Journal Club: Is Saline Toxic?

Outcomes of critically ill children requiring continuous renal replacement therapy

Hayes et al. J Critical Care (2009) 24:394-400;  PMID: 19327959

What was studied?

A number of retrospective studies in children and adults (including one by someone named Lane) demonstrate that volume overload at the initiation of renal replacement therapy for acute kidney injury (AKI) increases risk of death. The study I reviewed for today’s journal club examines a single-center (Children’s Hospital of Alabama) series of pediatric AKI patients treated with continuous renal replacement therapy (CRRT) from January 2000 through September 2005. In addition to examining predictors of mortality, a variety of secondary outcomes are included in the study (duration of mechanical ventilation, length of intensive care unit stay, days of hospitalization, and time to renal recovery). The investigators predicted that greater fluid overload at the time of initiation of CRRT would produce more adverse outcomes.

How was it studied?

After appropriate human subject protection review, charts of all CRRT patients were examined for standard demographic and diagnostic information. Fluid overload (FO) was calculated from admission to the intensive care unit until CRRT initiation:

(Total Intake Liters – Total Output Liters)/Admission Weight Kilos

I have one complaint with this score; if the patient were significantly volume depleted at the time of admission, it could overestimate volume overload. Given that a true “dry weight” would not be available for most patients, this is probably the best measure they could use.

Pediatric Risk of Mortality 2 scores (PRISM) were calculated for admission and onset of CRRT. Appropriate statistical analysis is described.

What was found?

Over this almost 6 year period, 76 courses of CRRT were studied, including 42 survivors and 34 nonsurvivors. The groups were similar for age, race, and sex. PRISM scores of “sickness” were similar, as were the requirement for blood pressure support mediations and level of kidney dysfunction. The number of hospital days before starting CRRT did not differ between the groups, nor did the type or dose of CRRT. Nonsurvivors were more likely to require a ventilator at the time of CRRT initiation, have higher airway pressures 24 hours into their course of CRRT, and had greater FO before starting CRRT.

If FO was above 20% of admission body weight when CRRT began, the odds of dying during the illness were increased 6-fold (95% confidence interval 2.2-17.0, p=0.0006). Risk of mortality also increased with sepsis (odds ratio 12.9, p=0.0001) and multiple organ dysfuntion syndrome. If only the kidneys had failed, all patients survived.

So they have confirmed the prior literature; what was new? For the 42 survivors, FO above 20% associated with longer need for a ventilator (16 v. 7 days), length of intensive care unit stay (21 v. 14 days), length of hospital stay (57 v. 27 days), and time to renal recovery (26 v. 8 days).

What does this mean?

This study confirms FO as a marker of mortality in children requiring CRRT for AKI. In addition, it shows worse outcomes for children who survive their illness, with longer time on a ventilator, on dialysis, and in the hospital.

Because of the retrospective and descriptive nature of the study, the major question remains:

Why is volume overload associated with worse outcomes in AKI?

When my own work found this association in bone marrow transplant patients, we hypothesized that sicker patients received more fluid for blood pressure support; our population also required more drugs to keep blood pressure up. In this study from Alabama, drugs for blood pressure support did not differ between these groups, nor did PRISM scores to estimate the level of “sickness” of the patients.

What is the alternative to FO as a marker, an epiphenomenon? Perhaps FO itself is toxic. Extra fluid may complicate ventilation and other body systems, especially if it leads to compromised nutritional support. Would earlier intervention with CRRT (perhaps at 10% FO) lead to better outcomes? Only a prospective multicenter study will answer this question.

Take-home message

Many physicians see fluid therapy as a completely benign thing to do, with little potential for adverse outcomes. Certainly, patients should receive fluid resuscitation, as noted by the study authors:

…it is vitally important that critically ill children in shock receive adequate treatment; we do not advocate withholding fluids from children during resuscitation.

This study provides one more piece of evidence that we need multicenter studies of earlier CRRT initiation. Only then will we know if saline is the bad guy or an innocent bystander in the morbidity and mortality of the critically ill.

Image courtesy of PhotoXpress.

Then Color Me Pinko

I have friends and relatives living in terror. They fear that they will lose their health care coverage to “Obama’s socialist agenda.”

Of course, their primary coverage is via Medicare, a government program. One could say a socialist program.

What is socialism? According to Wikipedia:

various theories of economic organization which advocate either public or direct worker ownership and administration of the means of production and allocation of resources.

