Large-volume diuresis is a topic that isn't discussed much in critical care curricula or textbooks. Nonetheless, this is a daily reality for intensivists, especially those living in the United States (where patients continue to be empirically treated with 30 cc/kg fluid as initial fluid bolus, for a broad variety of complaints). This chapter attempts to bridge the gap between most articles on diuresis (which focus largely on heart failure) and the realities of critical care medicine (where we are often struggling to reverse iatrogenic salt water drowning).
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The IBCC chapter is located here.
- The podcast & comments are below.
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I haven’t had time yet to read the whole thing, but I wholeheartedly agree that for massive diuresis (I call it “Dire Resis!” it is Lasix Q6 hours, PERIOD. One comment is that I don’t estimate some arbitrary daily goal (1-3 liters), but I estimate how much time we have in the hospital and how many liters they’re overloaded and divide the former by the latter – or, since those are hard to estimate I just go full bore to begin with and slow down if I think we get moving too fast. One comment on hypernatremia – my practice… Read more »
Hi, Josh! Fantastic post! I am glad to agree and practice such approach. I would just add an observation… I understand when you talk about hypernatremia in the ICU-hypervolemia-treatment-context, the recommendation of thiazide. The problem is: I have already encountered some misinterpretation about this issue, and some dehydrated patients being treated with thiazide. Nowadays, every time I talk about hypernatremia and thiazide, I begin asking what people have already heard about it, and then reinforce to always remember that the prototype patient of hypernatremia+thiazide is the hypervolemic HF treated solely with loop diuretics one. Maybe, such a mistake is not… Read more »
fantastic post for the physiology alone. making all my EM residents read this, as well as your ph guided fluids. thanks.
https://youtu.be/k_vF9s9Je3E
This nephrology pretty clever guy says better use once daily biger dose long acting Henlee loop diuretic..
Then several time smaller dose.
Thank you! We needed this so much in one place.
Any thoughts about SLGT II inhibitors for diuresis?
Hi Josh, what is the mechanism for hypernatremia in loop diuretic use? Im assuming the hypernatremia happens in between dosing of loop diuretics as most literature cites HYPOnatremia in loop diuretic use. if so, the mechanism would be an initial loss of free water and sodium with loops, followed by Na+ retention in between doses, thus creating a net increase in Na+. Is this the mechanism you’re speaking of? Just wanting to clarify as its a bit counter intuitive when thinking about the definitive mechanism of loops diuretics.
thanks!
anyone care to comment on the practice of adding albumin to the lasix pushes?