IV bolusing a fluid overloaded patient

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Had a patient recently that had metastatic breast CA. She had very low u/o post-op (ORIF for a pathological fracture). U/o didn't pick up over the next 3 days. She had baseline edema, and a pleurex catheter for frequent effusions (drained ~200-300mL every other day). She had a foley which was patent and no urge to void, but each bladder scan showed a different amount--anywhere from 0-300. Her abdomen was distended, hypoactive BS. No n/v, eating fine. I think it may have been day 2 of low u/o, and the team decided to bolus her. I took care of her the night after she had received over 5L fluid in 24 hours (the last liter went in over an hour). Her u/o was less than 400 during the same period. When I picked her up, she had pitting generalized edema (back, abdomen, groin, thighs, UEs and LEs). Her RR was increased (30s), she c/o SOB (on 2 L, which she is on at home), bibasilar rales, and she was tachy (120-130). I confirmed with the previous nurse that this was a change, even from the last few hours. EKG showed sinus tachy. That night she got no fluids and I gave her some Lasix. There was immediate but short lived diuresis (200mL in an hour, then 125 the next hour, 35 the next). Her respirations relaxed, VSS, though HR still 110. The next night I took this pt again. She was still grossly edematous, HR 100-115, other VS unremarkable. U/o was between 20-25/hr over the course of the previous day, with the exception of the times she received Lasix (pushed once on each shift--all 1x orders. 20mg each time). When I came in for night shift, the pt was getting IVF @ 100mL/hr. This was a decision made over the course of the day from multiple med consults--their rationale was they thought she was dry. They also had me push Lasix again (40mg this time) with a similar response as before.

Pertinent labs (some are approximated since I don't remember them all exactly):

Chemistires--Ca++ getting progressively lower over 2 days (from 7.9 down to 6.7). CO2 getting lower also (from 28 down to 21 I think). Cl increasing a little, going from normal to slightly high. K+ 4.5. Na++ 136. Mg 2.1

Renal function--normal Scr and BUN/Egfr>60. Solid values with no changes over time.

Hepatic function--Slightly increased AST/ALT. AST slightly higher, ALT nearly normal. (no hepatitis risk factors, no etoh, no hx of liver disease). Alk phos >300. Albumin 2.4. The rest WNL.

Hematology/coags--nothing significantly unusual for a post-op ortho pt.

BNP--Normal. No ECHO done due to normal BNP.

KUB and abdominal CT (for abdominal distension and low u/o)--unremarkable.

Chest xray--Mild pulmonary edema, though not significantly different from cxr done before pt was bolused.

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Thanks for reading this far. My MAIN question is about the pt's fluid status. She was 3rd spacing everywhere she could. One doc explained that this was related to low serum albumin, changing the osmotic gradient causing fluid to shift out of the vascular space. So, yes, she would be dehydrated. But I don't understand how bolusing and giving IV fluids will help. The doc felt that giving albumin is not necessarily effective in cases like hers, and improving her nutrition was the best option. But that takes time. I am wondering how the fluids/intermittent diuresing could help her--and obviously all of the nurses were concerned about the 3rd spacing and the risk of flash PE. I also am curious about the calcium decreasing (the team didn't want to replete it), and what her other abnormal labs might signify (Alk phos & AST, which are not liver specific).

I'm putting this in the CCU forum because I think you're all technical wizards. If it seems to be in the wrong place, sorry.

This pt case has been on my mind, and none of my trusty books accommodate this clinical scenario.

Oh, the patient was discharged to rehab on my day off, so, "stable-ish".

Any input would be awesome :typing

-Kan

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Why did the team not want to replace her Ca? What was their rationale?

While it does appear that the patient had some fluid overload...it looks like she was intravascularly depleted. bolusing would help to restore intravascular volume but eventually that would third space as well. Why were her vessels leaky?

Fluid bolus+Lasix will keep her peeing. Serum osmo would tell you a lot about her intravascular volume. UA with urine electrolytes would be helpful too.

What is her past medical history? RV or LV infarct/failure? CHF, COPD, any other pathologies?

A CVP would definitely be helpful in managing her vascular volume.

Sometimes managing volume status, renal function, and pulmonary function can be a tedious rope to walk.

