IV bolusing a fluid overloaded patient

[kanzi monkey]

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

[meandragonbrett]

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

[WindwardOahuRN, RN]

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.

[TakeBack]

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.

[hypocaffeinemia, BSN, RN]

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.

[criticalHP, MSN, RN]

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.

[WindwardOahuRN, RN]

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?

[geekgolightly, BSN, RN]

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!

[Manurse715]

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.