case study
Managing Late Post-Operative
Fluid Retention Following Cardiac Surgery Using Aquapheresis™
Introduction
Following open heart surgery, particularly in patients with valvular
heart disease and those with pre-operative congestive heart failure,
late volume shifts may occur. Whether related to inadequate diuretic
administration, dietary indiscretion, or medication interaction;
following discharge, patients may present emergently with peripheral
and/or pulmonary edema. The removal of free water is required and
diuretic therapy alone may not suffice.
Case History
A 62-year-old female with mitral and tricuspid insufficiency, who
had an enlarging left ventricular chamber and decreasing ejection
fraction, was referred for surgery. Post-cath, she developed contrast
induced nephropathy (Creatinine reaching 2.7 mg%). She was admitted
with pulmonary hypertension and fulminant congestive heart failure.
Surgical repair was accomplished with a P-2 quadrangular mitral
leaflet resection, placement of a #28 Taylor ring, a DeVega tricuspid
annuloplasty and closure of a patent foramen ovale.
In the immediate postoperative period, the patient
was treated with diuretics and had mild bilateral pleural effusions.
Her postoperative course was otherwise uncomplicated, and she was
discharged on diuretics (Bumex® 2mg PO bid) with her weight
declining. Seventy-two (72) hours following discharge, the patient
re-presented with an eight (8) pound weight gain, shortness of breath,
decreased urine output, hyponatremia (Na = 129), pleural effusions
and peripheral edema.
A PICC line was placed in the right antecubital
fossa and the patient underwent CHF Solutions’ form of ultrafiltration,
aquapheresis. Using the Aquadex FlexFlow™, she underwent two
eight (8) hour runs removing over 7 kg of fluid bringing her to
preoperative weight. The medical regimen was adjusted and she was
discharged without peripheral edema or shortness of breath. She
has required no further hospitalizations.
Comment
This situation represents an example of using the peripheral UF
unit to manage late postoperative fluid retention. The patient had
congestive heart failure and edema preoperatively, and in the early
postoperative period, and acute renal insufficiency, which limited
effective diuresis. In spite of being discharged on an adequate
medical regimen, there were significant fluid shifts following discharge
that resulted in pulmonary and peripheral edema. The response to
diuretics was inadequate on readmission, and fluid removal with
aquapheresis resolved the hyponatremia and edema, did not impact
potassium levels, and limited the aggressive use of diuretics resulting
in a shortened hospital stay.
Case history courtesy of:
Robert W. Emery, M.D.
Director of Cardiovascular Surgery
Regions Hospital
St. Paul, Minnesota
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