Dehydration and CHF

[WilcoWorld]

Are these conditions mutually exclusive?**If so, why do I see so many nursing home residents with edema, JVD, elevated BNP's (we're talkin' >600) but also with dry mucous membranes & elevated BUN/Cr ratios?

If it is something that can happen, how do you treat these people?

I suppose it's possible that someone with CHF could be tachypneic & a mouth breather, hence the dry mucosa. This same person could have little muscle mass and thus low Cr. So when the CHF leads to a decreased GFR & the BUN creeps up the low Cr causes a spuriously elevated BUN/Cr ratio, hence the person who is fluid overloaded may look dehydrated clinically... but that's a lot of ifs.

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[12R34Y]

Are these conditions mutually exclusive?**If so, why do I see so many nursing home residents with edema, JVD, elevated BNP's (we're talkin' >600) but also with dry mucous membranes & elevated BUN/Cr ratios?

If it is something that can happen, how do you treat these people?

I suppose it's possible that someone with CHF could be tachypneic & a mouth breather, hence the dry mucosa. This same person could have little muscle mass and thus low Cr. So when the CHF leads to a decreased GFR & the BUN creeps up the low Cr causes a spuriously elevated BUN/Cr ratio, hence the person who is fluid overloaded may look dehydrated clinically... but that's a lot of ifs.

This is fairly common (at least at my institution's ICU and ED). You get the guy who's got bad CHF, Cr 1.9 (baseline 1.2), hypo/hypertensive, look fluid up etc....

Problem is they are in a low cardiac output state thus not perfusing their beans very well. These are the nice candidates for dobutamine or some other inotropic support.

obviously this is an oversimplification, but lots of our CHF'ers are obviously fluid up and in failure, but hemodynamically stable and rising Cr. little milrinone or dobutamine and WAH-LA.

later

 

[roja]

Its been awhile since I reviewed this, but in general, CHF'ers are often dehydratd. Thier problem is not that they are fluid-overloaded but that thier fluid is misplaced- thier lungs and backing up on the right side. Hence why many will say lasix should not be used, but things like ACE-I and nitro are key...

 

[wrested]

Yeah, I've come across that, too. "Volume overloaded but intravascularly depleted" is what I called it, I think.

You could theoretically give something like 25% albumin and try to use the colloid oncotic pressure to draw some of the interstitial fluid back into the vessels... but I don't know if there is any data to back that up. I think we tried it in the ICU, but I can't remember what happened thereafter...

On a slightly different note, people are also working on "small volume resuscitation" with hypertonic saline (so medics can carry it easier onto the battlefield and the like... along with PolyHeme, etc.). Probably not such a good idea in this case, though.

Any thoughts?