Diuresis in Critical Care - Achieving a Negative Fluid Balance
Advantages Of A Negative Fluid Balance:
• Volume overload is very common in the later (e.g. de-escalation) phases of critical illness. Achieving a negative fluid balance is key to liberation from MV, mobility, & ultimate recovery.
• In people with sepsis, AKI, or who are post-op, risk of mortality increased by 1.19x per liter of positive fluid balance.
• USE FLUIDS PARSIMONIOUSLY IN RESUSCTIATION
• SWITCH IV TO PO
• USE HIGH CONCENTRATION MEDICATIONS
• AVOID MAINTENANCE FLUIDS
• REMOVE UNECCESARY MEDS
• Start with LOOP DIURETICS which are short acting and rapidly titrated to achieve UOP
• Add a THIAZIDE to augment diuresis, address diuretic resistance, & to correct hyponatremia
• Add a SPIRONOLACTONE (or ENaC INHIBITOR) to normalize Potassium homeostasis especially in high aldosterone states (CHF, Cirrhosis)
• Add ACETAZOLAMIDE to correct a contraction metabolic alkalosis & further augment diuresis.
• ULTRAFILTRATION is indicated for removal of fluids in volume overloaded patients who are refractory to diuresis. - Timing is controversial. Early nephrologv consult may be associated with improved survival in AKI.
- Nick Mark MD @nickmmark
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