Deresuscitation

[Radetzky]

How aggressive do you all think we should be with removing volume in our patients (post resolution of initial shock/hemodynamic instability)?

I was initially quite in favour of aggressive deresuscitation but Ive grown a little more cautious recently (eg ischemic guy in the context of having a lot of litres removed over a short space of time).

I’m not talking about your CHF patient or your cardiorenal pt or your ARDS pt. I’m talking about your general fluid balance positive edematous icu patient. Do you guys think that aggressively pursuing a negative fluid balance is actually beneficial? The studies are kind of mixed and contradictory so interested to hear what others’ practice is.

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[jdh71]

Define “aggressive”

I shoot for 1.5-2.0L off per day, MAX, if I had to give them a bunch to save them and now they clearly don’t need it.

Things that, obviously, help this are peeling back any drips as soon as possibly. I’m always asking myself what *really* needs to go in IV.

 

[leviathan]

Lots of studies correlating positive fluid balance with worse outcomes. Yes correlational studies but I remember one that showed it didn't matter if it happened spontaneously, with lasix, or with hemodialysis, all groups did better if the fluid was coming off.

 

[gro2001]

How aggressive do you all think we should be with removing volume in our patients (post resolution of initial shock/hemodynamic instability)?

I was initially quite in favour of aggressive deresuscitation but Ive grown a little more cautious recently (eg ischemic guy in the context of having a lot of litres removed over a short space of time).

I’m not talking about your CHF patient or your cardiorenal pt or your ARDS pt. I’m talking about your general fluid balance positive edematous icu patient. Do you guys think that aggressively pursuing a negative fluid balance is actually beneficial? The studies are kind of mixed and contradictory so interested to hear what others’ practice is.

I don’t think there is one size fits all solution here. Have to try to figure out their actual volume status, not just the balance during the hospital stay. Some folks who have been gradually getting sicker for days prior to the admission, might be coming in way volume down, so getting them to net even might be harmful, since their actual weight might be higher than admission. The opposite may be true with someone whos received aggressive volume resuscitation by EMS, in the ED, or in the OSH prior to transfer, which might not be reflected in your ins/outs.

Then you also have to think about physiology. Some patients might benefit with a zero to slightly positive balance (spasming SAH, severe AS, etc). Others I would err on the side of keeping dry (dry lungs work better than wet lungs).

I tend to dieurese until something tells me to stop: BUN/creatinine ratio starts rising, or they demonstrate themselves to be hypovolemic in some other way. My thinking is I can give back fluid really quickly if I had to, so I err on the side of drying them out (unless I think they are going to be very preload dependent for some reason).