Another plea. Please stop embarassing us. #FOAMed, #FOAMcc.

Despite physiological rationale, common sense, and a JAMA article now almost 2 years old, I still sadly see most of my internal medicine colleagues still routinely reaching for (ab)normal saline.

Its embarrassing.

I genuinely feel bad recommending other fluids in consultations, or in the room of a crashing patient asking the nurse to stop the bolus of NS and change it at least to RL, because it is such a ‘basic’ intervention. Prior to the JAMA article, I mostly gave people the benefit of the doubt. Resuscitation isn’t everyone’s field of interest, nor is physiology, so I didn’t feel that necessarily everyone HAD to know this and ascribe to it. I do understand the 10 year time of knowledge translation, but that’s why #FOAMed exists, to try to cut that down.

So please, unless your goal is specifically chloride repletion, take a deep breath and release your grasp on habit and tradition, and embrace physiology (at least to some degree) and stop using NS as a volume expander whether in bolus or in infusion. RL or plasmalyte – although not physiological, at least not as biochemically disturbing as is 0.9% NaCl.

Having said that, let’s keep in mind that human fluid is colloid, whether it includes a cellular suspension (blood, lymph) or not (interstitial fluid), made of a varying mix of proteins, electrolytes, hormones and everything else we know – and some we don’t – floating around. There is no compartment that contains a crystalloid solution.

I’m quite aware that no meta-analysis has shown that colloids are superior, but it likely is just a matter of the right colloid. Resuscitating with crystalloids is kinda like throwing a bucketful of water at an empty bucket across the room. 70-80% spill, if you’re lucky. And the cleanup may be more costly than a few sweeps of the mop. This is evidence based (SOAP, VASST, etc..).

So a plea to all, spread the word. Its a simple switch. Boycott hyperchloremic acidosis at least.

For more details, here’s a link to my earlier post on NS:




Bedside Ultrasound Clip Quiz: Abdominal pain and fever! #FOAMed, #FOAMcc, #FOAMus

Saw this poor fellow recently who presented to the ED with fever and abdominal pain. 73 years young. He came to my attention because of borderline BP (95 systolic) and a lactate of 4.5 mmol.

Here is a transverse scan at his lower right costal margin:


What do you think?

Turns out he had been having pain for about two weeks, and it had intensified about two days ago. His wife dragged him in.

What would you do?












This is septated fluid collection around the liver.  With the fever and history, sounds pretty suspicious for a septic source. After carefully scanning in all angles and watching for a while to make sure this wasn’t a strangely placed loop of bowel, a 22g needle aspiration showed cloudy bilious fluid and a trip to the OR a couple of hours later revealed a perforated duodenal ulcer.

He made it ok.