In short, public ownership constitutes socialism. I live in Nebraska, a generally red state, where “socialist” is considered a major insult, yet I purchase my water, gas, and electricity from publically-owned utilities with elected boards. Looks like socialism to me.

My children attend excellent public schools and universities. An educated electorate is essential to democracy, and most education in the US is subsidized by the public one way or another. More socialism in action.

Early intervention is  another service readily available through our socialist education system. Every state in the union put these programs into place during the 1990’s to target children with special needs. Their development improves with programs implemented before the traditional school age, sometimes during the first year of life. Most parents would not be able to afford the intensive behavioral and occupational therapy provided by these publically-funded programs.

Yup, early intervention programs are another example of pooling public resources to provide a public good. More of that “S” word.

Sarah Palin denounces socialism every chance she gets. She attended several public universities, though, and has thus benefitted from educational socialism. Yes, you pay to go to university, but it is highly subsidized via tax dollars, even for out-of-state students. State universities are big-government at work.

Palin claims to have turned down government handouts. Will she become even more suspect of public and government funding as the tea-party movement gathers steam? I hope not; for the sake of her son, Trig, I hope she accepts those socialist early intervention services.

Just say thanks- the American public does this because it is the right correct thing to do. We all want Trig to have the best life he possibly can. I personally want every child to have nutritious food, educational opportunities, vaccinations, and adequate healthcare, even though it means higher taxes for me. Even though it means a larger government. I would like every US citizen to have guaranteed health care, whether or not they are employed or have pre-existing medical conditions. I do not see how these changes to healthcare threaten individual freedoms in any way.

Guess that makes me a socialist. Please don’t shoot me.

STEM or Leaf or Something Else?

Over at Terra Sigillata, one of my favorite bloggers, Abel Pharmboy, asked if medicine and allied health fields should be considered STEM (science, technology, engineering, and mathematics) careers. The post and replies got me thinking (a dangerous occurrence), and my reply became too long for the comments. Thus, my own post.

Classifying professions is almost as difficult as classifying ethnicity; self-report is the gold standard.

In my own case, my advanced degree is an MD (even though mentors advised me to figure out a way to get a PhD). So 30% of my professional time is seeing patients; however, I play well with physiologists and study kidney disease in rats. So I would qualify as STEM, in that sense. Some would say that my work is not STEM in the government sense, because my funding source is NIH. I say science is science, whoever funds it. I know MD PIs who have had both NIH and NSF funding; where would they be classified?

If an allied health professional works in a clinical research center, is s/he STEM? The same skill set applies to those who work in purely caregiving settings- so why wouldn’t they be STEM? All have a certain background training in science; is that sufficient to qualify?

Finally, I wish to illustrate some parallels between clinical medicine and science. Healthcare is hypothesis driven, just as science is…

A scientist gets an idea and then

• Collects background data
• Develops a hypothesis
• Experiments
• Evaluates results of experiments and adjusts hypothesis accordingly

A healthcare provider sees a patient and then

• Collects background data (history & physical)
• Develops a differential diagnosis
• Tests the diagnosis, either through diagnostic tests or through response to treatment
• Evaluates the results of tests/treatment and adjusts diagnostic possibilities accordingly

There simply is not a firm boundary between healthcare and STEM. I will be interested to see what AbelPharmboy’s  poll shows [at this writing, the poll is in favor of healthcare=STEM, but the commentary is running the other direction]. Frankly I just don’t know that it matters. Except to those wishing to make a statistical point of some sort…

Photo courtesy of PhotoXpress.

Pesky Patients Prevent Prose

I came back from a couple of national meetings with a bunch of ideas for this blog. One involved Varmus’ comments on the impact factor; I actually wrote that one last week.

Then my inpatient care service ballooned beyond one patient. Kids were coming out of the woodwork wanting to see a nephrologist.

I hate when that happens.

Since handing over the service last night at 5, I have been trying to recover from 48 hours of everybody wanting my attention, and all wanting it NOW. I am just now feeling like I have my brain back.

It wasn’t enough to have a whole bunch of patients at once, though. We had our furnaces and hot water heater replaced during the same 48 hours. That just made those 2 days that much more special.

I will get my head back together and write more meaningful input. I promise.

Photo courtesy of PhotoXpress.

