Fluid management monitoring

Supportive care goals for the critically ill patient with ARF include aggressive fluid management. Cardiac output and blood pressure must be supported to allow for adequate tissue perfusion. However, a fine balance must be struck in this regard. For example, fluids must be typically restricted in anuric and ohguric patients unless the patient is hypovolemic or is able to achieve fluid balance via renal replacement therapy. If fluid intake is not minimized, edema rapidly occurs, especially in hypoalbuminemic patients. In contrast, vasopressors like dopamine >2 mcg/kg per minute or norepinephrine are used to maintain adequate tissue perfusion, but may also induce kidney hypoxia via a reduction in renal blood flow. Consequently, S wan-Ganz monitoring is essential for critically ill patients. 

The Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN, 2014) report advises that extremely unwell patients should be managed on a Specialist Eating Disorder Unit (SEDU) unless they need interventions only available in a medical hospital, e.g. IV fluids, cardiac monitoring. 

MANAGING DIARRHEA. Measures to manage diarrhea include a low-residue diet while the bowel rests. Electrolytes are monitored and supplemented as needed. Adequate hydration must be maintained intravenous fluids may be necessary. If diarrhea is severe, therapy may be delayed or stopped or the dose decreased. 

Most patients require aggressive fluid resuscitation during the first 24 h of management. Input/output ratios are not useful during this time period. Monitor for evidence of systemic or pulmonary edema... 

The role of diuretics in the management of SVCS is controversial. While patients may derive symptomatic relief from edema, complications such as dehydration and reduced venous blood flow may exacerbate the condition. If diuretics are used, furosemide is used most frequently with diligent monitoring of the patient s fluid status and blood pressure. 

The management of toxicity requires monitoring of electrolytes, regular CNS observations, use of anticonvulsants should seizures occur, increased fluid intake to promote excretion (unless renal function is impaired) and cardiac monitoring. Haemodialysis should be considered if conservative measures are ineffective or serum lithium is above 3.0 mmol L-l. However, it may be of limited additional value as the volume of distribution of lithium is high. 

The general management of hypertensive emergencies requires monitoring the patient in an intensive care unit with continuous recording of arterial blood pressure. Fluid intake and output must be monitored carefully and body weight measured daily as an indicator of total body fluid volume during the course of therapy. 

Antidiuretic hormone antagonists are used to manage SIADH when water restriction has failed to correct the abnormality. This generally occurs in the outpatient setting, where water restriction cannot be enforced, or in the hospital when large quantities of intravenous fluid are needed for other purposes. Lithium carbonate has been used to treat this syndrome, but the response is unpredictable. Demeclocycline, in dosages of 600-1200 mg/d, yields a more predictable result and is less toxic. Appropriate plasma levels (2 mcg/mL) should be maintained by monitoring. Unlike demeclocycline, conivaptan is administered by IV injection, so it is not suitable for chronic use in outpatients. Lixivaptan and tolvaptan should soon be available for oral use. 

The early 1960 s saw the introduction of flame atomic absorption spectrometry (AAS) to clinical laboratories and this provided a sensitive yet simple analytical technique for the estimation of some trace elements in biological fluids. Trace elements is now perhaps an inaccurate description for those metals previously detectable in only small amounts when using older and less sensitive analytical techniques. Many such elements can now be estimated with precision and this has proved a great stimulus to trace-element research in clinical medicine. The number of trace elements known to be essential to man has doubled in the last twenty years [1]. Specific and treatable diseases are now known to be associated with excess or deficiency of trace elements and even in advanced societies dietary intake of some elements may be less than ideal [2]. Thus, monitoring of biological fluids for trace element levels in both health and disease can contribute towards major advances in nutritional management. 

Edwards RJ, Pople IK. Side-effects of risperidone therapy mimicking cerebrospinal fluid shunt malfunction implications for clinical monitoring and management. J Psychopharmacol 2002 16(2) 177-9. 

With chronic pain, monitoring tools such as the Brief Pain Inventory, Initial Pain Assessment Inventory, or McGill Pain Questionnaire may be useful. Quality of Ufe must also be assessed on a regular basis in all patients. The best management of opioid-induced constipation is prevention. Patients should be counseled on proper intake of fluids and fiber, and a laxative should be added with chronic opioid use. 

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