Limiting diuresis

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WheezyBaby

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Just wondering yalls thoughts / practice. I've had a few anasarcic obese chf exacerbations that appear to comfortably diurese 10-15 L/d (stable lytes, bicarb, renal fxn, vitals). My staff in these instances has had us back off of diuresis. Obviously the data points we follow to evaluate efficacy of and complications from diuresis aren't perfect indicators of fluid / lytes / etc shifts, but I haven't seen instances of harm coming from vigorous diuresis in absence of changes in those indicators. Have you all seen bad outcomes from I've diuresis in these situations / do you limit your rate of diuresis?

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We all have a dry weight. Hit it. Back off if your patient is orthostatic or creatinine bumps or muscle aches from Bumex. Otherwise offload them.
 
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Add in some acetazolamide in your baseline co2 retainers when you start seeing that bump up - limits the risk of further co2 retention/co2-narcosis.

Not an uncommon occurrence, but diuretic gtts in ppl vented/sedated will sometimes wake up asking why their ears are ringing - wellknown side affect
 
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Just wondering yalls thoughts / practice. I've had a few anasarcic obese chf exacerbations that appear to comfortably diurese 10-15 L/d (stable lytes, bicarb, renal fxn, vitals). My staff in these instances has had us back off of diuresis. Obviously the data points we follow to evaluate efficacy of and complications from diuresis aren't perfect indicators of fluid / lytes / etc shifts, but I haven't seen instances of harm coming from vigorous diuresis in absence of changes in those indicators. Have you all seen bad outcomes from I've diuresis in these situations / do you limit your rate of diuresis?

I diurese as clinically indicated as tolerated.

The goal is to treat fluid overload and that includes peripheral edema. This is very important because the readmission rate for CHF is too high. The answer to your question is to continue until the aforementioned goal is achieved or until a safe transition to outpatient care is possible.

Monitor for complications. Check lytes (including magnesium) on a daily basis.

Of course you are not going to keep the patient admitted for ever. Once the major symptoms are controlled, consider switching to oral medications and assess response to ensure you have found an appropriate outpatient dose. Don't be afraid to use torsemide or bumetanide. Ensure proper follow up (within a week) with heart failure clinic or patient's PCP/cardiologist.

These admissions are also a good time to ensure that the patient is on the right meds at the right doses (ACE/ARBS, BB, Spironolactone) and to assess for need for device therapy - AICD.

Remember to reduce the afterload if there's flash pulmonary edema or severe hypertension. There's more to acute CHF than diuresis.
 
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Just wondering yalls thoughts / practice. I've had a few anasarcic obese chf exacerbations that appear to comfortably diurese 10-15 L/d (stable lytes, bicarb, renal fxn, vitals). My staff in these instances has had us back off of diuresis. Obviously the data points we follow to evaluate efficacy of and complications from diuresis aren't perfect indicators of fluid / lytes / etc shifts, but I haven't seen instances of harm coming from vigorous diuresis in absence of changes in those indicators. Have you all seen bad outcomes from I've diuresis in these situations / do you limit your rate of diuresis?

Maybe your staff meant that you should be careful with your rate of diuresis, not just the amount. If your goal is to pull off 10L, it might be best to do that over the course of 48-72 hours, vice in 1 day, especially in a patient who's relatively asymptomatic, and who's been volume up for a long time (say many weeks, now just coming in). It's the old mantra of medicine...go low and go slow in correcting your problem, unless you have a dire reason to correct quickly (ie severe dyspnea, patient is getting intubated, an ICU player etc).

I also agree with the comment above about switching to PO diuretics ASAP, but be careful in the PRN instructions you give to your patients. I don't know how many times we've told patients to take an extra pill or two if they weigh them selves and note a XX lbs weight gain, only to learn later that they don't even have a good scale at home to weigh themselves on. Kinda silly! I just want to tell them to take everything scheduled!
 
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Not an uncommon occurrence, but diuretic gtts in ppl vented/sedated will sometimes wake up asking why their ears are ringing - wellknown side affect

Well known side effect sure... but the doses needed are massive and almost never hit clinically, unless multiple ototoxic meds are used.

The lasix drip dose needed to cause hearing loss is usually >4-5mg/min ( lasix drips are ordered in mg per HOUR)- so 240-300mg/h (Normal lasix drip doses are 10-40mg/h).Tinnitus doses are even higher. It is pretty rare to get this unless you are giving multiple other ototoxic drugs. Boluses are usually not reached until similarly massive doses. For instance, you get tinnitus at 3200 mg of a single IV bolus of lasix.

As to the OP, rapid diuresis is no problem as long as you are monitoring lytes, rhythm and are not pulling faster than the rate of intravascular re-uptake of peripheral edema. I can tell you I recently had a patient where we diuersed 10 liters each day on 2 conssecutive days and 7 liters on the third. She lost >50lbs in 3 days. No issues- i mean other than the fact that she had bad enough cardiomyopathy to be 100 lbs overloaded.

Commonly I see people get diuersed faster than the rate of re-uptake, creatinine bumps and they get changed to PO diuretics and sent out volume overloaded.
 
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are not pulling faster than the rate of intravascular re-uptake of peripheral edema. .

Well that's just it. How do you know that you're not pulling faster than the rate of intravasc re-uptake, at least when you initially admit the patient? Do you really want to diuress him that fast, on day 1?
 
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Well that's just it. How do you know that you're not pulling faster than the rate of intravasc re-uptake, at least when you initially admit the patient? Do you really want to diuress him that fast, on day 1?

