CHF Exacerbations

[agranulocytosis]

---

Members do not see this ad.

Let's say in a situation where a patient has a severe CHF exacerbation where they are third-spacing water everywhere, their RAAS is running in full gear and they're retaining fluids to the point of volume overload. Common sense says we diurese them for symptomatic relief and give them some inotropic support.

Conceptually this makes sense to me. However, what I'm trying to grasp here is the idea that even though they might have more TBW on board, what does that say about their intravascular fluid volume?

Basically, I guess what I'm asking is should we expect patients with CHF exacerbations to be volume overloaded and diurese, leaving fluid resuscitation only if/when they are showing signs of volume depletion with hypotension and tachycardia?

 

[Labslave]

Let's say in a situation where a patient has a severe CHF exacerbation where they are third-spacing water everywhere, their RAAS is running in full gear and they're retaining fluids to the point of volume overload. Common sense says we diurese them for symptomatic relief and give them some inotropic support.

Conceptually this makes sense to me. However, what I'm trying to grasp here is the idea that even though they might have more TBW on board, what does that say about their intravascular fluid volume?

Basically, I guess what I'm asking is should we expect patients with CHF exacerbations to be volume overloaded and diurese, leaving fluid resuscitation only if/when they are showing signs of volume depletion with hypotension and tachycardia?

This is why diuresis in the real world is tricky business, or at least much more difficult than anything you're going to find in a Step II question. To illustrate this problem: I had a patient that was clearly volume overloaded and off the Starling curve, however we didn't want to deplete them intravascularly because they were pre-load dependent due to severe aortic stenosis. We started him on bumex and my senior went home for the night. I stayed on call overnight. I got paged at about 2 o'clock in the morning with the patient complaining of chest pain and shortness of breath. The question was, is this due to overly aggressive diuresis (not enough pre-load) or is the pt still volume overloaded and further deteriorating? Do I blindly give the pt a 500 cc bolus to cover for the aortic stenosis and see how he responds? Or do I aggressively diurese? As I learned, you check the urine output and get a stat CXR before making a decision.

Bottom line is that in the real world, you intravascularly deplete patients with CHF transiently and this is replaced by the third-spaced fluid. The ideal situation would be to reach a steady state in which you're constantly removing fluid from the intravascular space and replacing it with the third-spaced fluid at a constant rate, however by now you know that this is never the way it works. Hence why you need to be vigilant in watching I/Os and closely monitoring clinical status.

Strong work on recognizing the dilemma and good luck on the exam!

 

[Labslave]

Basically, I guess what I'm asking is should we expect patients with CHF exacerbations to be volume overloaded and diurese, leaving fluid resuscitation only if/when they are showing signs of volume depletion with hypotension and tachycardia?

I guess I didn't really answer your question...bottom line for your exam is to diurese first and worry about volume depletion later.

 

[agranulocytosis]

Wow, didn't realize students had that level of responsibility. The only things I would get paged about were trauma alerts coming in or doing a quick H&P on a new admit. In my experience thus far, any pertinent issues that arised overnight regarding floor patients that required decision making and placing orders bypassed us and went directly to the intern/junior. But I haven't done any Sub-I's yet so I still may have yet to experience that sort of responsibility.

Anyway...

Yeah I kinda figured I might be thinking too much about this since I don't want to be confused conceptually during this test. Still makes me wonder about the utility of these sort of exams when the reality of actual patient care is far more difficult that what we're being tested on.

Thanks for the wishes.

 

[IMDoc607]

Wow, didn't realize students had that level of responsibility. The only things I would get paged about were trauma alerts coming in or doing a quick H&P on a new admit. In my experience thus far, any pertinent issues that arised overnight regarding floor patients that required decision making and placing orders bypassed us and went directly to the intern/junior. But I haven't done any Sub-I's yet so I still may have yet to experience that sort of responsibility.

Anyway...

Yeah I kinda figured I might be thinking too much about this since I don't want to be confused conceptually during this test. Still makes me wonder about the utility of these sort of exams when the reality of actual patient care is far more difficult that what we're being tested on.

Thanks for the wishes.

