Diagnosis

Hypervolemia

Etiology

Causes [sre]

• IV therapy (ICU patients, sepsis, postoperative)

• High Na inntake

• Heart failure

• Renal failure (sodium/water retention)

• Liver failure

• Surgical impact (inflammation, trauma) impair the competence of the vascular barrier --> capillary leakage and protein-rich interstitial edema --> perioperative increase in body weight

Pathophysiology [v3w]

1. Total body volume of an adult:

   • The plasma and red blood cells: 5 l

   • Extracellular space: 15 l

   • Intracellular volume: 25 l

2. A volume of 500 ml saline or albumin infused into the circulation --> all three fluid compartments may be affected

3. Extravasation of fluid:

   • Hydrostatic pressure difference

   • Vascular permeability: sepsis, endotoxemia, systemic capillary leak syndrome

4. Extravascular to intravascular influx of fluid:

   • Colloid oncotic pressure gradient

5. Fluid overload may cause:

   • Reduced microcirculation

   • Increaesed hematocrit >70% --> risk of thrombosis

Complications [ney][agb][nrh]

• Pulmonary edema

• Pneumonia

• Wound infection

• Acute decompensated heart failure

• Anastomotic insufficiency

• Postoperative ileus

• Extremity/abdominal compartment syndrome

• Length of hospital stay

• Duration of mechanical ventilation

• Mortality

Epidemiology

Incidence per 100.000 [agk]

Approach

• Serial weight measurement [sre]

• Cumulative fluid balance

• Blood test: Electrolytes, creatinine, hematocrit

• ECG

• Chest x-ray

• Lung ultrasound

• Echocardiography

• Urine microscopy

• Central venous or pulmonary artery wedge pressure

• Intra-abdominal pressure

• Bioelectrical impedance bodycomposition analysis (BIA): a noninvasive method of fluid assessment, can provide estimates of total-body, extracellular, and intracellular water to allow the quantification of fluid overload and setting of dry weight

Treatment

1. Resuscitation of the critically ill with volume restriction: [sre]

   1. Rescue phase: fluid therapy is provided emergently during acute clinical instability

   2. Stabilization phase: optimize the hemodynamic status and aim for an even or slightly negative fluid balance

   3. De-escalation phase: aim to mobilize accumulated fluid during the initial resuscitation

2. Fluid removal: depend on renal function, urine output, and severity of fluid overload

   1. Diuretics: 1.0 to 1.5 mg/kg furosemide

   2. Hemodialysis:

      • Estimate the total quantity of fluid overload (volume of surplus)

      • The ability to remove fluid from the circulation without inducing hemodynamic instability (cardiac output and tissue perfusion)

Differential diagnoses

Acute liver failure, Asthma, Cancer origo incerta, Cirrhosis, COPD, Deep venous thrombosis, Diabetes insipidus, Fibrosing alveolitis, Heart failure, Hypothyroidism, Inferior vena cava syndrome, Lymphedema, Myocardial infarction, Nephrotic syndrome, Osmotic diuresis, Pneumonia, Portal hypertension, Postobstructive diuresis, Preeclampsia, Pregnancy, Pulmonary embolism, Renal failure