Most of these people who diuse tons just respond to normal diuretic doses in a supranormal response. In terms of telling how much you can diurese, Part of it is based on exam, part on experience with that patient. If they have edema, they have >10-15 lbs of fluid to be diuersed at least, much of that can be taken on day 1.

If they are 100 lbs over their dry weight you can be pretty sure you can be aggressive with diuesis.
 
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Most of these people who diuse tons just respond to normal diuretic doses in a supranormal response. In terms of telling how much you can diurese, Part of it is based on exam, part on experience with that patient. If they have edema, they have >10-15 lbs of fluid to be diuersed at least, much of that can be taken on day 1.

If they are 100 lbs over their dry weight you can be pretty sure you can be aggressive with diuesis.
Arent there some studies using ultrasound to help determine endpoints for diuresis?
 
My record diuresis was 50 kilos off a 300 kilo person in ca 5 days. A lot of diamox was involved. Clinical outcome good, as far as it could be.
 
Thanks for yalls input

Well that's just it. How do you know that you're not pulling faster than the rate of intravasc re-uptake, at least when you initially admit the patient? Do you really want to diuress him that fast, on day 1?

Yes, my question was specifically regarding the rate of diuresis not total volume. My experience is similar to instate's, you give them a normal dose of diuretic and check in later and they nurses have changed 2 Foley bags. Their hemodynamics are fine and their bmp ends up fine. Some of my staff back off diuresis because the rate seems too fast without having markers to support that it actually is too fast
 
Thanks for yalls input



Yes, my question was specifically regarding the rate of diuresis not total volume. My experience is similar to instate's, you give them a normal dose of diuretic and check in later and they nurses have changed 2 Foley bags. Their hemodynamics are fine and their bmp ends up fine. Some of my staff back off diuresis because the rate seems too fast without having markers to support that it actually is too fast

It makes sense to slow down before causing damage rather than waiting until you cause damage before slowing down.
 
It makes sense to slow down before causing damage rather than waiting until you cause damage before slowing down.

Sure, if someone is trending in the wrong direction, but at the same time I've diuresed 10 L a day without even a wayward creep in markers, and in other patients you can't even get negative with spot intermittent diuresis without causing an aki. I don't have anything to tell me that 2L a day vs 5L a day is safer in a given patient beyond it tending to be my morbidly obese patients with a decent component of right sided failure that get anasarcic then happily diurese large volumes
 
Sure, if someone is trending in the wrong direction, but at the same time I've diuresed 10 L a day without even a wayward creep in markers, and in other patients you can't even get negative with spot intermittent diuresis without causing an aki. I don't have anything to tell me that 2L a day vs 5L a day is safer in a given patient beyond it tending to be my morbidly obese patients with a decent component of right sided failure that get anasarcic then happily diurese large volumes

Yeah this is my approach. Dry them out or else they’ll be there for weeks. I’m a little more careful with RV failure since they can become hypotensive and their Cr is sensitive... at which point doing SCUF is almost always necessary alas
 
No evidence to support the dogma that there is some magic max volume limit of diuresis per day.
 
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Thanks for yalls input

Yes, my question was specifically regarding the rate of diuresis not total volume. My experience is similar to instate's, you give them a normal dose of diuretic and check in later and they nurses have changed 2 Foley bags. Their hemodynamics are fine and their bmp ends up fine. Some of my staff back off diuresis because the rate seems too fast without having markers to support that it actually is too fast

The big problem is that your objective data for having done goofed is delayed for at least 24 hours the way we generally practice. The first time you box a set of beans nuking thing from orbit will be the last time you find yourself yawning when a patient dumps 5-10L.

I mean it's kind of a tautology: if you didn't hurt the kidneys, you didn't hurt them. It doesn't matter if they dumped 50L, right?

I tend to temper my practice toward the situation where I might do the most harm to a few given the scenario. Even if most patients will tolerate one thing, those that won't, won't. I like a nice 1.5 to 2.0 per day off when diuresing max, in most situations (sick hearts are a different nuanced beast), I rarely see kidney problems I can't bring the patient back from at those rates. That's not a rando double blind cross over bull**** trial either. Experience and anecdote you take with as much salt as you need.
 
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The big problem is that your objective data for having done goofed is delayed for at least 24 hours the way we generally practice. The first time you box a set of beans nuking thing from orbit will be the last time you find yourself yawning when a patient dumps 5-10L.

I mean it's kind of a tautology: if you didn't hurt the kidneys, you didn't hurt them. It doesn't matter if they dumped 50L, right?

I tend to temper my practice toward the situation where I might do the most harm to a few given the scenario. Even if most patients will tolerate one thing, those that won't, won't. I like a nice 1.5 to 2.0 per day off when diuresing max, in most situations (sick hearts are a different nuanced beast), I rarely see kidney problems I can't bring the patient back from at those rates. That's not a rando double blind cross over bull**** trial either. Experience and anecdote you take with as much salt as you need.

In patients with sick hearts I routinely will diurese 4-5 L a day. Yeah occasionally we bump the creatinine but usually it improves their CVP and actually improves renal function if anything. I see non cards docs super afraid to diurese (even in an ICU setting) aggressively and all it does is keep the patient there longer. But to each their own.
 
I have had great experience with aggressive lasix drip plus acetazolamide intermittently pulling off >8L per 24h in the non-ischemic cardiomyopathy folks (meth rocks!).
Just last week, I was taking off more than 8L for three days without any clinical or biochemical evidence of injury.
Of course, this is in the ICU, where I have complete control (ie q12h potassium, continuous tube feeds, freedom!).
HH
 
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