That “Special” Time of Year

‘Tis the season when a doctor’s fancy turns toward… re-credentialing. Not roasted turkey with family and football. Not jingle bells and candles. Just packet after packet from insurers and hospitals wanting to know all about you.

They all want the same information in different order:

• Are you still licensed?
• Are you still board certified?
• Has anyone sued you?
• Are you impaired in your ability to practice?
• Have you kept up your skills?
• Are you insured for malpractice?

Copies of your CV, your license, your DEA certificate, and your continuing medical education coursework accompany each form. You must also supply 3 to 5 peer references who are familiar with your practice. Also, your original signature (NO STAMPS) in 3 to 7 places.

Perhaps they would like a note from my kindergarten teacher? I believe she died, but a séance wouldn’t be much more work…

Repeat this process for each hospital or clinic at which you see patients. Fill out similar forms for every insurer. Then have your secretary make and keep copies (because at least one application will be lost).

As I struggle through this quagmire of paperwork, I wonder why this cumbersome process still exists. All of these parties request the same information; perhaps they could get together and come up with a single universal form. Even better, we could put that universal process form online. The amount of paper I am required to submit boggles the mind. The requirements can be interesting as well; some parties want only black ink while others specify only blue pens be used. (One year I used purple just to, perhaps, cause a bit of trouble.)

When you add up the cost in paper, time, and postage, we could put together a national online web-based process. Collecting these sorts of data is not rocket science. Of course, it would require some cooperation among competitors, but it is within reach. A bit of government guidance could make this reality! It would reduce administrative costs and reduce the hassle factor with a learning-curve less-steep than the electronic medical records funded by the stimulus plan!

Imagine filling out this stuff once… That would leave a lot more time for myself and my staff to enjoy family and football and bells and candles, not to mention actually taking care of patients and performing the rest of our academic duties.

Healthcare for all?

Denver, our cat, died of chronic kidney disease a few months ago after 18 years of life with our family. He required extra care, medications, and a special diet for the last 2 years of his life, and it cost $1-2 per day to keep him going. He was happy and interactive until his last day, and the expense was worthwhile.

My daughter has been generally healthy, but she does have a couple of “pre-existing conditions” that might prevent her from getting health insurance. We hope she will find a job with good group coverage, or that reforms pass that will allow her to be covered.

While the healthcare debate mires in political mud, Representative Thadeus McCotter of Michigan has proposed the Humanity and Pets Partnered Through the Years (HAPPY) act. The bill would give pet owners a tax deduction of up to $3500 annually for the care of their animal companions. (For a detailed news story, click here)

Based on covereage of the proposal, its primary aim is economic stimulus. As McCotter told DoggyTV:

Anything that puts cash back in Americans' hands during the economic crisis is a good thing.

All well and good, but exploring the congressman’s web site reveals that this republican does not believe the current stimulus package is beneficial. So why would a pet owner tax deduction be more stimulating? I mean, I would love to deduct my pet expenses for the year, but, frankly, it was a luxury to keep a sick, geriatric pet alive.

I then explored his comments on the Obama healthcare proposal, and they confuse me. His statements suggest that our “system” is not in crisis, nor is reform required. I thought the Big 3 Auto Makers were behind reform! Don’t they still count in Michigan politics?

I hope congress lets this bill drift away. Don’t get me wrong; I love my pets, but my daughter’s health and insurability is far more important to me. I think we should guarantee coverage for every US citizen before we think about reducing taxes for pet owners.

HAPPY won’t make me that way.

Why Not Everyone?

For a while I have considered posting on “the public option” in healthcare that I am most familiar with, the Medicare End-Stage Renal Disease Program. The history of this disease-specific program is fascinating, and I think it provides a good example of what “the public option” could be (and why private insurance companies are scared).

See, you can get public coverage now if:

1. You are employed by the government (like congress)
2. You are or were in the military
3. You are of “retirement age”
4. You are disabled
5. You are poor with dependent children or you are a dependent child
6. You have kidney failure

That’s a whole lot of health care already run by the government. In my experience, it works pretty well with far fewer headaches than many of the private insurers generate.

I was toying with a post about this topic; however, someone has provided a far more compelling story than I could tell as a physician. Jennifer Nix in Salon tells us the history and realities of the Medicare ESRD program through a family saga:

My family's 36-year journey with end-stage renal disease -- the only long-term, chronic disease classification for which the U.S. government provides insurance coverage, regardless of age or income -- offers a telling case study into what once met Congress' standard of an unequivocal, moral imperative to provide public-financed health insurance. My family history mirrors exactly the period from 1973 to 2009, during which this entitlement program has allowed access to life-saving dialysis and kidney transplants, treatments previously denied to all but a very privileged few.

