Diuresis in Critical Care - Achieving a Negative Fluid Balance Advantages Of A Negative Fluid Balance: • Volume overload is very common in the later (e.g. de-escalation) phases of critical illness. Achieving a negative fluid balance is key to liberation from MV, mobility, & ultimate recovery. • In people with sepsis, AKI, or who are post-op, risk of mortality increased by 1.19x per liter of positive fluid balance. MINIMIZE INs: • USE FLUIDS PARSIMONIOUSLY IN RESUSCTIATION • SWITCH IV TO PO • USE HIGH CONCENTRATION MEDICATIONS • AVOID MAINTENANCE FLUIDS • REMOVE UNECCESARY MEDS MAXIMIZE OUTs: • Start with LOOP DIURETICS which are short acting and rapidly titrated to achieve UOP • Add a THIAZIDE to augment diuresis, address diuretic resistance, & to correct hyponatremia • Add a SPIRONOLACTONE (or ENaC INHIBITOR) to normalize Potassium homeostasis especially in high aldosterone states (CHF, Cirrhosis) • Add ACETAZOLAMIDE to correct a contraction metabolic alkalosis & further augment diuresis. • ULTRAFILTRATION is indicated for removal of fluids in volume overloaded patients who are refractory to diuresis. - Timing is controversial. Early nephrologv consult may be associated with improved survival in AKI. - Nick Mark MD @nickmmark #Diuresis #Negative #Fluid #Balance #management #criticalcare
