant. What amount is significant. And how can I measure BP (and derivative pulse pressure) in suggested particular parts od respiratory cycle if the patient is unconscious, and on breathing machine.
Ivan Stevanovic When assessing the effect of passive leg raise on pulse pressure, the threshold increase in pulse pressure at which a patient is said to be likely fluid responsive ranges from >9 to >12%. When looking at the respiratory variation in pulse pressure, most studies cite an almost identical number of between >10 to >12% variation as being indicative of fluid responsiveness. Some authors have recommended subdividing possible pulse pressure variation into 3 categories instead of one (i.e. 13% likely fluid responsive). A detailed yet fascinating paper that talks about this (and is a great example of the complexities of coming up with cutoff values for diagnostic tests): www.ncbi.nlm.nih.gov/pubmed/21705869 To measure the pulse pressure variation due to respiration requires invasive monitoring. In the ICUs in which I've worked in the US, it's possible to print off the blood pressure tracing from an a-line in real time. Simply print it off for 20 or so seconds, and then compare the largest and smallest pulse pressures. Unfortunately, while straight forward and easy, this is a very approximate method. There are a variety of medical devices and proprietary software that computes pulse pressure variation automatically in real time, but I have no direct experience with them.
Sorry, I had originally intended to make one, but subsequently got distracted by other topics. Still plan to come back to it some time, but there have been so many requests for other topics, it's hard to prioritize.
If a patient presenting with septic shock does improve lactate or AMS after fluid administration, when do I stop administering fluid? Or do I administer it indefinitely?
It's not really possible to make a general statement. Certainly a persistently elevated lactate and persistent AMS suggest the patient *may* not be adequately resuscitated, but those are only 2 factors to consider. The primary hemodynamic problem may not be insufficient volume, but may instead be vasodilation and/or low cardiac output. And maybe the patient's lactic acidosis and AMS have nothing to do with perfusion at all. Over resuscitation is definitely a problem that clinicians need to look out for.
+davo171 Absolutely! They are all offered with the Creative Commons Non-Commerical/Attribution/Share Alike 3.0 license, which means they are free for anyone to distribute as long as no one claims it to be their own work, or attempts to directly profit from it.
Also a paramedic student & I'm learning a bunch from your videos. Thank you so much! Quick question: where do IOs stack up compared to introducers (which are outside my scope), 14-16G peripheral IVs, etc. Around where I live, they are commonly used as they are generally quicker & easier (especially over the terrible roads). My preceptors all say "If they're sick enough to need an IV, they're sick enough to need an IO."
Using some quick math I turned 30mL/kg into 1L/72.5lb which helped me think about it clinically. However, that doesn't match your recommendation of 1-2L for a non CHF/ESRD pt. Would you recommend using a 3L bolus for a pt. over 215lb and 4L for a pt. over 290lb, or is that too much?
I may be biased by the population of patients that I treat, which tend to be predominantly old men with lots of CV risk factors, and thus have relatively high rates of heart failure (which may be undiagnosed) and diastolic dysfunction. With that consideration, I've rarely, if ever, ordered/recommended more than 2L of bolused IVF at one time. I much prefer smaller boluses and more frequent reassessment. This is probably different from other practice settings (e.g. community EDs) where patients have lower rates of occult cardiac disease, and where docs can be more stretched and without the bandwidth for q10 min reassessments.
+amro el-hadi For fluid requirements in hyponatremia and hypernatremia, the calculations are in the videos on those specific topics. Calculations for maintenance fluid will be an upcoming video specifically on that topic. For resuscitation fluid, although some resources will give tables that attempt to estimate fluid deficit based on various vital sign abnormalities and other exam findings, I do not advocate doing this. Trying to predict the total amount of fluid that will be needed risks under or overshooting by targeting a specific amount of IV fluid volume, instead of targeting normal hemodynamics. Instead, look for signs of adequate resuscitation as described in the video (e.g. good urine output, normalized mental status, normalized lactate, MAP>60-65, etc...). If the patient doesn't have these, then he/she needs more fluid.
João Paulo Almeida ScvO2 is helpful in monitoring adequacy of fluid resuscitation in a patient already felt to be fluid responsive, however it might not be so helpful in determining which patients are fluid responsive to begin with, starting at time point 0. See: www.ncbi.nlm.nih.gov/pubmed/21791090
I am a practicing general surgeon in South Korea, and I must say your videos are very educational and helpful.. I too am waiting for your video on maintenance fluids. Thank you!
I am a practicing general surgeon in South Korea, and I must say your videos are very educational and helpful.. I too am waiting for your video on maintenance fluids. Thank you!
You are a gem! As a new intern, these videos are concise, informative and great for practice. Thank you!
