Volume State

This covers consideration for managing the volume state of the critically ill, considerations for fluid resuscitation are covered under Fluid.

De-Resuscitation

Diuresis:

  • Furosemide is the diuretic of choice for volume control
  • However, further issues may arise that require intervention:
    • Hypernatraemia
      • Furosemide produces dilute urine
        More water is eliminated relative to sodium (it’s dilute), resulting in concentration of ECF contents and ↑ Na+.
      • Correction of hypernatraemia classically requires administration of free water, which is inefficient
      • Consider a thiazide to ↑ renal sodium elimination
    • Metabolic alkalosis
      • Contraction alkalosis due to volume depletion
        ↑ Renal resorption of Cl- and HCO3-
      • Consider acetazolamide 250-500mg IV BD
    • Hypomagnesaemia/Hypokalaemia
      Often require repletion.

In the outpatient population, frusemide diuresis often leads to hyponatraemia - patients are thirsty from diuresis and drink large volumes of free water, thereby diluting their ECF.

Electrolytes:

  • Hypernatraemia
    • Treat with free water or IV dextrose

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.
  2. Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. New England Journal of Medicine. 2022;386(9):815-826. doi:10.1056/NEJMoa2114464
  3. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021;326(9):830-838.
  4. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021;326(9):818-829.