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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.

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Intravenous Fluids Post-Marathon: When and Why?


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intravenous fluids post marathon when and why

Intravenous Fluids Post-Marathon: When and Why?

Scott W. Pyne, M.D.

United States Naval Academy

Annapolis, Maryland

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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
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
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 pre 1999
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
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
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
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
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
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
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
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
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
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
Hyponatremia in Distance AthletesPulling 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
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
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
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
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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
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
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
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
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
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
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
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
Benefits

Treat identifiable conditions

Lessen the strain on emergency and hospital services

Training

IV Risk and Benefit
  • Risks
    • Discomfort
    • Tissue injury
    • Bleeding
    • Infection
    • Embolization
    • Worsening electrolyte imbalances
    • Utilize resources
financial costs of iv treatment
Financial Costs of IV treatment
  • Average Cost for IV fluids at Ironman events is around $10,000.
  • My costs:
    • 1 liter 0.9% NaCl $12.18
    • 18ga angiocath $ 1.94
    • IV tubing $ 1.35
    • Misc supplies $ 2.00
    • Total $17.47 plus people to do it.

Mayers LB, Noakes TD. A Guide to treating ironman triathletes at the finish line. Phys Sports Med. 2000;28(8).

challenges addressing iv fluids
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
Treatment Expectations
  • Runners are educated
  • Previous experience in other medical tents
  • Expectations of the medical system
patient expectations
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
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
Expectation Correlation?
  • Total expenditure on health as a percentage of the Gross Domestic Product in 2006 World Health Report
    • Thailand 3.3%
    • China 5.6%
    • United Kingdom 8%
    • South Africa 8.4%
    • Canada 9.8%
    • United States 15.6%
  • European Commission relates that there is no direct correlation between the level of expenditure and overall healthcare performance.
medical tent expectations
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
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
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
why do we want to give iv
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
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
Conclusions
  • “First, do no harm”
  • Diagnose first, treat second
  • Have clear indications for interventions that you do and do not perform.
i hope you enjoyed the ride
I hope you enjoyed the ride!

swpyne@annapolis.med.navy.mil