Read the full story: I love my socialist kidney.

We have identified a number of groups for whom we, as a society, feel a moral imperative to provide health coverage. Isn’t it time that a nation with our wealth and spirit extends that opportunity to all of our citizens?

Photo courtesy of PhotoXpress.

Something To Cheer About?

A friend sent me this ditty a few days ago:

I cannot figure out what US citizens are so afraid of losing through meaningful healthcare reform. It’s not like our current nonsystem gives us longer lives or costs less than other countries…

Of Cats and Health Care

For the past week I have neglected my blog while providing hospice care to Denver the Wondercat. The big guy finally succumbed to uremia, at home among his loved ones.

People may envy our cat’s death. He lived to the ripe old age of 18 years (about 97 in people-years). He lost his appetite the final 7-10 days of his life. He remained active until the final 4 days when he lost some strength. He was mostly unconscious the final 2 days, but he did not appear to suffer. We left him asleep Sunday night, and he was dead  Monday morning.

If you are an older adult in the US, you may wish to discuss such end-of-life issues with your physician. Would you want dialysis or feeding tubes or other sorts of care? If you don’t talk about it now, it may be left to others later – and you may not get what you want! Your loved ones may want to keep you alive with any treatment possible, or they may wish to withdraw therapies that you would prefer be continued! Efforts were underway to encourage this sort of conversation between physician and patient by actually paying doctors for the time these discussions take. Of course, this provision has now been dropped from the reform bills after being dubbed a “death squad.”

Your doctor will still discuss your wishes with you, even though Medicare does not cover this “luxury item” for the elderly. All of us will die one day, and we should consider our wishes while we can express them. Because we can’t all be as lucky as Denver the Wondercat.

Much Ado About Health Care

Walking from my building to the cafeteria presented obstacles today. Nebraska’s senator Ben Nelson, 6 floors below me, is running a town hall meeting on health care. The auditorium and all overflow rooms filled an hour ago; the line of humanity flows from the front door of the building, under the skywalk (from which I photographed the participants), around the complex, and down the hill.

I am pleased so many people mobilized to discuss health care; I just hope the discussion remains rational, without mention of “death squads” or other nonsense. Police are out in force checking IDs. We are a weapon-free campus, so no sidearms are showing.

I hope the people of this country can come together and guarantee healthcare for everyone. I have patients who have lost coverage when a parent was fired. The parent then gets a new job, but the pre-existing illness will not be covered. I have heard parents talk of divorce so the child can get Medicaid for a major illness. All of this is wrong in a nation with our resources.

Boomsday, Redux

This morning I heard a startling news item on NPR:

For example, this moment, during President Obama's town meeting yesterday, the meeting was hosted by AARP, and at one point a caller named Mary put this question to the president about something that she had heard is in the House bill.

MARY: I have been told there is a clause in there that everyone that's Medicare age will be visited and told to decide how they wish to die. This bothers me greatly, and I'd like for you to promise me that this is not in this bill.

I knew this was another case of fiction becoming reality!

Last year, Christopher Buckley’s novel Boomsday kept me entertained through a flight somewhere and well into the night after arrival (this explains my drowsiness the next morning). The title refers to the date when the majority of baby boomers retire, precipitating an economic catastrophe for the country.

The heroine is Cassandra Devine, a savvy 29-year-old PR professional working in an agency run by one of the guys from Thank You for Smoking, an earlier Buckley work. She writes a popular blog (a la Dr. Isis), and she inspires her readers to storm golf courses and gated communities to terrorize the Medicare set. One late night she develops a concept of “voluntary transitioning” for boomers; in other words, they get some benefits (free Botox? reduced inheritance taxes?) if they agree to kick the bucket at age 70. Yup, it’s voluntary suicide. She repeatedly tells people that this is a “meta-issue” meant solely to drive the conversation and get the economic mess fixed, but like many ideas, this one develops a life of its own and is soon out of her control.

Unfortunately, this book has one thing completely in common with reality: tough choices don’t get made.

I won’t tell you any more about the book, because you really ought to read it yourself. Hell, you should buy it and help out Mr. Buckley who lost his job at the National Review (founded by his dad) because he endorsed Barak Obama for president!