You are not given that responsibility. I was on a sub-I where they made you the intern. Regardless of any page you received, your resident made all the decisions. You put in orders and if they need to be changed then the resident would do it.

With all due respect, I am not buying it unless LabSlave is actually a resident. Students do not make those calls.

 

[Labslave]

With all due respect, I am not buying it unless LabSlave is actually a resident. Students do not make those calls.

I'll just copy and paste what I wrote:

"The question was, is this due to overly aggressive diuresis (not enough pre-load) or is the pt still volume overloaded and further deteriorating? Do I blindly give the pt a 500 cc bolus to cover for the aortic stenosis and see how he responds? Or do I aggressively diurese? As I learned, you check the urine output and get a stat CXR before making a decision. "

The questions I wrote above were reflecting my thought process. I was first page on the patient. I arrived and recognized the dilemma, thinking about it after I paged my senior resident to come help out. She got there, asked me what the I/Os were and ordered a stat CXR (hence why I stated that I learned something). I explained what I was thinking and she said she was thinking the same thing.

CXR came back wetter than the last one. We sat the patient up in bed and transfered them to the ICU while promptly increasing the diuresis. It ended up becoming a much more interesting case, but I'll spare you guys the details.

I will make an additional note saying that my school does not play around with subI's. We are first page for everything, but instructed to be liberal with subsequent pages to higher-ups. Because this was obviously a therapeutic dilemma, I clearly would not make this decision on my own. Sorry if that wasn't clear!

 

[agranulocytosis]

Ha, no need to apologize. I was sitting here thinking that my clinicals experience wasn't up to what it should be after I read your post. There were thoughts of emailing my clinical director to let him know what's up. But whatever, only so much can be conveyed through the written word.

At least now I know what I should look out for in my Sub-I's, like politely asking the nurses to jot down my pager number so I can be paged about my patients before the junior gets paged.

Funny how I derailed this whole thing.

 

[IMDoc607]

I'll just copy and paste what I wrote:

"The question was, is this due to overly aggressive diuresis (not enough pre-load) or is the pt still volume overloaded and further deteriorating? Do I blindly give the pt a 500 cc bolus to cover for the aortic stenosis and see how he responds? Or do I aggressively diurese? As I learned, you check the urine output and get a stat CXR before making a decision. "

The questions I wrote above were reflecting my thought process. I was first page on the patient. I arrived and recognized the dilemma, thinking about it after I paged my senior resident to come help out. She got there, asked me what the I/Os were and ordered a stat CXR (hence why I stated that I learned something). I explained what I was thinking and she said she was thinking the same thing.

CXR came back wetter than the last one. We sat the patient up in bed and transfered them to the ICU while promptly increasing the diuresis. It ended up becoming a much more interesting case, but I'll spare you guys the details.

I will make an additional note saying that my school does not play around with subI's. We are first page for everything, but instructed to be liberal with subsequent pages to higher-ups. Because this was obviously a therapeutic dilemma, I clearly would not make this decision on my own. Sorry if that wasn't clear!

Ok my bad...it came off as you did all of this with no supervision. My school is similar. You are to be the first page for everything as well. We are also told to be very liberal with paging the higher-ups.

My bad 👍

Did you find your sub-I to be extremely helpful? I did and I am thankful I picked the site because residency starts this summer. Did they let you guys put in orders? I was at a hospital that had electronic orders and we were allowed to put any orders we wanted to (antibiotic tx, fluids, etc), but a flag would show on the residents account. If they approved it then it would be carried out but they would cancel them if they felt they were unnecessary.

 

[Labslave]

Ok my bad...it came off as you did all of this with no supervision. My school is similar. You are to be the first page for everything as well. We are also told to be very liberal with paging the higher-ups.

My bad 👍

Did you find your sub-I to be extremely helpful? I did and I am thankful I picked the site because residency starts this summer. Did they let you guys put in orders? I was at a hospital that had electronic orders and we were allowed to put any orders we wanted to (antibiotic tx, fluids, etc), but a flag would show on the residents account. If they approved it then it would be carried out but they would cancel them if they felt they were unnecessary.

No worries at all. I was too vague in my original post and can understand why you would have been annoyed.

