3/ So, again, why is a #neurologist interested in chloride?
Because neurologists ❤️ giving chloride.
Ur thinking, “No. I have literally never ordered chloride.” … But, think of all the 23.4% and 3% sodium you have ordered.
All that sodium comes with a bystander: Chloride.
4/ Most intensivists agree there is nothing “normal” about 0.9% NS.
The SMART Trial (NEJM 2018) does NS might lead to more adverse renal events? tinyurl.com/4bzw2rb9
15K pts received resusc w/ 0.9%NS vs. Plasma-Lyte/LR.
EndPoint: death, renal replacement tx, Cr⬆️>200% b/l
5/ In the balanced group, 14.3% had a primary endpoint vs. 15.4% in the saline group. Which is a small, but sig diff (P=0.04). Given 5 million people are admitted to ICUs each year, that percentage point adds up.
9/ But what about NeuroICU patients? Are they getting AKIs & if so, is it Cl- related? @neuro_intensive took a look in our SAH cohort from 2009-14 (n=1672 that’s a lot of SAH pts @emoryneurocrit!) to answer this!
1,267 aSAH pts included in the study, 212 pts developed an AKI.
10/ In this cohort, those that developed an AKI were more likely male, w/ HTN, CAD, DM. They also had ΔCl- of 9.24 vs 3.77 during their admission.
Serum Cl (not Na) was associated w/ AKI, OR=1.2 [1.12-1.29].
11/ Ok. So maybe increasing chloride tracks with AKI… but, we are giving 23.4% to save the brain!
(and obviously, little biased here but brain🧠> kidney… I mean, the kidney doesn’t even have an emoji)
And since the brain needs all that sodium, kidney be damned. Right?
12/ The❓is, is there a better hypertonic solut?
Which brings us to the ACETatE trial.
Low-Cl- vs high-Cl-containing HTS for the treatment of SAH–related complications: The ACETatE (A low ChloriE hyperTonic solution for brain Edema) Randomized Trial
13/ The ACETatE trial was a single center pilot study comparing use of 30cc NaCl (23.4%) & 50cc NaCl/Na-acetate (16.4%) in aSAH pt at risk of AKI (Cl- >109).
Fluid comp shown ⬇️. NaCl/Na-Acetate solution: ⬆️ in vol & absolute Na content, but ⬇️ in Na conc. & has 33% less Cl-.
14/ 32 pts were randomized. 15 to the NaCl “normal” 23.4% and 17 to NaCl/Na-Acetate 16.4%. In those that got the more balanced hypertonic, the ΔNa+ trended higher and ΔCl- trended lower.
15/ In the 2º outcomes: AKI rate was ⬆️ in the NaCl group compared to the NaCl/Na-Acetate group & most patients had hyperchloremia bf AKI. Importantly, there was no difference in outcomes. Both lowered ICP by the same degree (p=0.6) & had the same sustained effect (p=0.4)
16/ While small and ultimately underpowered for funding reasons, the pilot demonstrated the safety of replacing 23.4% NaCl with a chloride-lean solution and both had similar effects on ICP and outcomes and the AKI rates were lower with the “balanced” HTS solution.
17/ So, does this matter in the neuroICU?
In @EmoryNeuroCrit SAH cohort, mortality rate is sig. higher in patients with AKI (28.3% vs 6.1% in the non-acute kidney injury group [p < 0.001]).
18/ True in other groups.
In 458 mod-severe TBI unadjusted mortality was ⬆️ for pt w/ time weighted average Cl->125 mmol/L & TWA Na>160 mmol/L. When adjusted for the burden of hyperNa & hyperCl-, only hyperchloremia was independently associated w/ in-hosp mortality. @SMuehlschMD
19/ Take aways:
⭐️0.9%NS =not normal. Balanced fluids👍
⭐️HyperCl may ⬆️ acidosis, inflammation, renal vasoconstriction, & AKI
⭐️Neurologist can inadvertently ⏫ Cl- w/ 23.4%
⭐️“Balanced” HT solutions ⬇️ ICP & may prevent AKI
⭐️We must be thoughtful about the solutions we give
20/ ⭐️Every number on the BMP matters. (Yes, even chloride.)
1/ A 20 yo woman comes in because she has recurrent headaches. She describes visual aura, photo-/phonophobia & pain that improves with rest. She also describes a sharp, stabbing, lancinating pain from the back of her head during the episodes.
A #ContinuumCase
2/ What is this?
(PS ChatGPT FTW with "what does an aura look like?" !!)
3/ The patient likely has TWO things:
1⃣Occipital neuralgia causing the pain that radiates from the back of her head
2⃣chronic migraine with aura.
Patients with occipital neuralgia OFTEN have both, and occipital neuralgia is very rarely an isolated headache syndrome
1/ 🥳Big News! This is the 1⃣0⃣0⃣th #CONTINUUMCASE!!
To celebrate? A must know dz, bc w/ this disease:
Time is Spine!
A 39 yo woman with Sjogren’s syndrome comes to the ED with sudden neck pain. Then arm weakness. Then leg weakness. All within 24 hours.
Now she can’t urinate
2/ On your exam, mental status=intact. But she has terrible vision in the right eye, which she reports is from a sjogrens attack.
She has 3/5 arm strength, 2/5 leg strength.
As shown above 🔼 she has a longitudinally extensive lesion w/ contrast at C2 and C3.
Is this Sjogrens?
3/ You complete a spinal tap.
‼️There are 120 WBC with a lymphocytic predominance‼️
A 58 yo woman with breast cancer on active chemo presented with shortness of breath.
She was just found to have (A).
Unfortunately, a head CT reveals (B).
They want to know – can she be a/c’ed? A #ContinuumCase
2/ Thoughts?
3/ Why does this feel like such a common conundrum? A few reasons.
1⃣incidence of brain mets may be 🔼 due to improved detection & better control of extracerebral dz
2⃣VTE is common in cancer patients & may also be 🔼 (more detection, longer life expectancy & novel treatments)
1/ A 35 yo M has lower limb weakness & painful hand & foot paresthesias.
EMG suggested axonal neuropathy and a presumed diagnosis of GBS was made.
After PLEX he was not better, instead he was becoming confused & ataxic.
How might a Thanksgiving Turkey solve this #ContinuumCase?
2/ Note: PLEX does not work immediately. In fact, many pts fail to have a response to immunotherapy during their hospitalization. Many continue to progress DESPITE treatment.
This does not mean that the treatment isn’t working. More is not better!
3/ Ok, off my soap box!
As you should for all confusing cases, you go back to the bedside and the patient tells you that over the last 2 months, he’s had increasing stress that resulted in an escalation of alcohol intake and reduced food intake.