Heart failure, with fluid overloading

Indications for renal replacement therapy in the acute setting and for other disease processes are different from those for ESRD. A common mode of ESRD therapy in the outpatient setting is intermittent hemodialysis (IHD) where a patient receives intense treatment over the course of a few hours several times a week. Acute renal failure in the inpatient setting is often treated with continuous renal replacement therapy (CRRT), which is applied for the entire duration of the patient s clinical need and relies upon hemofiltration to a higher degree than IHD (Meyer, 2000). Other nonrenal indications for CRRT are based on the theoretical removal of inflammatory mediators or toxins and elimination of excess fluid (Schetz, 1999). These illnesses include sepsis and systemic inflammatory response syndrome, acute respiratory distress syndrome, congestive heart failure with volume overload, tumor lysis syndrome, crush injury, and genetic metabolic disturbances (Schetz, 1999). 

For patients with fluid deficits, it is safer and more cost-effective to correct fluid abnormalities using standard intravenous fluids (e.g., sodium chloride 0.9% in water, dextrose 5% in water, and lactated Ringer s solution). Minimizing fluid volume in PN may be indicated in patients with fluid overload, such as critically ill patients who receive large-volume resuscitation fluids, patients with oliguric (urine output less than 400 mL/day) or anuric (urine output less than 50 mL/day) renal failure, and those with congestive heart failure. It is reasonable to... 

Thiazide diuretics are ineffective once the GFR becomes less than 25 mL/min, and loop diuretics are often used at high doses (e.g. furosemide 500 mg to 1 g daily) to gain an effect. Metolazone is effective when combined with a loop diuretic. Potassium-sparing diuretics such as amiloride are not recommended. Spironolactone is not generally used, but is beneficial in low dose for the treatment of heart failure even in patients on dialysis. Beta-blockers and calcium channel blockers are generally well tolerated. Any ankle swelling with calcium channel blockers must not be confused with fluid overload. 

Heart failure is a clinical syndrome characterized by a history of specific signs and symptoms related to congestion and hypoperfusion. As HF can occur in the presence or absence of fluid overload, the term heart failure is preferred over the former term congestive heart failure. Heart failure results from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.1 Many disorders such as those of the pericardium, epicardium, endocardium, or great vessels may lead to HF, but most patients develop symptoms due to impairment in left ventricular (LV) myocardial function. 

The mainstay of treatment for vaso-occlusive crisis includes hydration and analgesia (see Table 65-7). Pain may involve the extremities, back, chest, and abdomen. Patients with mild pain crises may be treated as outpatients with rest, warm compresses to the affected (painful) area, increased fluid intake, and oral analgesia. Patients with moderate to severe crises should be hospitalized. Infection should be ruled out because it may trigger a pain crisis, and any patient presenting with fever or critical illness should be started on empirical broad-spectrum antibiotics. Patients who are anemic should be transfused to their baseline. Intravenous or oral fluids at 1.5 times maintenance is recommended. Close monitoring of the patient s fluid status is important to avoid overhydration, which can lead to ACS, volume overload, or heart failure.6,27... 

Fluid overload occurs commonly in patients with renal failure, often in the absence of associated heart disease. If salt and water intake is not controlled in the patient who is oliguric or anaemic, plasma volume and symptoms of congestive heart failure ensue. Hypertension and coronary heart disease with increasing age contributes to the congestive heart failure. Diuretics like loop-diuretics or metolazone may be of value. Digitalis should be used with caution in patients on dialysis as cardiac arrhythmias may ensue in patients receiving dialysis in the presence of hypokalemia. 

In five of eight patients treated with fresh frozen plasma to achieve rapid correction of anticoagulation after warfarin-related intracranial hemorrhage, there were complications of fluid overload (10). In two of these patients congestive heart failure developed, resulting in myocardial infarction and renal insufficiency respectively. Two patients had supraventricular tachy-dysrhythmias and one developed pulmonary edema. 

Cardiovascular disease mortality, accounting for 50% of all deaths in ESRD, is defined by death caused by arrhythmias, cardiomyopathy, cardiac arrest, myocardial infarction, atherosclerotic heart disease, and pulmonary edema. Patients with ESRD should be considered in the highest risk group for subsequent cardiovascular events. Among dialysis patients, the prevalence of congestive heart failure is approximately 40%. Both coronary artery disease and LVH are risk factors for the development of heart failure. In practice, it is difficult to determine whether cardiac failure reflects left ventricular dysfunction or extracellular fluid volume overload. 

One must keep in mind that older patients with uric acid kidney stones also may have hypertension, congestive heart failure, or renal insufficiency, and obviously should not be exposed to overload with aUcalinizing sodium salts or unlimited fluid intake. Acetazolamide, a carbonic anhydrase inhibitor, produces rapid and effective urinary alkalinization and sometimes is used in conjunction with alkali therapy. When a 250-mg dose of acetazolamide is given at bedtime, the excretion of an acidic urine in the early morning hours is avoided. The usual tachyphylaxis (rapid tolerance) to this drug is obviated by a daily repletion dose of bicarbonate. 

Cardiovascular Cardiomegaly, myocardial ischemia, murmurs, and abnormal electrocardiogram patients with SCD have lower blood pressure (BP) than the normal population normal BP values for SCD should be used for diagnosis of hypertension ("relative" hypertension) heart failure usually is related to fluid overload... 

Congestive heart failure is common and is related to fluid overload, hypertension, or atherosclerosis. Some workers have postulated a uremic cardiomyopathy. The enhancement by parathormone of cellular calcium uptake may contribute to myocardial calcification, degeneration, and fibrosis (M26). There is a higher incidence of calcification of the aortic and mitral valves, as well as of visceral and peripheral arteries in association with uremic hyperparathyroidism (M13). In addition to PTH, middle molecules (B19), phenols (L3), guanidino-succinic acid (K5), or cobalt (P6) may contribute to the observed cardiotoxicity in vitro of uremic serum. 

Diuretics are used clinically to treat hypertension (see Chapter 32) and to reduce edema associated with cardiac, renal, and hepatic disorders. Three fundamental strategies exist for mobilizing edema fluid correct the underlying disease, restrict Na intake, or administer diuretics. The most desirable course of action would be to correct the primary disease however, this often is impossible. Restriction of Na+ intake is the favored nonpharmacologic approach to the treatment of edema and hypertension and should be attempted however, compliance is a major obstacle. Diuretics therefore remain the cornerstone for the treatment of edema or volume overload, particularly that owing to congestive heart failure, ascites, chronic renal failure, or nephrotic syndrome. 

Cor pulmonale is right-sided heart failure, often secondary to chronic obstructive pulmonary disease (COPD). Because mannitol pulls fluid off the brain, it may lead to a circulatory overload, which the heart with right-sided failure could not handle. This client would need an order for a loop diuretic to prevent serious cardiac comphcations. 

Mannitol is an osmotic diuretic and works by pulling fluid from the tissues into the blood vessels. Clients diagnosed with heart failure or who may be at risk for heart failure may develop fluid volume overload. Therefore, the nurse should assess lung sounds before administering this medication. 

Therapy, treatment of diseases that are associated with body fluid overload, congestive heart failure... 

Figure 10.29 (a) Fluid index and impedance over 6 months (b) example of impedance reduction before heart failure hospitalization (arrow) for fluid overload and impedance increase during intensive diuresis during hospitalization. Reproduced with permission Yu et al. (2005). 

Cardiovascular—jugular venous distension, edema, skin cool and pale, with decreased capillary refill (> 4 seconds) Signs of hypovolemia and possible heart failure, hypertension may be present if fluid overload... 

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