Should fluids be administered in a patient with urosepsis, acute kidney injury (AKI), and pulmonary edema?

From the Guidelines

In urosepsis with AKI and pulmonary edema, fluid management should be cautious and conservative, with initial resuscitation using limited crystalloid fluids (500-1000mL) to maintain organ perfusion, as recommended by the Surviving Sepsis Campaign guidelines 1. This approach is supported by the KDIGO practice guideline, which suggests using isotonic crystalloids rather than colloids for expansion of intravascular volume in patients at risk for AKI or with AKI 1. The goal is to provide enough circulatory support for sepsis management while avoiding exacerbation of pulmonary edema and further kidney injury from fluid overload.

Key considerations in fluid management include:

• Using crystalloids as the first-line fluid for resuscitation, as they are recommended by the Surviving Sepsis Campaign guidelines 1 and the KDIGO practice guideline 1
• Avoiding colloids, such as albumin or starches, due to the lack of evidence supporting their superiority over crystalloids and the potential for adverse effects 1
• Monitoring patients closely, including hourly urine output, serial physical exams for edema and crackles, and daily weights, to assess the effectiveness of fluid management and adjust the approach as needed
• Considering the use of diuretics, such as furosemide (20-40mg IV), if pulmonary edema worsens, as they may be beneficial in managing volume overload in patients with AKI 1

The use of vasopressors, such as norepinephrine (starting at 0.05-0.1 mcg/kg/min), should be considered if the patient remains hypotensive after initial fluid challenge, to provide additional circulatory support. Nephrology and critical care consultation is advisable for complex cases requiring renal replacement therapy. By taking a cautious and conservative approach to fluid management, clinicians can balance the competing concerns of sepsis, pulmonary edema, and AKI, and provide optimal care for patients with urosepsis and AKI.

From the FDA Drug Label

Adults: Parenteral therapy with Furosemide Injection should be used only in patients unable to take oral medication or in emergency situations and should be replaced with oral therapy as soon as practical. Acute Pulmonary Edema The usual initial dose of furosemide is 40 mg injected slowly intravenously (over 1 to 2 minutes). If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).

The management of urosepsis with AKI and pulmonary edema requires careful consideration of fluid management. While furosemide can be used to treat pulmonary edema, the decision to run fluids should be based on the patient's individual needs and response to treatment.

• The use of diuretics like furosemide may help alleviate pulmonary edema, but it may not address the underlying cause of urosepsis.
• Fluid management in sepsis typically involves administering fluids to support blood pressure and perfusion, but in the presence of pulmonary edema, this must be done cautiously to avoid worsening the condition.
• The FDA drug label for furosemide does not provide direct guidance on fluid management in urosepsis with AKI and pulmonary edema 2.

From the Research

Fluid Resuscitation in Urosepsis with AKI and Pulmonary Edema

• The decision to run fluids in urosepsis with Acute Kidney Injury (AKI) and pulmonary edema is complex and requires careful consideration of the patient's volume status and renal function 3, 4.
• Appropriate fluid resuscitation is important to prevent further kidney damage in patients with sepsis-associated AKI 3.
• However, aggressive volume resuscitation may contribute to end-organ dysfunction, and the practice of early goal-directed therapy may offer no benefit over conventional therapy and may be harmful 5.
• A positive fluid balance is associated with an increased risk of AKI and is a negative predictor for recovery of renal function 6.
• The role of fluid resuscitation on kidney injury stems from the high renal vulnerability to hypoxemic injury, and fluids have a poor oxygen solubility and hemodilution decreases blood viscosity, promoting intrarenal shunting and heterogeneity 6.
• General management principles for AKI include determination of volume status, fluid resuscitation with isotonic crystalloid, treatment of volume overload with diuretics, and discontinuation of nephrotoxic medications 4.