As a critical care pharmacist, you will see more emphasis on using de-resuscitation as part of fluid stewardship in critically ill patients. Positive fluid balance in ICU patients is linked to poor outcomes, such as increased mortality and length of stay. Continue to promote judicious fluid use. For example, stop maintenance fluids that aren’t necessary and minimize hidden fluids from med diluents, such as by switching IV medications to oral (PO). If patients develop fluid accumulation, the jury’s still out on the best way to de-resuscitate, since there’s limited evidence.
Consider these practical strategies. Think of an IV loop diuretic first. Use a standard dose, such as furosemide 40 mg. If patients have declining kidney function, start with a higher dose, such as furosemide 60 mg or 80 mg. Or if patients take a loop diuretic at home, use twice their home dose, due to tolerance. For instance, start with 60 mg IV for 60 mg oral doses at home since IV is about twice as much as oral. Double the dose every 1 to 2 hours as needed until reaching about furosemide 200 mg IV per dose or its equivalent. Going higher usually isn’t more effective.
If fluid balance is still positive, add an oral thiazide, such as metolazone 5 mg daily. Save IV chlorothiazide for NPO patients. It seems to work as well as metolazone, but costs much more. Don’t usually switch to another loop diuretic, there aren’t data to show switching IV loops for de-resuscitation is helpful. And don’t automatically START with a loop diuretic continuous infusion. It may increase urine output more than intermittent doses, but doesn’t have better outcomes and may be less convenient.
If your patient develops metabolic alkalosis on a loop diuretic, consider adding acetazolamide. Monitor electrolytes, especially potassium and magnesium. Add a nurse-driven replacement protocol during de-resuscitation.
REFERENCES
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Bissell BD, Laine ME, Thompson Bastin ML, Flannery AH, Kelly A, Riser J, Neyra JA, Potter J, Morris PE. Impact of protocolized diuresis for de-resuscitation in the intensive care unit. Crit Care. 2020 Feb 28;24(1):70. Available at: https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-2795-9
Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, Blackwood B, Fan E. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. Available at: https://pubmed.ncbi.nlm.nih.gov/27734109
Bissell BD, Donaldson JC, Morris PE, Neyra JA. A narrative review of pharmacologic de-resuscitation in the critically ill. J Crit Care. 2020 Oct;59:156-162. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0883944120306079?via%3Dihub
Silversides JA, McAuley DF, Blackwood B, Fan E, Ferguson AJ, Marshall JC. Fluid management and deresuscitation practices: A survey of critical care physicians. J Intensive Care Soc. 2020 May;21(2):111-118. Available at: https://pubmed.ncbi.nlm.nih.gov/32489406
Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014 Nov-Dec;46(5):361-80. Available at: https://pubmed.ncbi.nlm.nih.gov/25432556