Fluid Resuscitation for Renal Failure/CHF

[FazzDazzle]

I'm an ER nurse and have attempted to find some articles online but want would appreciate hearing how you or your facility handle sepsis bundles/fluid resuscitation in your hospital for pt's with CHF or renal failure.

Recently I've had pts who are "Sepsis Screen Positive" who would automatically receive 2-3L of fluid for possible sepsis but have not due to hx of CHF or renal failure.

One case in particular we did not bolus my pt despite his SBP was high 70s to low 90s for hours (good color, no changes in mental status, not super tachy, "provider aware of BP" in all my notes) as he had a hx of severe CHF and had been overloaded with fluid extremely easy in the past. The provider was finally considering putting him on pressors after many hours but he was very complicated, and had received some units of blood, so they held off as long as possible.

Less than a week later we had a very similar case with a pt in renal failure who had a hx of hypoTN and syncope. He at least received a 500ml bolus but no more despite being scheduled for dialysis in less than 24 hours. He was more symptomatic than the previously stated pt.

Obviously we also have many pt's coming in now with flu and/or pneumonia in addition to their CHF and COPD who meet the "sepsis protocol". I'm just looking for input, even anecdotal, because I always forget to ask providers about these situations during "free time" (hahaha, we all know that doesn't exist).

Thanks

[april*rn]

Those scenarios are frustrating. You are stuck between a rock and a hard place.

For HF , I see small fluid blouses (250-500ml at a time) and sometimes cardiac drips for support.

Renal failure- pretty much normal sepsis treatment then more frequent dialysis as tolerated. They get edematous for a few days usually.

[gemmi999]

I've seen a few different things. If a pt. is hypotensive and tachycardic and a CHF-er, we'll give them a fluid bolus AND albumin AND lasix. I've seen patient's have Albumin for IV maintenance for the first 24 hours in order to keep fluids from third-spacing. Sometimes it works. A lot of times I see more of the CRF pt's who aren't dialysis ready yet who get ARF on top of their chronic due to sepsis and hypotension and we end up giving even *more* fluid to get them making at least a little urine.

[CraigB-RN, MSN, RN]

The key in any patient is that they get the fluid they need and not a drop more. Which is sometimes pretty difficult. Think more in terms of perfusion and no focus on numbers.

Over the past year the fluid volume thoughs have changed a little and we've found that just dumping crystaloid in patients isnt always the best choice. We've also discovered that more rapid use of pressors is a good thing.

I don't have a link, but google the current surving sepsis guidlines.

The second idea is not to focus on a set BP or pulse for that matter. A well beta blocked patient may not respond "normally" The only other thing I'd make sure to note was urine output. I've had patients with systolic in the 90 producing 35cc urine an hour.

[offlabel]

It doesn't have to be guess work at all. Dynamic assessment of fluid responsiveness has received a lot of attention in the last decade and have really increased our understanding of how to decide when enough fluid is enough. SVV/PPV, PLR and end expiratory occlusion tests are all very practical ways to make the determination of fluid v. inopressor.

All of these are decent indicators of response of cardiac output to a fluid bolus, and, if used correctly, minimize the chance of fluid overload in any patient.

More and more, the Surviving Sepsis guidelines are being "set aside" with the blessing of hospital clip board warriors, in light of these assessment tecniques.

[MunoRN, RN]

The current recommendation of the Sepsis Consortium (Sepsis 3) is that these broad screening tools like the ones commonly used to screen ED patients should no longer be used, which includes just giving fluids based on the screening alone. There needs to be some sort of assessment of volume status (IVC collapsibility, etc)

[offlabel]

The current recommendation of the Sepsis Consortium (Sepsis 3) is that these broad screening tools like the ones commonly used to screen ED patients should no longer be used, which includes just giving fluids based on the screening alone. There needs to be some sort of assessment of volume status (IVC collapsibility, etc)

What "broad screening tools" do they specifically refer to? Mind sending a link along? I find it interesting that they assume that an ultrasound machine with people to stand around and man it are coming out of the wood work.

[MunoRN, RN]

What "broad screening tools" do they specifically refer to? Mind sending a link along? I find it interesting that they assume that an ultrasound machine with people to stand around and man it are coming out of the wood work.

The commonly used screening tool has been 2 or more SIRS criteria (temp, RR, etc). From Sepsis 3 "The current use of 2 or more SIRS criteria (Box 1) to identify sepsis was unanimously considered by the task force to be unhelpful." Some of my shifts are spent as a rapid response nurse, we get a daily audit of inpatients that meet this criteria, typically between 70% and even 90% of the patients in the hospital, which doesn't do much to narrow things down. Jumping to the treatment stage just based on these criteria can do harm than good. Consensus Definitions for Sepsis and Septic Shock | Critical Care Medicine | JAMA | The JAMA Network

Our ED docs do their initial and repeat assessments of potential sepsis patients with ultrasound, and our ICU docs, except for a couple of the older ones, do their rounds with an ultrasound in tow.

[twss2323]

As other have mentioned, look at the surviving sepsis guidelines.

I actually went to an AACN presentation the other day about the sepsis guidelines and CHF/renal patients and fluid resuscitation was a topic of discussion. The current recommendation is to do small volume boluses of 250-500mL at a time and use passive leg raise to assess fluid volume status. If there is a greater than 10% increase in MAP with passive leg raise, they're fluid responsive and need more fluid. You resuscitate them as long as they are responsive.

[MYSTICOOKIEBEAR]

My philosophy is that if they need the fluid to maintain a map that is consistent with life or a map that the attending is okay with, I always give it. If a patient has a BP of 80s over 40s with a map in the 50s but their baseline systolic is in the 90s I am not so worried. It really comes down to what Cardiology (for HF) or Nephrology (for renal) is okay with.

There have been times where I have had to massively fluid resuscitate both of these patient populations in a critical care setting because if we don't, we are risking impaired end organ perfusion, and also at risk for the patient coding. We might be shooting ourselves in the foot for a problem later, but if we don't do an intervention now (fluid resuscitate), we won't have a patient to worry about later since they will no longer be with us. We need to get through the first 4 hours before we can get to the next 8.