It sounds like we either go to the same med school or at least med schools that have very similar philosophies and EMRs. I put in all the orders for my patients just as you described above.

My subIs were EXTREMELY helpful. I think they actually helped me a lot for Step II because I developed a good deal of clinical judgment while on the services. I know I'll be able to walk in on day 1 of my internship and be able to survive, because I know how hard and challenging it's going to be. My subIs also helped me become more comfortable with uncertainty, which, as I'm realizing, is a huge part of what makes our superiors look so much more knowledgeable and comfortable. Appropriate expectations are everything.

 

[IMDoc607]

No worries at all. I was too vague in my original post and can understand why you would have been annoyed.

It sounds like we either go to the same med school or at least med schools that have very similar philosophies and EMRs. I put in all the orders for my patients just as you described above.

My subIs were EXTREMELY helpful. I think they actually helped me a lot for Step II because I developed a good deal of clinical judgment while on the services. I know I'll be able to walk in on day 1 of my internship and be able to survive, because I know how hard and challenging it's going to be. My subIs also helped me become more comfortable with uncertainty, which, as I'm realizing, is a huge part of what makes our superiors look so much more knowledgeable and comfortable. Appropriate expectations are everything.

Yea I feel like I may be able to walk in on my first day and not be totally clueless. I also agree that a big part of the challenge is actually being comfortable with decisions. I remember plenty of times when I was the first one to make a decision that of course needed approval. I came in one morning and this guy was c/o chest pain & SOB. He was admitted the prior day for a STEMI in which they did an angioplasty. I ordered a stat EKG and cardiac enzymes (I did the whole set but I was looking at the CK-MB the most) since I was concerned may be he was having another infarction. In that circumstance, I put the orders in and told the nurses. They did the EKG right away and drew blood for the enzymes. After that was all done I paged my senior immediately and she then approved the orders.

I felt at that time there was no harm in drawing blood and getting an EKG without approval. His EKG showed no changes from the prior day and his enzymes were negative x 3. Sometimes I feel there are cirumstances that call for immediate intervention and I didn't want to wait for the senior to sign on to a computer to approve the orders. Drawing blood and getting an EKG is noninvasive and harmless to the patient as opposed to sitting there while he may be infarcting.

Sorry again man and your thought process was really impressive!

 

[Labslave]

Yea I feel like I may be able to walk in on my first day and not be totally clueless. I also agree that a big part of the challenge is actually being comfortable with decisions. I remember plenty of times when I was the first one to make a decision that of course needed approval. I came in one morning and this guy was c/o chest pain & SOB. He was admitted the prior day for a STEMI in which they did an angioplasty. I ordered a stat EKG and cardiac enzymes (I did the whole set but I was looking at the CK-MB the most) since I was concerned may be he was having another infarction. In that circumstance, I put the orders in and told the nurses. They did the EKG right away and drew blood for the enzymes. After that was all done I paged my senior immediately and she then approved the orders.

I felt at that time there was no harm in drawing blood and getting an EKG without approval. His EKG showed no changes from the prior day and his enzymes were negative x 3. Sometimes I feel there are cirumstances that call for immediate intervention and I didn't want to wait for the senior to sign on to a computer to approve the orders. Drawing blood and getting an EKG is noninvasive and harmless to the patient as opposed to sitting there while he may be infarcting.

Sorry again man and your thought process was really impressive!

I think not feeling totally clueless is about as much as we can hope for at this point. For what it's worth, it looks like you're well on your way!

Getting back to Step II stuff, I think things like this really illustrate how knowing too much can actually hurt you on this exam. There were so many questions of the 'what's your next step?' variety in which I remember thinking, "Yeah, well in the real world I would want to all of these things." I used my subI experiences to help with clinical context (and don't get me wrong, I think it helped a ton), but if I had chosen answers on my exam as I would have chosen them in real life, I wouldn't have done nearly as well. I guess what I'm saying is that for future exam takers, don't just blindly pick an answer choice based on what you've seen in the hospital unless you have verified that with questions/reading or have no other information to go on. Often times, people don't practice what's preached and vice versa.