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Specializes in PICU/NICU.

I would imagine they kept bolusing her because although she was edematous, she was still fluid depleted intervascularly and needed the fluid. Now, why no albumin was given- I don't really know. With a low serum albumin(which will have an effect on the calcium also) I'm suprised she was not given albumin along with the lasix to help pull that fulid back into the intervascular space and diures out.

When I have a blown up pt with a low albumin/ca+/total protein, I will usually receive orders for XXX gms of Albumin Q6 times 4 doses. If a lasix dose is ordered, it is usually given around one of these doses of Albimin.

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Thank you both so much for your replies. Meandragon (love the name), my only guess as to why they didn't want to replete the calcium was because there was a corresponding albumin deficit--so her serum calcium was only "relatively low" based on her serum osm. (I am well aware that I may have just made that up). The pt's significant hx included metastatic CA and pleural effusions--There was no indication that she had any cardiac disease history in her record nor was there record of an echo. One was ordered initially, then cancelled based on her normal BNP. One doc I spoke with said that BNP was that CHF specific, that there was no indication for an echo with a normal result.

Picnic, I appreciate your input on what you would normally do under those circumstances (because I don't see these circumstances that often). If the team wanted to treat her vascular volume status, I don't understand why they wouldn't at least add albumin to that, since it really seemed like most of the fluid she was getting was not going to the right place.

Thank you again--it is so frustrating treating a patient whose condition/medical orders seem to lack coherence. I wish that the team would round with nurses.

-Kan

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this may be a case of health care rationing.....albumin, last i knew, and that has been a while, is expensive.....if she is any where near terminal....prob. wont see it done.....doubt if diet is going to be of any help ..... good luck

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Is she is hypoalbuminemic, she needs oncotic tone. You can mke the case to not give her colloid (albumin or PRBC) if the fluid overload is not causing resp failure, and manage conservatively w/ nutritional support.

While the BNP may be normal, an Echo is still useful to determine intravascular volume status, even in the absence of heart failure. Other options are CVP or Swan.

The Ca may no be replaced b/c it is corrected "up" for the low albumin levels.

If her creatinine isn't bumping, she's stable on NC, then pumping in more crystalloid will only load her more. Let her be oliguric or provide oncotic tone (more albumin).

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Thanks Takeback. That makes sense, and may be why she wasn't given albumin or had Ca replaced.

What do you think about giving her D5NS w/ 20K @ 100 the day after she was bolused so heavily (she was positive >4L)? She was eating and drinking just fine. This wouldn't increase oncotic tone, and the fluid definitely wasn't coming out on its own.

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Thanks Takeback. That makes sense, and may be why she wasn't given albumin or had Ca replaced.

What do you think about giving her D5NS w/ 20K @ 100 the day after she was bolused so heavily (she was positive >4L)? She was eating and drinking just fine. This wouldn't increase oncotic tone, and the fluid definitely wasn't coming out on its own.

I wouldn't give the D5 if she had another glucose source (PO diet), and not necessarily the KCl if she had adequate K intake from diet or PO supplements.

So NS, or NSOL/LR if she had a mild met acidosis (acetate in sol'n)

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Specializes in CCRN-CSC.

if she has/had a PICC or TLC etc, transduce a CVP off of that. Also, I noticed that she didn't have a Hx of HTN. Maybe she did? Who knows...

I say this for one thing... Pts with htn need higher filling pressure. And if you perfuse kidneys, that likes a higher pressure, with what may be "text book normotensive" you're not meeting the demands of her renal perfusion.

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Specializes in CCU/MICU.

Her calcium was probably lower because she had gotten 5L of fluid in. Personally, if the first liter or 2 doesn't work (unless the patient is CLEARLY dehydrated) I would have recommended doing something else. 5 liters is alot to bolus a patient who is not in critical care. It is likely that she does need her albumin replaced, and is a lot less risky than pumping someone with that much fluid. They could have also tried switching to a hypertonic fluid, but you have to be careful that you aren't messing up the electrolytes even more.

If the patient's creatinine and BUN are fine and you have tried a bolus, I know that a lot of our intensivists would let it hang. Would probably also have given more lasix (as long as the BUN/CR stayed fine) to get some of that extra fluid off.

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.

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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.

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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.....

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