Isn't fluid status a high priority?

(Burke Mamlin) #1

I’m surprised that I&O (input & output) management hasn’t been mentioned as a high priority. I assume one of the primary, life-saving interventions an ETU can provide would be to monitor fluid losses (i.e., estimating volumes of diarrhea, vomitus, and urine collected) and replenish them through normal saline IVs. If you have limited IV fluids and/or staff to deliver it, then you’d want to get those fluids into the patient who lost 10 liters of fluids in the past 24 hours before the patient who lost 1 liter. I assumed that ETUs would prioritize both the collection and monitoring of fluids. For example, an incredibly easy-to-use-in-the-red-zone page for recording ins & outs:

and a patient dashboard ranked by fluid status (those the most negative listed first)… maybe even patient avatars that call out the patient’s fluid status:

Maybe these features are already being discussed and I just haven’t been in those conversations.

(Darius Jazayeri) #2

On the Save the Children forms these questions are (I think) included in the Inpatient Followup form. (See here.)

It’s a good question: we haven’t so far talked about how to sort the existing inpatients by priority. (Just by their assigned ward location.)

(Burke Mamlin) #3

While fluid intake and output can be performed during routine checking of vitals by nursing, it is often not part of an encounter or a predictable workflow; rather, recorded as fluids are given (oral, IV fluids, blood transfusions) and collected/cleaned (urine, diarrhea, vomitus). Each can be recorded as a number of mL (milliliters) and reported as the total ins minus the total outs over the past 24 hours. Patients with large deficits (e.g., -3000 mL) are in trouble for dehydration; patients with large excess (e.g., +3000 mL) are at risk for fluid overload.

I’d approach these with a targeted form for quickly recording counts, expecting that they would be entered ad hoc as they are given or collected. Allowing entry of negative numbers allows for quick corrections for mistaken entries.

Anyway, not worth building if they aren’t crying out for it. Given what I know of EVD combined with some of the I&O’s I’ve seen reported (10-12 liters/24 hours for some, which is massive), I’m just guessing that managing fluid balance and prioritizing fluid resuscitation would be far more critical & lifesaving compared to recording hiccups or coughs throughout the day. And, a system that made I&O recording & monitoring incredibly simple would be a lifesaver.

But I’m not an Ebola expert and I’m not the one in the field, so treat this is just my 2¢ from the sidelines.

(Hamish Fraser) #4

Hi Burke thanks for those comments. It is definitely a priority for the system and should be on our road map though I don’t think we have a clear idea of the workflow yet. I expect it will be along the lines you described. Regards


(Hamish Fraser) #5

It looks like there may be a need to add fields for the volume (accurate or approximate) of fluid losses in the hydration section to allow a running total as per Burke’s comment. Regards


(Allison Stewart) #6

Hi all,

I am in the field, so let me give you the field clinical perspective on this topic. It’s true that fluid management is important in the treatment of Ebola patients. However, the reality of the field is that it is almost impossible to estimate with any level of accuracy fluid loss. You have to remember that the patients are only being seen on rounds - and rounds are only about 45 minutes long (due to PPE). This means that is you have 25 sick patients, your time with each patient is less than 2 minutes per patient. Combine that with the fact that most patients will be pretty ill and won’t recall how often they lost fluids (how often they vomited or went to the bathroom) and because their byproducts are hazardous waste - we can’t measure them and ensure staff safety. The best we can do is try to make sure they are drinking their ORS and water - but even that is difficult. Unlike a normal clinical care setting, patients aren’t being monitored at all times. Because of all of this - we generally attempt to use clinical proxies for dehydration - like capillary refill time, skin pinch, consciousness, etc.

This is probably why you haven’t seen much discussion on this - or much priority.

(Hamish Fraser) #7

Thanks Allison that makes sense about the fluid balance situation.

It does sound like some web cams for realtime monitoring could be helpful for these patients. Someone could track 5 or 10 of them between visits and observe events like vomiting or fluid intake and improve the estimates. Ideally you have an audio link and a local member of staff who can talk to them (in their own language).

Has this approach been discussed? There is a lot of kit to do this kind of thing these days for home monitoring of patients which also include simple vital sign monitoring in some cases. Regards


(Andrew Kanter) #8

We added concepts for specific Is and Os, Perhaps we need more qualitative estimates, although cap refill is quantitative.

(Darius Jazayeri) #9

I remember @ball saying that our SL team mentioned wanting to try Go Pro cameras. I don't know if this went anywhere.

-Darius (by phone)

(Burke Mamlin) #10

@Allison – thanks for the response. Makes perfect sense.

@Darius – My impression of Go Pro cameras is they’re designed as an indestructible observer where the video is downloaded after the “event”. Assuming you want to monitor a stream, less heavily marketed, inexpensive, wifi IP cameras would probably serve the need better. :slight_smile: