Pulmonary Edema / Fluid Overload

1. assess Airway, Breathing and Circulation

• check the patient’s airway patency and give oxygen via face mask or nasal cannula to improve their oxygen saturation. Oxygen is an important first step to stabilize the patient.
• monitor the patient’s vital signs closely – oxygen saturation, heart rate, blood pressure and urine output. Record the initial values and monitor them every 5-15 minutes.

2. Start 2 large bore IV lines

• this is a priority so I can administer IV fluids and medications. Having 2 IV lines allows for administration of different types of fluids and drugs.
• draw blood for full blood counts, electrolytes, creatinine, BUN and arterial blood gas analysis. The labs will give me important information on fluid status, organ function and acid base balance to guide further treatment.

3. Give IV furosemide 40mg to increase diuresis

1. as the patient is oliguric, IV diuretics are needed to offload excess fluid. Furosemide will help increase urine output.
2. Monitor the patient’s urine output closely after furosemide. I will assess their response and give additional doses of furosemide 20-40mg every 30-60 minutes based on volume status, labs and urine output. The goal is to achieve at least 100-150mL/hour.

4. Give IV fluids with half normal saline at 50-100 mL/hour initially

• 5 liters of IV fluids given likely caused fluid overload, so I will use half normal saline to help correct any electrolyte abnormalities like hyponatremia.
• I will start IV fluids at a slow rate and adjust based on urine output, labs and the patient’s volume status. The goal is to match urine output with IV fluid rate.

5. Monitor for signs of pulmonary edema and treat aggressively

• listen to the lungs for crackles, monitor oxygen saturation for signs of worsening.
• If pulmonary edema develops, I will give IV furosemide, morphine 2-5mg IV and nitrates 5-10mg sublingually to help relieve venous congestion and bronchodilation. Nitroglycerin IV infusion may also be needed.

6. Perform an urgent ECG

• to rule out myocardial ischemia as a cause of hypertension and tachycardia which can make fluid overload management more complex.

7. Consider specialist consult

• If the patient does not improve with initial management, I will call cardiology and nephrology for further guidance. Refractory cases may require more aggressive diuresis, inotropic support or even renal replacement therapy.

Based on the symptoms you have described, it sounds like the patient is experiencing a complex and potentially life-threatening medical condition that requires immediate attention. The combination of hypertension, tachycardia, desaturation, and oliguria suggests that the patient may be experiencing a fluid overload syndrome, which can be caused by a variety of factors, including excessive fluid administration, impaired kidney function, and heart failure.

As the first step, I would assess the patient’s airway, breathing, and circulation to ensure that they are stable. If the patient is hypoxic, I would provide supplemental oxygen via a nasal cannula or non-rebreather mask to improve their oxygen saturation. I would also monitor the patient’s blood pressure, heart rate, and urine output to assess their hemodynamic status.

Next, I would review the patient’s medical history to determine if there are any underlying conditions that may be contributing to their symptoms. This may involve reviewing the patient’s medication history, laboratory results, and imaging studies to identify any potential causes of their fluid overload.

In terms of treatment, the first step would be to reduce the patient’s fluid intake and increase their urine output. This may involve administering diuretics, such as furosemide, to promote diuresis and reduce fluid overload. However, given that the patient is already on furosemide and appears to be refractory to this treatment, alternative strategies may be required.

One potential approach would be to perform renal replacement therapy, such as hemodialysis or continuous renal replacement therapy, to remove excess fluid and correct any electrolyte imbalances. This may be particularly effective if the patient has impaired kidney function or if diuretic therapy has been ineffective.

In addition to fluid management, it may be necessary to address any underlying causes of the patient’s symptoms, such as heart failure or sepsis. This may involve administering medications to improve cardiac function, such as inotropes, or treating any underlying infections with antibiotics.

Overall, the management of this patient requires a comprehensive and multidisciplinary approach that addresses both the underlying causes of their symptoms and the immediate hemodynamic concerns. Close monitoring of the patient’s vital signs, urine output, and laboratory parameters is essential to guide ongoing management and ensure a positive outcome.