CONFLICTING FLUID PROBLEMS
A patient with extravascular expansion (3+ lower-extremity edema and pulmonary vascular congestion) secondary to congestive heart failure (CHF) also has intravascular depletion (creatinine 1.3 mg/dL, mucous membranes appear dry, heart rate 90-99 beats per minute, and low urine output). How should I go about correcting this patient’s fluid problem? What are your thoughts about using albumin followed by furosemide (Lasix)?
—Ed Soumi, MD, Las Vegas
The fact that this patient has continuing symptoms of both right and left heart failure (lower-extremity edema plus pulmonary vascular congestion) indicates the need for continued diuresis. I am not convinced that there is concomitant intravascular depletion since both sinus tachycardia and borderline creatinine values are seen with CHF. (Blood urea nitrogen is actually a better indicator of pre-renal dehydration.) Before proceeding further, I would want to know the etiology of the CHF (ischemic? cardiomyopathic? etc.) and have some measure of left ventricular function. If the serum albumin is not low, the combination of albumin and furosemide will not help—and may even make things worse. In summary, if this were my patient, I would seriously consider hospitalization with determination of cardiac output as well as pulmonary artery and systemic venous pressures, at a minimum. Right-heart catheterization would obtain these data. This could rule out intravascular depletion in the setting of CHF. I would also obtain an echocardiogram and a complete metabolic workup, including a liver panel, and proceed from there.
—Peter F. Cohn, MD (100-14)