The truth is no one really wants retirees to “pick their method of death:”

Mr. DAU: The House bill includes a provision that would allow Medicare to pay doctors for taking the time to talk with their patients about the very difficult choices that people face at the end of their life about health care: What kind of interventions you might want in the case of a bad accident or debilitating illness. It would empower individuals to make the best possible health care choices for them and their families and allow doctors to provide their patients with this so that no one's guessing at the end of a person's life.

SIEGEL: Because you're saying that that consultation that the doctor would offer or another health care professional might offer would, under the bill, now become covered by Medicare.

Thus far the debate on health care reform is a mess, driven more by fear than fact. I truly hope that our government can get it together and cover all of our citizens.

In the meantime, I’m waiting for Christopher Buckley to write another book!

Holidays in the Hospital

University of Nebraska considers July 3 a holiday. The city of Omaha does as well.

Unfortunately, my patients missed the memo.

So I’m at my desk. I have just finished rounding on the patients at one hospital. The new admission has finally gotten to the other one, so I can head on over there and finish rounds.

There are a lot of people working on holidays, and not just doctors. Waiters, retail clerks, and others are all out there plugging away.

If you go to a restaurant or drop by a store this weekend, think about saying thanks to the people working through the holiday.

And have a happy Independence Day – even if you only see the fireworks through a plate glass window or on TV!

Photo courtesy of Photoexpress.com.

The Daddy Track

Earlier I wrote about childbearing. One commenter asked about the effect our kids had on my husband's career (Jim is sitting on the deck of the USS Missouri during our January vacation in Oahu).

We were married 6 months before he graduated from medical school. My final year we lived in different cities. It was difficult, but I did several electives in Chicago, where he was, and we got through it. He then had to do a year after residency to allow me to "catch up" so we could start our fellowships in Minnesota together. He was a research fellow with his endocrine section. He got a paper out of the year and had no call for the first 9 months of our daughter's life. This worked out well since I was still overnight in the hospital at least every fourth day.

Then we were in our fellowships with home call, but with a child with recurrent otitis media, AKA ear infections. I can still remember awakening at 4:30am to see if she had a fever. If she did, we could give the Tylenol and get it low enough to drop her off at daycare. By the time it went up again, one of us would have seen enough patients to go get her. We often did parking ramp hand-offs. Needless to say, the first 6 months of non-stop clinical service were brutal for us. We had a home daycare provider who we are friends with to this day, and she was often the saving grace for our sanity.

Time crunches were a bit less problematic once our research endeavors started, at least for me. I usually had something I could work on at home if Jen got sick, and her ear infections began to let up a bit. I found the lab wonderful, like Dorothy stepping into the colorful world of Oz after that dusty, B&W Kansas. My husband ended up in a molecular biology lab whose taskmaster demanded meetings first thing Monday morning and on Friday afternoons. At 5pm. Jim lost his desire to do basic science quickly.

When the end of our training approached, I found a faculty position and he went into private practice. It was during this period that we had our son. Jim's hospital had on-site daycare with extended hours to support nurses on 12 hour shifts. He often got to lunch with the kids. On the other hand, my daughter got really good at photocopying articles in the library on snow days. Her school had before and after school programs on site. We could usually drop her off and pick her up without much difficulty between the two of us.

After 7 years, we were invited to University of Nebraska. My husband is in academia again, doing clinical research. I have continued doing lab work as well as patient care, teaching, and administrative work. My schedule has remained flexible enough that a nanny who had to leave early every Wednesday or a school day starting at 8:30 could be accomodated. I was also older - old enough to realize that no one was going to fire me because I had to leave by 4:15 every Wednesday! That was the way it was. I got work done and produced papers and everyone else could just deal with it! Having half of your group get up and leave because they have to pick up the kids sends a clear message to those in charge. It also helps that I am in pediatrics; our annual meeting has long had sponsored childcare and lactation support services because we are "kid-friendly."

Did children delay my husband's career? It is hard to know what his accomplishments would have been without the kids, and the impact of the 7 years of private practice is bigger than anything we could probably attribute to the offspring.

I guess the bottom line is that you have to be flexible when you have kids. This is true whether you are in academia or a stay-at-home parent, whether you are male or female. Children are separate beings who will not necessarily repect your own plans! When it comes to career paths, we each make our own. In the end, having a fulfilling life on all fronts is what matters.