Thank you Dr Strong, this is a second time i listen to this lecture. I am so glad to find your channel. I was looking for video to teach how to read EKG. which lead me to watch many video of you. I would be so out of date if i never ever ran into this video :) . I thank you once more.
+trisha mirza Sorry, UA-cam is not allowing me to reply directly to your comment...
Lactate is discussed in detail in my video on the causes of an elevated anion gap metabolic acidosis, from about minute 4 through 15 (ua-cam.com/video/CmQOtP3pFus/v-deo.html). I don't have a video that specifically discusses haptoglobin, but the topic of anemia (which would include this) is on my list of topics to cover, but unfortunately, I can't offer any specific estimate of when I will get to it.
Regarding dehydration, having a very elevated ratio of BUN to Cr is suggestive of it, as is having an elevated serum bicab (i.e. often listed on lab reports as "CO2"), high urine specific gravity, low urine fractional excretion of sodium, and having hylaline casts present on a urinalysis. But ultimately, a diagnosis of dehydration is best made from a combination of history and the physical exam.
what is the graph called u mentioned for CI?
Great video, it would be great to make a new video about what have changed since then taking into account new evidence.
I enjoy all your lectures ! more videos I review, more i hope to be resident in your team, so thank you again
Your explanation hits the depth of the info we really need . Thanks alot
Hello Dr. Strong!
When are you uploading Lesson Number 4? It would be of great help.
Thank you
Im so grateful i make these videos dr strong. Thank u !
Thank you Dr Strong. It is a very great lecture as always. I am very fortunate to run into your lectures series.
Great series! Would love to see the maintenance fluids video if you ever get a chance to record it.
Hello Dr. Strong,
Normally during inspiration the decease in intra-thoracic pressure will cause an increase to blood flow to the right side of the heart and since more blood remains in the lungs during inspiration there is a small drop in systolic pressure (less than 10 mmHg unless we have a tamponade for example). So just to understand -everything mentioned in around minute 5:50 is because of the positive pressure of the ventilator in inspiration which is exactly the opposite to the negative pressure effect in physiological inspiration?
Thanks for being the #1 online source for medicine and much more :)
+DocHemulin Yes, that's correct.
Thanks for your clarification, I was confusing the physiological and ventilator situations whilst watching too!
Perfect explanation @DocHemulin. Thanks Dr.
My preceptor who is a trauma surgeon ripped into me yesterday because I asked why LR Instead or NS. I almost cried he was so mean. This was helpful! I won’t cry about this topic again. Rip year 3
I'm so sorry to hear that. On top of being a jerk, I bet he couldn't even provide you a correct answer. Clerkship preceptors are usually great, but there are definitely some bad apples who should not be working with students.
you always corelate the basic medicine with our clinical practice, thank you so much!!
Stil waiting on maintenance fluids video :(
great informative knowledge about fluids dynamics keep up cme fluids management tmk
Eric,Thank you for such an informative IVF lesson.
Love your videos Dr. Eric!!! Keep making more!! Thank you!!
I'm an emergency as well as critical care specialist ,( double whammy,right?😅) And I saw ur video first time today and tmrw I am going to tell my students to see ur video before coming to my lectures.
Amazing video. Thank you so much. Is there a Lesson 4 available for maintenance fluids in this series? Can't seem to find it
Hi Eric, just watched the first 3 videos in the IV fluids playlist- thank you so much, they're great!
At the end of the third video you mentioned a fourth video on maintenance fluids, have you ever uploaded it? I'm looking forward to watching it!
Same here
I just found out that its been 6 years since audiences started requesting for the 4th video.
When comparing maximum and minimum pulse pressures and stroke volume, what would be ""significantly different" ?? Apart from that, great video.
I think there may be a sensitivity/specificity angle to the CVP->fluid responsiveness issue. low CVP is sensitive, but not specific. So if CVP is low, we don't know whether pt will be fluid responsive. But if it's normal, we can feel confident they are adequately resuscitated (ie non-responsive). Still learning, but this is my impression.
Hello doctor Strong, you have no idea how much i appreciate the work you do, your videos are amazing, will be please tell us when will be the final video of this series released? thank you again.
Also as an FYI: since this video was made, there has been new evidence supporting LR over normal saline in some cases, check out SALT-ED trial and SMART trial.
Thank you Dr Strong , but what is cardiac index ? How to quick calculate? I didn’t hear well, you said cardiac output per ? How to get those quicker than old paradigm? I get that is this patient fluid responsiveness ?
