Fluid Management : Diuretics & The Danger of Fluid Overload

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Arie Zainul Fatoni

Department of Anesthesiology and Intensive Therapy Brawijaya University - dr. Saiful Anwar General Hospital

Malang 2023

Fluid Management :

Diuretics & The Danger of

Fluid Overload

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BIODATA

dr ARIE ZAINUL FATONI, SpAn KIC

Dokter Anestesi RSUD Kab Lombok Utara 2014 - 2015 Dokter Anestesi RSUD dr Saiful Anwar Malang 2016 - skrg

081336163333 [email protected]│

S1 : Pendidikan Kedokteran FKUB-RSSA Malang

Sp1 : Prodi Anestesi FKUB-RSSA Malang Sp2 : Prodi Sp-2 KIC FK UNPAD-RSHS Ban- dung

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DISCLOSURE

I have NO Financial disclosure or conflicts of interest with the presented material in this

presentation

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THANKS TO

I Made Agus Kresna Sucandra

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Objective

• AKI

• Fluid Overload

• Management

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• Teaching Hospital in Malang, East Java , Indonesia

• 727 beds

• ICU 30 beds

• Isolation ICU 7 beds

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Introduction

• Loss of renal function > reduced sodium filtration & inappropriate suppression of tubular reabsorption > volume expansion

• Associated with HT, CHF, LVH, edema

• Poor clinical outcome

• Multi pathophysiologic pathway

• Organ cross-talk & distance organ injury

Khan YH, Sarriff A, Adnan AS, Khan AH, Malhi TH.. Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle. PloS One. 2016; 11;7

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Case

• Patient day 4 in ICU, admitted with septic shock because of

community-acquired pneumonia, inflammatory markers decreasing, now oedematous with cumulatife fluid balance + 6000 ml, on FIO₂ 0.45 PEEP 10 cm H₂O to maintain SaO₂ .92%. BW 50 kg in 1^st day

• Problem: overloaded, oedematous, difficult to wean

• Plan?

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Fluid Overload

• Fluid resuscitation > restore cardiac output, systemic blood pressure, renal perfusion

• Required for volume management:

• Underlying pathophysiology

• Evaluation of volume status

• Solution for volume repletion

• Maintenance & modulation of tissue perfusion

• Fluid overload  morbidity & mortality

• 86% positive fluid balance, 35% had FO

• 46% diuretics  94 % loop diuretic (Furosemide)

Ann Am Thorac Soc. 2015 Dec; 12(12): 1837–1844; Wichmann et al. Annals of Intensive Care (2022) 12:52 ; Claure-Del Granado and Mehta BMC Nephrology (2016) 17:109

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Annual Update in Intensive Care and Emergency Medicine 2018

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Definitions

• Daily fluid balance: daily difference in all intakes and all outputs, which frequently does not include insensible losses.

• Cumulative fluid balance: sum of each day fluid balance over a period of time (1^st week)

• Fluid accumulation: positive fluid balance, with or without linked fluid overload.

• Fluid overload: The percentage of fluid accumulation is defined by dividing the cumulative fluid balance in liters by the patient’s baseline body weight and multiplying by 100%. Fluid overload is defined as a cut-off value of 10% fluid accumulation, as this is associated with worse outcomes  pulmonary edema or peripheral edema.

BMC Nephrol 17, 109 (2016). https://doi.org/10.1186/s12882-016-0323-6; Annual Update in Intensive Care and Emergency Medicine 2018

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Assessment of Fluid Overload

• History and physical examination

• Chest radiography

• Laboratory

• Bioimpedance vector analysis

• Thoracic ultrasound

• Vena cava diameter ultrasound

• Hemodynamic monitoring

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History and physical examination

• History: heart failure, shock etc

• Evaluation : daily fluid balance, BW

• - Physical Examination:

• dispnea (PND)

• 3rd heart sound gallop > useful

• pulmonary rales,

• lower extremity edema,

• JV distention, IAP

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Chest radiography

• Most used tests to evaluate hypervolemia

• Cardiomegaly,

• Congestive vascular hili,

• Kerley b-lines

• Signs of pulmonary edema

• pleural effusions

• CHF  poor predictive value

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Laboratory

• serum urea, creatinine

• electrolytes imbalances

• CBC  dilutional anemia

• capillary leak index (CRP/Albumin ratio)

