ACHIEVING A NEGATIVE FLUID BALANCE by Nick Mark MD ONE onepagericu.

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ADVANTAGES OF A NEGATIVE FLUID BALANCE: In people with sepsis, AKI, or who are post-op, risk
• Volume overload is very common in the later of mortality increased by 1.19x per liter of positive Evaluation of a patient with
Optimize renal perfusion
(e.g. de-escalation) phases of critical illness. fluid balance. Fluid overload (FO) is defined as: Perfusion = MAP - CVP
INs diuretic resistance
• Achieving a negative fluid balance is key to OUTs 𝑭𝒍𝒖𝒊𝒅 𝑰𝒏 − 𝑭𝒍𝒖𝒊𝒅 𝑶𝒖𝒕 Keep MAP > 65mmHg,
𝑭𝑶(%) = ∗ 𝟏𝟎𝟎 R/o compression reduce venous congestion
liberation from MV, mobility, & ultimate 𝑰𝑪𝑼 𝒂𝒅𝒎𝒊𝒕 𝒘𝒕 POCUS exam to look (via fluid removal)
recovery. for tense ascites or
other etiologies
MINIMIZE INS MAXIMIZE OUTS
USE FLUIDS PARSIMONIOUSLY IN RESUSCITATION Start with LOOP DIURETICS which are short
Assess fluid responsiveness and/or fluid tolerance prior to BOLUS LOOP acting and rapidly titrated to achieve UOP
DIURETIC If no Exclude obstruction
boluses (goal directed instead of empiric fluids); examples
response, FUROSEMIDE – Start with 20-40 mg IV (diuretic POCUS exam of
include VExUS, Lung B-lines, EtCO2, PPV, PAC, NICOM, etc naïve), higher doses required in renal failure bladder and kidneys
double
Assess the dose (dose = 30*Cr) or if on home diuretics (dose = 2x to look for
SWITCH IV TO PO home dose); double dose q2 hrs until response hydronephrosis
UOP q 2hr
Earlier IV to PO transitions can limit IV fluids. Antibiotics & or maximum dose reached (160-200 mg); 5-40
electrolytes replacements can be large volumes (>1 L/day) Once an effective mg/hr (rebolus w/ increases), duration 6-8 hrs
Sequential targeting
dose is found BUMETANIDE – Start with 1 mg, max dose 10
of the nephron with
Schedule more mg; 0.5-2mg/hr, duration 6-8 hrs
USE HIGH CONCENTRATION TORSEMIDE – Start with 10-20 mg, max dose diuretics
BOLUSES or DCT PCT
MEDICATIONS 100-mg; duration 4-6 hrs
start DRIP
NORepinephrine
Concentrate medications for CVCs. Equivalent dosing of loop diuretics: furosemide 40 mg PO = furosemide 20 mg IV =
bumetanide 1 mg PO/IV = torsemide 20 mg PO/IV = ethacrynic acid 50 mg IV/PO NCC
4mg 250mL
L o re m ip s u m d o lo r s it a m e t, c o n s e c te tu r

a d ip is c in g e lit, s e d d o e iu s m o d te m p o r 0.9% Sodium

Vasopressors, abx, & electrolyte
replacement can be concentrated
in c id id u n t u t la b o re e t d o lo re m a g n a a liq u a .

Na > 135 or resistant Add a THIAZIDE to augment diuresis, address

Chloride
CA IV
U t e n im a d m in im ve n ia m , q u is n o s tru d
e x e rc ita tio n u lla m c o la b o ris n is i u t a liq u ip e x

e a c o m m o d o c o n s e q u a t. D u is a u te iru re

Injection USP ENac

(e.g. at ‘maximum’ dose, 16 mg
1000mL

to LOOP diuretic? diuretic resistance, & to correct hypernatremia

L o re m ip s u m d o lo r s it a m e t,
c o n s e c te tu r a d ip is c in g e lit, s e d d o

e iu s m o d te m p o r in c id id u n t u t la b o re
e t d o lo re m a g n a a liq u a . U t e n im a d

norepinephrine saves 2.1 L/day

m in im ve n ia m , q u is n o s tru d

CHLORTHIAZIDE 500-1000mg IV daily, duration

e x e rc ita tio n u lla m c o la b o ris n is i u t
a liq u ip e x e a c o m m o d o c o n s e q u a t.
D u is a u te iru re d o lo r in re p re h e n d e rit

in vo lu p ta te ve lit e s s e c illu m d o lo re e u

consider
f u g ia t n u lla p a ria tu r. E x c e p te u r s in t

compared to standard 4 mg conc)

o c c a e c a t c u p id a ta t n o n p ro id e n t, s u n t
in c u lp a q u i o f f ic ia d e s e ru n t m o llit

is 50-60 hrs
a n im id e s t la b o ru m .

THIAZIDE CD
METOLAZONE 5-10 mg PO daily, lasts 24-48 hrs
AVOID MAINTENANCE FLUIDS INDAPAMIDE – 5-10 mg PO daily
ICU patients seldom require MIVF High Aldo or low K Add a SPIRONOLACTONE (or ENaC INHIBITOR) NKCC
to replace insensible losses. MIVF with diuresis? to normalize Potassium homeostasis especially
can be a huge fluid load. Even consider in high aldosterone states (CHF, Cirrhosis) LoH
“KVO” infusions can be significant SPIRONOLACTONE SPIRONOLACTONE – 25-100mg PO daily; ideal

(e.g. 15 ml/hr = 2.7 L/week)
REMOVE UNECCESARY MEDS
Consider removing unnecessary
IV meds to limit fluids. (e.g. low
dose esmolol gtt can be 750
ml/day)
On rounds, always try to
reduce the number of
infusion pumps attached
to the patient
v1.4 (2020-10-22)
furosemide:spironolactone ratio is 20:50
AMILORIDE – 5-10 mg PO daily
Metabolic
alkalosis? Add ACETAZOLAMIDE to correct a contraction
metabolic alkalosis & further augment diuresis.
consider
ACETAZOLAMIDE – 500 mg IV daily; increase to SPECIFIC CIRCUMSTANCES
ACETAZOLAMIDE
maximum of 500 mg TID Hypoalbuminemia – use bumetanide over
Diuretic
furosemide (less albumin binding)
refractory? ULTRAFILTRATION is indicated for removal of Cirrhosis – be cautious about over diuresis
Consider fluids in volume overloaded patients who are (risk for hepatorenal sx); use a 50:20 ratio
ULTRAFILTRATION refractory to diuresis. of spironolactone:furosemide; check urine
& RRT Timing is controversial. Early nephrology consult Na/K to evaluate efficacy of diuresis
may be associated with improved survival in AKI. Nephrotic Sd – 2x doses of loop diuretics