Intravenous Fluids Post-Marathon: When and Why?

1
Intravenous Fluids Post-Marathon When and Why?

• Scott W. Pyne, M.D.
• United States Naval Academy
• Annapolis, Maryland

2

• 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.

3
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 USAs use of IV fluids?

4
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

5
Marine Corps Marathon 1999-2003
6
United States Naval Academy 2003-present
7
No IV Needed
8
Marine Corps Marathon pre-1999

• Caring clinicians
• Treated runners like Marines
• Few treatment protocols
• Liberal intravenous fluids for post-exercise
  collapse
• Universal good outcomes

9
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

10
Medical and Physiological Considerations in
Triathlons

• US triathlons 1982-1986 (gt6000 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.
11
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
12
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.
13
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 199527(12)1595-16
01.
14
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 gt10 to
  15 minutes

Holtzhausen LM, Noakes TD Clinical Journal of
Sports Medicine 19977292-301.
15
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 200028(8).
16
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 gt130mmol/L

Mayers LB, Noakes TD The Physician and Sports
Medicine 200028(8)
17
Elevate the Feet and Pelvis
Mayers LB, Noakes TD The Physician and Sports
Medicine 200028(8).
18
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
200028(9).
19
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
200032(1)124-133.
20
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 200129(7).
21
IV for Exercise Associated Muscle Cramps

• Dramatic improvement with normal saline
• American Journal of Sports Medicine 199927(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

22
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.
200438488-491.
23
Evaluation and Treatment of Marathon Associated
Hyponatremia

• On-site sodium analysis
• Exercise Associated Hyponatremia (EAH) Concensus
  Panel. 2005. Clin J Sports Med. 200515208-213.
• 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.
  2005353(4)427-428.

24
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

25
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

26
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?

27
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

28
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

29
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.

30
IV Risk and Benefit

• Risks
• Discomfort
• Tissue injury
• Bleeding
• Infection
• Embolization
• Worsening electrolyte imbalances
• Utilize resources

• Benefits
• Treat identifiable conditions
• Lessen the strain on emergency and hospital
  services
• Training

31
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.
200028(8).
32
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

33
Treatment Expectations

• Runners are educated
• Previous experience in other medical tents
• Expectations of the medical system

34
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 200217817-824.
35
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
199813273-276.
36
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.

37
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

38
Glorification of Playing with Pain

• Chicago Bears Dick Butkus
• American Football leave field and return to win
  the game.
• Lance Armstrongs ability to control the Central
  Governor.
• Contrast to World Cup

39
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

40
Beware of the Rogue Clinician
41
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

42
Recommendations for IV Fluids

• Significant dehydration causing cardiovascular
  instability
• Cannot be effectively orally hydrated
• Unconscious with serum sodium gt130mmol/L
• Symptomatic Exercise-Associated Hyponatremia with
  3 NaCl
• Consider for resistant exercise associated muscle
  cramping
• Recommend Sodium assessment prior to IV

43
Conclusions

• First, do no harm
• Diagnose first, treat second
• Have clear indications for interventions that you
  do and do not perform.

44
I hope you enjoyed the ride!
swpyne_at_annapolis.med.navy.mil