Decongestion and acetazolamide

[lymphocyte]

Really interesting trial from European Society of Cardiology. ADVOR. Adding acetazolamide 500mg IV daily + the usual IV frusemide resulted in higher rates of clinical decongestion at 3 days with no signals of harm in acute decompensated heart failure. I suspect this practice will become more widely adopted, even for garden variety ICU Michelin Man de-resuscitation. I usually reserved acetazolamide (at a higher dose) for managing alkalosis in diuresis but it might be worth giving a low dose up-front.

https://www.nejm.org/doi/10.1056/NEJMoa2203094

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[Katheudontas parateroumen]

Really interesting trial from European Society of Cardiology. ADOVAR. Adding acetazolamide 500mg IV daily + the usual IV frusemide resulted in higher rates of clinical decongestion at 3 days with no signals of harm in acute decompensated heart failure. I suspect this practice will become more widely adopted, even for garden variety ICU Michelin man de-resuscitation. I usually reserved acetazolamide (at a higher dose) for managing alkalosis in diuresis but it might be worth giving a low dose up-front.

https://www.nejm.org/doi/10.1056/NEJMoa2203094[

Nice I think I heard about this recently. Also interesting use of hypertonic saline with lasix was very effective and preserved Cr which is a bonus.

https://www.internationaljournalofcardiology.com/article/S0167-5273(14)00445-8/fulltext

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[chessknt]

I saw this the other day, agree it seems that if there is evidence for it then I'll be adding it on though I have rarely used it before.

 

[Drägerman]

Nice I think I heard about this recently. Also interesting use of hypertonic saline with lasix was very effective and preserved Cr which is a bonus.

https://www.internationaljournalofcardiology.com/article/S0167-5273(14)00445-8/fulltext

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“Hyperdiuresis” is an interesting theory with a small but growing body of evidence.

PulmCrit- Hyperdiuresis: Using hypertonic saline to facilitate diuresis

This is part of the PulmCrit Bleeding Edge series, which explores particularly controversial topics. Using hypertonic saline to facilitate diuresis seems

emcrit.org

 

[Radetzky]

Maybe I’m just cynical but i find it hard to get excited about a study that basically says “two diuretics result in more diuresis than one”.

Similarly the there’s some controversy around replicatability of the hypertonic results from a particular group of authors, and if you look closely at the others they either report change in Cr as the primary outcome (is this a meaningful outcome?) or the intervention group ends up getting higher doses of diuretics plus the numbers are extremely small.

IMO we haven’t even gotten the basics right yet, which include, don’t stop diuresis because the Cr rises, use big doses of loop diuretics, add in other diuretics that actually get rid of sodium early on, and give the pt time to refill their intravascular compartment if needed.

 

[lymphocyte]

Maybe I’m just cynical but i find it hard to get excited about a study that basically says “two diuretics result in more diuresis than one”.

Similarly the there’s some controversy around replicatability of the hypertonic results from a particular group of authors, and if you look closely at the others they either report change in Cr as the primary outcome (is this a meaningful outcome?) or the intervention group ends up getting higher doses of diuretics plus the numbers are extremely small.

IMO we haven’t even gotten the basics right yet, which include, don’t stop diuresis because the Cr rises, use big doses of loop diuretics, add in other diuretics that actually get rid of sodium early on, and give the pt time to refill their intravascular compartment if needed.

It's a cheap drug. No signals of harm. Two antiplatelet agents result in more antiplatelet activity than one but are not always better. Not sure why you're cynical.

The "basics" you talk about are not uncontroversial and the evidence isn't as clear cut as it is in this case, though I agree with some of those strategies.

 

[aafisahar]

Been doing this since like 2016 except use metolazone instead of diamox. **** gets people out of the hospital fast as ****.

 

[end stage fibro]

Been doing this since like 2016 except use metolazone instead of diamox. **** gets people out of the hospital fast as ****.

Whoa whoa… nephro is telling me max 1 to 2 L a day to minimize AKI 🤔

 

[aafisahar]

Whoa whoa… nephro is telling me max 1 to 2 L a day to minimize AKI 🤔

their wedge is 40, 1-2L might get him out of the hospital by Presidents' day