Nikki writes, in reply to Jane:
<Once the epidural has worn off, the blood vessel tone
increases, forcing the extra intravascular fluid out into the "third
space." This is the root of the edema that occurs in normo-tensive
patients.>
<Dear Friends:
Thank you Jane Kershaw for an answer that explains why edema increases
after delivery.>
As valuable as those insights are, there is much more to it than that. Put
as simply as I can, when lots of crystalloid IV (non-protein) IV fluid is
given, it dilutes the concentration of protein in the blood stream. It is
this concentration of protein that functions to keep the necessary amount of
fluid within the blood vessels. When the concentration level drops, more
fluid "escapes" into the "third space" There was a quote from Guyton in my
last post that addressed this also.
Some time ago, Denise Fisher told of us of a New Zealand midwife, Dawn
Hunter, who had studied the matter in relation to delayed lactogenesis
II..(This was from a summary, and I don't recall that she specifically
mentioned the presence of edema, but I feel sure that that was part of the
equation, as that was why Denise reported it to me.)
Dawn noted that when the mother's level of a protein called albumen, went
quite low there was a delay in lactogenesis II.( Measuring the albumen level
is apparently a simpler test than the COP test I mentioned in JHL.)
I discovered that one of our Lactnetters is currently in her anesthesiology
residency, so I "struck up an e-conversation" with her. Her name is Sarah
Reece-Stremtan, and her residency plus home responsibilities including
mothering her 2 y.o. son William make her computer time short, so I asked
her if I could report some of our conversation about this matter. I hope she
herself has time soon to tell us more.
After I told her about Dawn's hypothesis and my wondering whether giving
some albumen as part of the IV fluids might be a partial solution to
edema,Sarah wrote:
<I first learned about giving albumin (salt-poor albumin, or "SPA" as they'd
like to call it) during an ICU rotation last fall. I've never seen it or
Hespan used outside of the ICU for some reason -- I believe that albumin is
*very* expensive, or sometimes difficult to get or something, as I remember
the pharmacy calling us once to say that they didn't have enough to give to
one of our patients that we kept ordering it for. We would really only use
it in patients who were hypotensive and needed intravascular repletion yet
who couldn't handle IVF boluses because they were already fluid overloaded
-- usually renal patients but occasionally CHF (congestive heart failure) or
liver patients. ICU medicine -- which I love! -- seems to be all about
volume status. When I'm on the floor and we have patients with edema not
due to CHF, it seems like their albumin levels are usually lower than 3,
probably 2.5, before we see significant edema without any other cause. But
we would never give them SPA unless they had MASSIVE edema and were
crashing/hypotensive and on their way to the ICU. Now I wonder how long its
effects last???
I think that IVF are given so routinely to moms in labor because nobody
wants to have to use pressors (that could cause vasoconstriction of
placental blood supply) and fluids are usually a great way to help maintain
BP -- and epidural anesthesia often causes hypotensive periods. I'll just
have to be cognizant of how much fluid I'm giving moms during c-sections --
and then try to make sure that the healthy babies are given immediately to
mom instead of being whisked off and presented to mom a good 2+ hours later.
:)>
I asked her who was responsible for the rate of the IV fluid, (which adds up
to extra amounts.) I also asked her something I have asked on LN before, in
hopes of getting some of the dieticians interested in finding someone who
would want a research project:
<One sentence that stood out for me in one of the references is that the OB
researchers found that many moms received more IV fluid than the doctor
ordered (in labor) because nurses, presumably, didn't stick strictly to the
gtts/min rate specification.
I presume the anesthesiologist would be controlling the rate in cases of
boluses, but when an epidural is in place for a long time, would anyone else
besides them be controlling the rate?? (It's now been 30 years since I
worked anywhere near an L&D when I quit the hospital in 1976 to move to a
public health job. I. . . Things have really changed.