The claims you make around minute 6 with regards to the effects of positive pressure on LV/RV preload and afterload were a little confusing. I consulted an older clinical review on the matter (www.ncbi.nlm.nih.gov/pmc/articles/PMC1414045/), which seems to disagree with some of your conclusions and has left me even more confused. Any chance you could shed some light on this? Thank you for your videos!
Are there any prospective trials focused on mortality between NS and balanced solutions yet?
sir, when is the 4th video of the series coming out? Desperately need it :-)
I am an intensivist in training, and I literally spent months reading and experimenting on hemodynamics and fluid choices... and I must say that this series serves as an excellent primer for students and a great revision tool for residents!
eagerly waiting for the last video!
+Darshan Jani Thanks for the message. I have a small handful of videos I need to do in order to complete some unfinished series (last IVF video, one on pressors for shock series, COPD diagnosis/treatment, some mechanical ventilation topics, etc...). I'm hoping to tackle all of them before winter break, but unfortunately I can't guarantee it.
+Strong Medicine I understand sir! all the subscribers are indebted and we couldn't have demanded more from you :-) You are positively effecting thousands of professional life! Thank you and I wish you good luck!
+Darshan Jani *lives
+Darshan Jani You're welcome! Glad the videos have been helpful.
Hey there! Congrats on your videos I'm a huge fan, but I'm still waiting for the 4th video in the IV fluids series, when is it coming out?
Dear Dr Strong, can you please make a video about lactate, haptoglobin and their importances? Also, how can I understand dehydration from looking at the labs? Is it the concentration of creatinine and BUN? THANKS.
How is pulse pressure variation determined, given that it is so dynamic? Can it only be determined in catheterized patients? Thank you for the very helpful videos.
Came here as my father in law is in septic shock and the Dr's are saying his blood pressure is too low for them to give him anything. He's 82 and it seems like from the moment he went into hospital, there's been little to no urgency in his care.
Hi where is the maintenance fluid lecture? Thank you Dr Strong
Please make the video about maintenance fluids!
Thanks for this great job
Dear Dr. Strong,
These videos have become part of my syllabus & I want to thank you for them.
Q). In the above video, when you represent options of venous access and speed of infusion @17:25.
Where would an intraosseous line fall in the hierarchy.?
Kindest Regards
Dr. O.G
please post videos how to understand and interpret various graphs
GREAT GREAT EXPLANATION!!! Thankyouuu very much
Dr.Strong,love all your videos. Had a couple of doubts though,
1.How does Inspiration in Mechanical ventilation reduce LV afterload?
2. How does lactate in RL get converted to Bicarb and benefit acidosis while the same in shock worsens acidosis?
1. I discuss it in my video on the physiologic effects of mechanical ventilation, starting around 4:00: ua-cam.com/video/plcrzGTOBmw/v-deo.html
Let me know if you still have questions after watching.
2. There's not really a single pretty pathway by which lactate from RL (or LR, depending on where you are practicing) gets converted to bicarb. However, the lactate in RL is predominanly in the form of sodium lactate (which is not an acid), rather than lactic acid.
Thanks very much, I did not get it about dynamic test, may be I try to listen once more.
Is the next video in this series ever being published? Thank you!
q.q
I have an assignment to write on fluid therapy. Do you have all this in writing (hard copy)? would like to use this as a reference. very god information.
Dr Eric, you are great..
Sir, i could not find the link for maintenance IVF
I'm so sorry, I never finished it! Too many other topics and requests to distract me...
Its okay sir, its a matter of immense pleasure for me that you responded
dear dr Strong thanks for another excellent lecture. Please explain further, in 7:12 You have said that difference between pulse pressure at the and of inspirium and expirium should be significant. What amount is significant. And how can I measure BP (and derivative pulse pressure) in suggested particular parts od respiratory cycle if the patient is unconscious, and on breathing machine.
Ivan Stevanovic When assessing the effect of passive leg raise on pulse pressure, the threshold increase in pulse pressure at which a patient is said to be likely fluid responsive ranges from >9 to >12%.
When looking at the respiratory variation in pulse pressure, most studies cite an almost identical number of between >10 to >12% variation as being indicative of fluid responsiveness. Some authors have recommended subdividing possible pulse pressure variation into 3 categories instead of one (i.e. 13% likely fluid responsive). A detailed yet fascinating paper that talks about this (and is a great example of the complexities of coming up with cutoff values for diagnostic tests): www.ncbi.nlm.nih.gov/pubmed/21705869
To measure the pulse pressure variation due to respiration requires invasive monitoring. In the ICUs in which I've worked in the US, it's possible to print off the blood pressure tracing from an a-line in real time. Simply print it off for 20 or so seconds, and then compare the largest and smallest pulse pressures. Unfortunately, while straight forward and easy, this is a very approximate method. There are a variety of medical devices and proprietary software that computes pulse pressure variation automatically in real time, but I have no direct experience with them.
