Re: IV bolusing a fluid overloaded patient

Originally Posted by shocker29

This is kind of touchy, but I find that some of the non-critical care docs don't necessarily have the expertise needed to really effectively manage problems that are outside of their specialty range. Chances are, if the patient was in a critical care unit, the low UO would have been handled a bit different. You said that the patient ended up being discharged to a rehab, so it doesn't sound like harm was done (hopefully), but the probably might have been handled in a fashion that was better for and more comfortable for the patient.

Depends on what kind of unit whether it was surgical or medical. Surgeons usually like to drown their patients. But I agree, if the pt had been in the unit, it likely would have been handled a bit different.

Re: IV bolusing a fluid overloaded patient

Originally Posted by meandragonbrett

Surgeons usually like to drown their patients.

b/c postops third space- the issue is not the total volume of lfuid given, but the portion that remains in the intravascular space.....

Re: IV bolusing a fluid overloaded patient

Originally Posted by TakeBack

b/c postops third space- the issue is not the total volume of lfuid given, but the portion that remains in the intravascular space.....

Yes, I know this. But after 10 liters of crystalloid....we ARE drowning a patient one way or the other

Re: IV bolusing a fluid overloaded patient

Transduce a CVP, if you have a central line. If you are unable to do this on the floor and you have a RRT they can rig a set-up and get the readings off a transport monitor if you have transport monitors that have that capability. An accurate CVP will put an end to the question of whether or not she is intravascularly dry.
According to corrected calcium calculations her serum calcium is okay. I'd have them order ionized calciums from now on---more accurate. You might want to order a serum cortisol test or a cortisol stim test. Decreased cortisol levels can result in poor urine output.
She may be third-spacing related to her metastic disease and vasculature permeability secondary to chemotherapy or vasculitis.
Other possibilities may include undiagnosed thyroid disease---order TFT's. With the co-morbidity of metastatic cancer the possibilities are just about endless here. She most certainly has hypoproteinemia and it may not be fixable by diet alone. Sometimes cancer patients suffer from malabsorption syndromes related to the destruction of the gastric endothelium secondary to chemotherapy. She might need TPN to correct her deficits.

Re: IV bolusing a fluid overloaded patient

Originally Posted by WindwardOahuRN

An accurate CVP will put an end to the question of whether or not she is intravascularly dry.

Just for the record, not all the time. There are several conditions (TR, constrictive pericarditis, pericardial effusion, RV failure) where an elevated CVP does not necessarily reflect intravascular fluid overload.

Swan ganz or echo may be better evaluations for LV filling.

Re: IV bolusing a fluid overloaded patient

Just to echo the others, my very first thought when reading the thread title was "what is the patient's CVP readings?"

Even with edema, you need to keep adequate intravascular volume lest you succumb to prerenal acute renal failure and make matters worse.

And your docs are right: IV albumin isn't all that useful in restoring albumin-- nutrition is.

Re: IV bolusing a fluid overloaded patient

I agree with the other posters, a CVP would be most helpful in this situation. The calcium was not replaced most likey because the albumin was low. The CA is closer to normal if you correct for the albumin. Her liver enzymes would be sl elevated due to hepatic hypertension. If the pt is eating then that is the optimal way to correct her albumin, but you are right, it takes time for that to happen. A schedule of albumin and a lasix drip at 5-10mg/hr for 24-48 hrs would do this lady some good. I'd like to see an Echo, and a swan (yeah, I'm a number freak) but knowing her CVP and PA would give a better overall picture and aid in proper management. They could also try to ultrafiltrate for fluid if she because so overloaded, but I'd try the lasix drip first.

Re: IV bolusing a fluid overloaded patient

Originally Posted by TakeBack

Just for the record, not all the time. There are several conditions (TR, constrictive pericarditis, pericardial effusion, RV failure) where an elevated CVP does not necessarily reflect intravascular fluid overload.

Swan ganz or echo may be better evaluations for LV filling.

Okay, just for the record, true. But we are talking about this particular patient. Gross anasarca, oliguria---a quick echo to rule out the most obvious cardiac etiology would be useful but a CVP would be the least invasive and most rudimentary of readings to get when trying to put the facts together here.
I have a feeling that this may be more involved than just a "backup" of fluid due to cardiac or hepatic reasons. Due to her metastatic disease I would suspect that she has vascular permeability/leakage that is contributing greatly to her edema. Most of us who have been doing this for some time have seen the eventual picture---metastatic CA, grossly bloated patient with weeping edema, no urine output, on levo, organs failing one by one. It's such a mixed picture that it's often difficult to figure out what preceded what as far as problems go but the end picture is pretty much always the same with little variation on the theme.
Swans have fallen greatly out of favor over the last ten years or so. Years ago just about everyone in the ICU (teaching hospitals where I worked, anyway) had a Swan. Mr. Swan and Mr. Ganz made their fortunes and then studies came out showing that in many cases the risks far outweighed the benefits. They have their place, of course, but start with the basic diagnostics before going the more invasive route.
How about a Vigileo, for example? You can get a CO and CI without the possibility of blowing a pulmonary artery or tickling a ventricle into VT. But a Vigileo or PA would buy her a trip to the ICU and this might be something her docs are trying to avoid, for a multitude of reasons. A central line for sure, if only a PICC, would be where I would start. You can get baseline numbers from an echo. The least invasive of diagnostic procedures, as first steps.
Just a thought.
In any case this lady has a tough road ahead of her and at the very least we can try to minimize the medically approved torture. Perhaps this is what her docs are trying to do, knowing the prognosis?

Re: IV bolusing a fluid overloaded patient

Originally Posted by WindwardOahuRN

Transduce a CVP, if you have a central line. If you are unable to do this on the floor and you have a RRT they can rig a set-up and get the readings off a transport monitor if you have transport monitors that have that capability. An accurate CVP will put an end to the question of whether or not she is intravascularly dry.
According to corrected calcium calculations her serum calcium is okay. I'd have them order ionized calciums from now on---more accurate. You might want to order a serum cortisol test or a cortisol stim test. Decreased cortisol levels can result in poor urine output.
She may be third-spacing related to her metastic disease and vasculature permeability secondary to chemotherapy or vasculitis.
Other possibilities may include undiagnosed thyroid disease---order TFT's. With the co-morbidity of metastatic cancer the possibilities are just about endless here. She most certainly has hypoproteinemia and it may not be fixable by diet alone. Sometimes cancer patients suffer from malabsorption syndromes related to the destruction of the gastric endothelium secondary to chemotherapy. She might need TPN to correct her deficits.

This!

Re: IV bolusing a fluid overloaded patient

Albumin is expensive and while it is DUH logical for us to sit there and say "Dude, no oncotic pressure, low albumin, gross 3rd spacing, increased vascular permeability...give albumin..."
Research suggests that colloids may not be any more effective in fluid resuscitation than isotonic crystalloids. Surgery will make you 3rd space and then it should start coming back in a 2-3 days.
Why they let her wallow around in pre-renal for three days seems foolish. Is she a DNR? I bet the White Coats might have gotten DNR confused with Do Not Treat.