Correction of hypovolemia

Correction of hypovolemia is the most important aspect of the management of oliguria. Administration of fluid optimizes cardiac performance and reverses the compensatory mechanisms which mediate fluid retention.

Overt hypovolemia is managed by rapid fluid resuscitation, preferably by warm colloids which may achieve normal intravascular volume status faster than crystalloids. Ideally, patients should have a pulmonary flotation catheter in place for assessment of left ventricular stroke volumes in response to intermittent fluid challenges.

In some patients aggressive fluid administration may lead to interstitial pulmonary edema due to increased pulmonary capillary permeability. Pulmonary interstitial edema can decrease pulmonary compliance, and such a trade-off may be acceptable. However, other patients may unpredictably develop alveolar edema in which oxygenation deteriorates rapidly. Unfortunately, in the oliguric patient this may not be easily reversible other than by venesection or hemofiltration. Diuretics and vasodilators may be useful in this situation but usually only temporarily. Judging how rapidly intravenous fluids should be given, particularly in the non-ventilated patient with a permeability defect, may become a matter of trial and error. The fear of alveolar edema, particularly in patients with poor oxygenation from a primary pulmonary insult, may be justification to refrain from aggressive fluid therapy, an acceptance of ARF, and early management with hemofiltration.

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