Given the expense of SPA, I'd love to be able to persuade some of the
nutritionists on LN to do some research in feeding moms a very high protein
diet in the first 24 hours. By my reasoning, the protein would enter the
circulation promptly on digestion by virtue of being picked up into the
lymphatic capillaries in the gut and taken directly up to the superior vena
cava. Does that make any sense??? >
Her reply:<I was thinking about the advice to eat a high-protein diet in the
early days, and that really makes a lot of sense. I know that when we get a
nutrition consult for our patients, they almost always ask that we check a
pre-albumin level for them to help assess total nutritional status, since
albumin levels vary so much according to recent dietary intake. So it
follows that trying to raise albumin levels through high dietary intake of
protein could conceivably raise serum oncotic levels and help keep fluid in
the intravascular space. Certainly worth a try -- something I'll do myself
next time, since the part of recovery from childbirth that was the worst for
me was the elephantine size of my ankles and feet for many days afterward
(had initial latching problems, but in spite of my obvious lower extremity
edema, the LC who helped me was surprised by how soft my areolae remained.)
During my labor -- and I don't have enough experience yet otherwise! -- the
only time the anesthesiologist came in my room was to get the epidural going
the first time, and then to re-dose it when it wore off. I know I got a lot
of IVF, but I didn't pay attention to how much -- I think you're right in
that they probably just start up a certain rate and then keep them going
whether they're clinically indicated or not, and that nursing staff are
really probably responsible for much of that. During C/S, the
anesthesiologists are in charge of IVF, and I know they treat it like any
other major surgery in terms of keeping the fluids going. >
My reply to her:
<when you have time, would you address the clinical part of it? It will
mean so much more coming from you, and I really would love to get all the
nutritionists on the list interested in encouraging whomever they can to
formally research the idea!!!
A big first meal of an omelet with 3 eggwhites and a whole egg , perhaps
with a little meat from a pork chop or steak, a little tofu scrambled in for
those who are not down on soy, some milk, or even a milk shake with a little
protein powder mixed in, etc.,next meal, some steak or a pork shop or some
fish, etc., all into the lacteals and on up to superior vena cava to raise
the albumen level quite quickly so that fluids would be drawn back into the
circulation and get to the kidney rather than staying out in the "third
space" . Probably much more efficacious in these cases than the diuretics
and diuretic foods like watermelon, etc. that are commonly suggested on the
list.This problem interfaces with so many disciplines, and we can all
benefit from improvements.>
There are so many disciplines involved in the creation and the resolution of
edema. Not only would it be interesting to get L& D nurses interested in
tracking rates and amounts as carefully as possible, but a high protein diet
for the first 24 hours certainly doesn't sound as if it could cause any
harm, seems worth a try., What do others think, especially our nutritionists
and RD's??
Jean
****************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA
<I was thinking about the advice to eat a high-protein diet in the early
days, and that really makes a lot of sense. I know that when we get a
nutrition consult for our patients, they almost always ask that we check a
pre-albumin level for them to help assess total nutritional status, since
albumin levels vary so much according to recent dietary intake. So it
follows that trying to raise albumin levels through high dietary intake of
protein could conceivably raise serum oncotic levels and help keep fluid in
the intravascular space. Certainly worth a try -- something I'll do myself
next time, since the part of recovery from childbirth that was the worst for
me was the elephantine size of my ankles and feet for many days afterward
(had initial latching problems, but in spite of my obvious lower extremity
edema, the LC who helped me was surprised by how soft my areolae remained.)
During my labor -- and I don't have enough experience yet otherwise! -- the
only time the anesthesiologist came in my room was to get the epidural going
the first time, and then to re-dose it when it wore off. I know I got a lot
of IVF, but I didn't pay attention to how much -- I think you're right in
that they probably just start up a certain rate and then keep them going
whether they're clinically indicated or not, and that nursing staff are
really probably responsible for much of that. During C/S, the
anesthesiologists are in charge of IVF, and I know they treat it like any
other major surgery in terms of keeping the fluids going. I know they still
try to keep patients NPO during labor at my hospital, and as the OB
anesthesiologist put it, "aspiration pneumonia is a hell of a bad way to
die, especially for a brand-new mom..." So I'm sold on that practice, at
least. :)
Found out I get to do my OB anesthesia month in November, and am *really*
looking forward to it. So much to learn!
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