Stop Hypernatremia, Use Metolazone, for Aggressive, Controlled, Effective Diuresis
| Status: | Completed |
|---|---|
| Conditions: | Pulmonary |
| Therapuetic Areas: | Pulmonary / Respiratory Diseases |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 4/2/2016 |
| Start Date: | June 2012 |
| End Date: | June 2013 |
| Contact: | James Case, MD |
| Email: | Caseja@ohsu.edu |
| Phone: | 5034949000 |
Stop Hypernatremia, Use Metolazone for Aggressive, Controlled, Effective Diuresis
Patients who are on mechanical ventilation in an intensive care unit often require diursis
as part of their pre-extubation regimen. The drug of choice for diuresis has traditionally
been furosemide. However, this drug cause hypernatremia (a rise in serum sodium) in a
significant proportion of patients. Hypernatremia is traditionally treated by providing free
water supplementation to the patient. This strategy creates a vicious and unproductive cycle
of giving free water, and then diuresing it off. We propose a strategy for breaking this
cycle by using a second diuretic-- metolazone-- which has a tendency to rid the body of more
sodium, thereby minimizing hypernatremia.
as part of their pre-extubation regimen. The drug of choice for diuresis has traditionally
been furosemide. However, this drug cause hypernatremia (a rise in serum sodium) in a
significant proportion of patients. Hypernatremia is traditionally treated by providing free
water supplementation to the patient. This strategy creates a vicious and unproductive cycle
of giving free water, and then diuresing it off. We propose a strategy for breaking this
cycle by using a second diuretic-- metolazone-- which has a tendency to rid the body of more
sodium, thereby minimizing hypernatremia.
Mechanical ventilation is a mainstay of Intensive Care. Weaning from mechanical ventilation
remains a significant issue in Intensive Care Unit (ICU) care worldwide. It is well
established that a strategy of diuresis with negative fluid balance shortens the duration of
mechanical ventilation in both acute lung injury and cardiogenic pulmonary edema patients.
Despite publication of at least one formalized but complex evidence-based conservative fluid
strategy, there is no practical, uniformly implemented protocol for setting or achieving
volume status targets. The default approach at many hospitals involves using ad hoc doses
(either intermittent or continuous) of a loop diuretic (usually furosemide) with
instructions to monitor fluid balance and follow electrolytes in an attempt to reach
arbitrary target volume diuresis. Moreover, there are barriers to achieving any particular
target, including pre-existing renal failure/diuretic resistance, diuretic-induced
creatinine elevation, acquired diuretic resistance, hypotension from volume loss, and
electrolyte derangements including hypokalemia and hypernatremia. Strategies exist for
preventing or treating the above complications but there is presently no accepted standard
for preventing or treating diuretic-induced hypernatremia. In fact, the standard current
intervention is to replace the free water deficit that may be induced by the loop diuretic,
while simultaneously perpetuating the free water deficit by continuing to administer the
causative loop diuretic. This approach is circular and does not effectuate the desired
negative fluid balance. We will address the lack of an accepted prevention strategy using a
randomized controlled clinical trial in ICU patients with the following specific aims:
1. Conduct a randomized, pilot trial of standard versus metolazone supplemented diuresis
in ICU patients with the primary outcome of improved negative fluid balance.
2. Assess secondary outcomes including time to extubation, exacerbation of renal failure,
and incidence of electrolyte derrangements in the treatment and control arms.
3. Track whether initial hypernatremia within the control group is a risk factor for poor
diuresis with furosemide, and whether it delays extubation.
The anticipated benefits of our proposed intervention involve fundamental ICU and patient
care quality measures: avoiding the pitfalls of hypernatremia and diuretic resistance should
lead to more effective diuresis, which should in turn lead to a more negative fluid balance,
earlier liberation from the ventilator, and a shorter length of stay in the ICU.
remains a significant issue in Intensive Care Unit (ICU) care worldwide. It is well
established that a strategy of diuresis with negative fluid balance shortens the duration of
mechanical ventilation in both acute lung injury and cardiogenic pulmonary edema patients.
Despite publication of at least one formalized but complex evidence-based conservative fluid
strategy, there is no practical, uniformly implemented protocol for setting or achieving
volume status targets. The default approach at many hospitals involves using ad hoc doses
(either intermittent or continuous) of a loop diuretic (usually furosemide) with
instructions to monitor fluid balance and follow electrolytes in an attempt to reach
arbitrary target volume diuresis. Moreover, there are barriers to achieving any particular
target, including pre-existing renal failure/diuretic resistance, diuretic-induced
creatinine elevation, acquired diuretic resistance, hypotension from volume loss, and
electrolyte derangements including hypokalemia and hypernatremia. Strategies exist for
preventing or treating the above complications but there is presently no accepted standard
for preventing or treating diuretic-induced hypernatremia. In fact, the standard current
intervention is to replace the free water deficit that may be induced by the loop diuretic,
while simultaneously perpetuating the free water deficit by continuing to administer the
causative loop diuretic. This approach is circular and does not effectuate the desired
negative fluid balance. We will address the lack of an accepted prevention strategy using a
randomized controlled clinical trial in ICU patients with the following specific aims:
1. Conduct a randomized, pilot trial of standard versus metolazone supplemented diuresis
in ICU patients with the primary outcome of improved negative fluid balance.
2. Assess secondary outcomes including time to extubation, exacerbation of renal failure,
and incidence of electrolyte derrangements in the treatment and control arms.
3. Track whether initial hypernatremia within the control group is a risk factor for poor
diuresis with furosemide, and whether it delays extubation.
The anticipated benefits of our proposed intervention involve fundamental ICU and patient
care quality measures: avoiding the pitfalls of hypernatremia and diuretic resistance should
lead to more effective diuresis, which should in turn lead to a more negative fluid balance,
earlier liberation from the ventilator, and a shorter length of stay in the ICU.
Inclusion Criteria:
- ICU patients who are intubated and slated for diuresis in anticipation of extubation.
- Patients must be hypernatremic (Na > 140 mEq/L) at the time diuresis is initiated or
become hypernatremic over the course of receiving loop diuretics in anticipation of
extubation.
- GFR > 30 ml/min [as calculated by the MedCalc MDRD formula {GFR = 170 x PCr - 0.999 x
Age - 0.176 x BUN - 0.170 x Albumin0.318 x 0.762 (for women) x 1.180 (for blacks)} ]
Exclusion Criteria:
- History of allergy to furosemide or any thiazide diuretic
- Inability to place enteral access
- Moribund status
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