Wondering how you all approach those complicated patients who are total body overloaded but intravascularly dry, as there doesn't seem to be a great deal of evidence based medicine to guide us.
Let me give an example- patient with bad pancreatitis and hypoalbuminemic with an oxygen requirement and maybe a small effusion but otherwise not too terrible an Xray, who is persistently oliguric and has worsening renal function.
Common practice seems to be to keep giving fluids with the aim of maintaining a semblance of intravascular volume but this never seems to work IMO. Sometimes we give albumin but again I've never really seen this make a dramatic difference, and there's not too much literature out there.
Then there's the pieces out there like this one PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure that suggest these patients might actually be developing elevated intra-abdominal pressures that are actually responsible for the renal dysfunction which we are therefore making worse with our fluids. As much as this makes sense, diuresing these patients somehow feels wrong.
Curious as to your approaches. In my part of the world ICUs often won't accept 80 year olds with multiple comorbidities who often end up being exactly the population that develops these problems, so we are often left managing them on the wards.
Let me give an example- patient with bad pancreatitis and hypoalbuminemic with an oxygen requirement and maybe a small effusion but otherwise not too terrible an Xray, who is persistently oliguric and has worsening renal function.
Common practice seems to be to keep giving fluids with the aim of maintaining a semblance of intravascular volume but this never seems to work IMO. Sometimes we give albumin but again I've never really seen this make a dramatic difference, and there's not too much literature out there.
Then there's the pieces out there like this one PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure that suggest these patients might actually be developing elevated intra-abdominal pressures that are actually responsible for the renal dysfunction which we are therefore making worse with our fluids. As much as this makes sense, diuresing these patients somehow feels wrong.
Curious as to your approaches. In my part of the world ICUs often won't accept 80 year olds with multiple comorbidities who often end up being exactly the population that develops these problems, so we are often left managing them on the wards.