This is very helpful. Thank you :)
When you say fluid should be given 1-2L or 30ml/kg body weight at a time, what will be the duration of time
excellent as always!
waiting for the final video on maintenance fluid
Hi, thanks for the videos, i'm can't seem to find the maintenance fluid video
Sorry, I had originally intended to make one, but subsequently got distracted by other topics. Still plan to come back to it some time, but there have been so many requests for other topics, it's hard to prioritize.
Sir please make a part 4 for the maintenance fluids
Nice , I love you sir
If a patient presenting with septic shock does improve lactate or AMS after fluid administration, when do I stop administering fluid? Or do I administer it indefinitely?
It's not really possible to make a general statement. Certainly a persistently elevated lactate and persistent AMS suggest the patient *may* not be adequately resuscitated, but those are only 2 factors to consider. The primary hemodynamic problem may not be insufficient volume, but may instead be vasodilation and/or low cardiac output. And maybe the patient's lactic acidosis and AMS have nothing to do with perfusion at all. Over resuscitation is definitely a problem that clinicians need to look out for.
Cant find the maintenance Vid :(
Good vids, may I show these to my Paramedic students?
+davo171 Absolutely! They are all offered with the Creative Commons Non-Commerical/Attribution/Share Alike 3.0 license, which means they are free for anyone to distribute as long as no one claims it to be their own work, or attempts to directly profit from it.
+Eric's Medical Lectures Thank you kindly!
Im a Paramedic instructor and IM PA, its a pleasure to view them, very well done.
davo171 Thanks!
Also a paramedic student & I'm learning a bunch from your videos. Thank you so much!
Quick question: where do IOs stack up compared to introducers (which are outside my scope), 14-16G peripheral IVs, etc.
Around where I live, they are commonly used as they are generally quicker & easier (especially over the terrible roads). My preceptors all say "If they're sick enough to need an IV, they're sick enough to need an IO."
Sir pls upload video on maintenance fluids
Using some quick math I turned 30mL/kg into 1L/72.5lb which helped me think about it clinically. However, that doesn't match your recommendation of 1-2L for a non CHF/ESRD pt. Would you recommend using a 3L bolus for a pt. over 215lb and 4L for a pt. over 290lb, or is that too much?
I may be biased by the population of patients that I treat, which tend to be predominantly old men with lots of CV risk factors, and thus have relatively high rates of heart failure (which may be undiagnosed) and diastolic dysfunction. With that consideration, I've rarely, if ever, ordered/recommended more than 2L of bolused IVF at one time. I much prefer smaller boluses and more frequent reassessment. This is probably different from other practice settings (e.g. community EDs) where patients have lower rates of occult cardiac disease, and where docs can be more stretched and without the bandwidth for q10 min reassessments.
Makes sense, thanks!
can you provide a link for your powerpoints ? thank you
Sir i cnt find the fourth part on iv fluids
Start at 8:30
Hey did you delete the maintenance fluid lesson?
No, it wasn't deleted, but was rather never finished. I wasn't satisfied with it at the time, and never circled back to it. I'm sorry.
But how to calculate the fluid need and deficits sir
+amro el-hadi For fluid requirements in hyponatremia and hypernatremia, the calculations are in the videos on those specific topics. Calculations for maintenance fluid will be an upcoming video specifically on that topic.
For resuscitation fluid, although some resources will give tables that attempt to estimate fluid deficit based on various vital sign abnormalities and other exam findings, I do not advocate doing this. Trying to predict the total amount of fluid that will be needed risks under or overshooting by targeting a specific amount of IV fluid volume, instead of targeting normal hemodynamics. Instead, look for signs of adequate resuscitation as described in the video (e.g. good urine output, normalized mental status, normalized lactate, MAP>60-65, etc...). If the patient doesn't have these, then he/she needs more fluid.
Wish I could be your student in your team sir!
Omg where are the rest
Can one predict fluid bolus responsiveness based on ScvO2?
João Paulo Almeida ScvO2 is helpful in monitoring adequacy of fluid resuscitation in a patient already felt to be fluid responsive, however it might not be so helpful in determining which patients are fluid responsive to begin with, starting at time point 0. See: www.ncbi.nlm.nih.gov/pubmed/21791090
Eric's Medical Lectures Thank you so much!
Eric's Medical Lectures Just as a side note, in my institution we tend to avoid NSaline to resuscitate patients due to its low pH.
I am a practicing general surgeon in South Korea, and I must say your videos are very educational and helpful.. I too am waiting for your video on maintenance fluids. Thank you!