• Decreased serum osmolarity

• BNP and N-terminal (NT)-pro-BNP levels can be increased

BMC Nephrol 17, 109 (2016). https://doi.org/10.1186/s12882-016-0323-6; Annual Update in Intensive Care and Emergency Medicine 2018; Ann Intensive Care. 2012; 2(Suppl 1): S1

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Bioelectric-Impedance Vector Analysis

• Estimating body composition > soft tissue hydration (2 - 3% error)

• Noninvasive, inexpensive, versatile

• body fluid volume

• Detect less than 500 ml change of tissue hydration

• BIVA ? CVP (high / medium / low)  Usefull

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Ultrasound

• B-Lines

• IVC dilated

• Cardiac dysfunction

• RI

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Hemodynamic Monitoring

• CVP /PAOP  be careful (High PEEP, IAH)

• EVLWI (Extravascular Lung Water Index)

• PVPI (Pulmonary Vascular Permeability Indices)

• FO PVPI > 2.5 and EVLWI > 12 mL kg-1 PBW⍨

BMC Nephrol 17, 109 (2016). https://doi.org/10.1186/s12882-016-0323-6; Annual Update in Intensive Care and Emergency Medicine 2018; Ann Intensive Care. 2012; 2(Suppl 1): S1

Anaesthesiology Intensive Therapy 2014, vol. 46, no 5, 361–380

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European J of Heart Fail, Volume: 21, Issue: 2, Pages: 137-155, First published: 01 January 2019, DOI: (10.1002/ejhf.1369)

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AKI

FO should not merely be considered an expected consequences of fluid resuscitation or severe AKI >

probably mediator of adverse outcome

BMC Nephrol 17, 109 (2016). https://doi.org/10.1186/s12882-016-0323-6; Annual Update in Intensive Care and Emergency Medicine 2018 - 2020

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Prevention of Fluid Overload

1. Assessment of intravenous fluid need: Only the three major indications need to be examined thoroughly for the purpose of a clinical audit: resuscitation; maintenance; and replacement or redistribution.

2. Clear prescription: Every intravenous fluid prescription has to be detailed to ensure correct administration and that a fluid management plan is available to warrant the continuity of care.

3. Quality standards: The information in the hospital’s fluid guideline or bundle is used to create different quality standards.

4. Appropriateness: These standards represent the necessary elements to do a full and qualitative check of appropriateness

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4D: Drug, Dose, Duration, De-escalation

4P: Physician, prescription, pharmacy, preparation, patient Fluid Therapy : 4D Fluid Prescription : 4P

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Management

Diuretics

• Stabilization phase + FO  morbidity

• FST & ratio of daily furosemide dose equivalent to urine

output (mg/ml per day) ≥1.0

• 1^stline  Loop diuretics

• Single vs Combination

• Electrolytes Imbalance

Extracorporeal Therapy

• Continuous Renal

Replacement Therapy (CRRT)

• IHD

• SCUF (slow continuous ultrafiltration)

• CVVH (continuous veno- venous hemofiltration

• CAPD

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DIURETICS

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European Journal of Heart Failure (2019) 21, 137–155

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LOOP DIURETICS

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Front. Nephrol. 2:879766. doi: 10.3389/fneph.2022.879766

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• Furosemide alone,CRRT, Furosemide and Albumin

• DFS : Fluid balance minus 0,3 – 47,6 cc/kg/day or weight loss > 1 kg/day or 10 kg in 5 days or 5480 in 3 days

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Summary

• Fluid Overload  morbidity and mortality

• Evaluation daily fluid balance

• Pharmacological management : Diuretics

• Extracorporeal

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QS, Al-Ma’idah:32

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THANK U

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Case

• Patient day 4 in ICU, admitted with septic shock because of

community-acquired pneumonia, inflammatory markers decreasing, now oedematous with cumulatife fluid balance +5000 ml, on FIO₂ 0.45 PEEP 10 cm H₂O to maintain SaO₂ .92%. BW 40 kg in 1^st day

• Problem: overloaded, oedematous, difficult to wean

• Plan?

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GOAL DIRECTED FLUID DERESUSCITATION

Advance Access publication 10 September 2014 . doi:10.1093/bja/aeu299

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