Fluid management and deresuscitation practices – An opportunity for collaboration

We read with interest the findings of the survey by Silversides et al. ¹ and wish to raise consideration for an interdisciplinary approach to deresuscitation. The authors highlight several notable findings in their survey, including large variability in deresuscitation practice, with 14% of providers opting for fluid administration for diuretic un-responsiveness during fluid overload. Further, regarding diuretic selection for fluid removal, approaches also varied from 7.9% utilizing intermittent bolus diuretics and up to 53.7% utilizing continuous infusion diuresis with albumin concomitantly. ¹

We similarly surveyed 98 critical care clinical pharmacists in the American College of Clinical Pharmacy database. In alignment with these authors' findings, the majority of our respondents did not have a protocol or guideline for initiation of diuresis (68.8%) at their institution. Signs of edema were the most common indication for diuresis initiation (92.5%) and 31.3% of our respondents cited follow-up monitoring of diuretic effectiveness occurred 24 h after initiation or during next-day patient care rounds (Table 1). Over half of our cohort (56.8%) believed appropriate diuresis was administered within 72 h post-shock, while 30.9% believed patients received inadequate diuresis through the stay. The most common rationale for inappropriate diuresis were under-dosing and inappropriate frequency, while the largest perceived barrier was overall lack of education regarding the harm of fluid overload. Adjunctive agent use also varied (Table 2).

Table 1.

Approach to diuretic dosing and monitoring.

Characteristic	Response, n (%)
Institutional approach to diuresis (n = 93)
Mandated protocol	2 (2.2)
Non-mandated guideline	4 (4.3)
Published protocol (non-institutional)	2 (2.2)
Disease-state dependent protocol	1 (.1)
Cost restrictions	6 (6.5)
Pharmacy-provided education	20 (21.5)
Unsure	5 (5.4)
None	61 (65.6)
Other	2 (2.2)
Frequency of loop diuretic administration (n = 83)
Less than every 6 h	2 (2.4)
Every 6 h	11 (13.3)
Every 8 h	26 (31.3)
Every 12 h	43 (51.8)
Every 24 h	6 (0.2)
One-time dosage	51 (61.5)
Continuous infusion with bolus	25 (30.1)
Continuous infusion without bolus	13 (15.7)
Diuretic regimen efficacy assessment (n = 83)
Within 2 h	10 (12.1)
Within 6–8 h	36 (43.4)
Within 12 h	18 (21.7)
Within 24 h	17 (20.5)
Shift change	1 (1.2)
Subsequent day interdisciplinary rounds	9 (10.8)
Unsure	1 (1.2)
General volume assessment (n = 83)
During resuscitation only	15 (18.1)
Multiple times daily	30 (36.1)
Daily	46 (55.4)
Every 24–48 h	3 (3.6)
Once prompted	2 (2.4)
Upon finding volume overload indicators	37 (44.6)
Extubation potential	24 (28.9)
Unsure	2 (2.4)

Table 2.

Adjunctive agents utilized and indication (n = 83).

Indication	Acetazolamide (n = 63)	Albumin (n = 68)	Chlorothiazide (n = 57)	Metolazone (n = 72)
Failure to achieve target	3 (4.7)	16 (23.5)	37 (64.9)	60 (83.3)
Hepatorenal syndrome	0 (0.0)	51 (75.0)	1 (1.8)	5 (6.9)
ADHF	4 (6.4)	7 (10.3)	22 (38.6)	30 (41.7)
Serum bicarbonate	58 (92.1)	0 (0.0)	1 (1.8)	0 (0.0)
Serum sodium	1 (1.6)	2 (2.9)	11 (19.3)	19 (26.4)
Home regimen	4 (6.4)	0 (0)	7 (12.3)	20 (27.8)
Per mandated criteria	2 (3.2)	14 (20.6)	7 (12.3)	1 (1.4)
Other	5 (7.9)	11 (16.2)	5 (8.8)	3 (4.2)

Note: All responses presented as n (%) Table 2.

ADHF: acute decompensated heart failure.

Notable within our survey, limited pharmacist involvement was observed overall (Figure 1). Pharmacist-assisted or pharmacist-driven protocols have shown increased rates of target attainment, improved monitoring, and higher appropriateness of drug therapy.^2,3 The defined fundamental and desirable roles of a critical care pharmacist include interdisciplinary education, assistance with pharmacotherapy selection and monitoring, participation in clinical research, and development and implementation of protocols. ⁴ Correspondingly, pharmacist assistance in our cohort, when performed, encompassed many activities (Figure 2).

Figure 1.

Frequency of pharmacist involvement in deresuscitation.

Figure 2.

Pharmacist recommendations regarding deresuscitation.

Our survey supports the finding by Silversides et al. regarding a wide variability in current approaches to deresuscitation while suggesting limited pharmacist involvement overall. We believe the lack of standardized deresuscitation measures as seen in both cohorts represents an opportunity for interdisciplinary collaboration and concur that development of standardized approaches and randomized controlled trials of deresuscitation are needed. Given the lack of surrounding diuretic pharmacokinetic and pharmacodynamics in this population, pharmacists are in a unique position to assist with development of such protocols. ⁵ We propose the inclusion of clinical pharmacists in project and/or protocol development in alignment with standard pharmacy roles to assist in the overall improvement of clinical outcomes in the critically ill population.