Putting a lid on precious bodily fluids



An old and true chestnut is that people are roughly 60% water and that we evolved in a lineage of land-based life selected to have complex and finely tuned mechanisms to maintain proper internal levels of salts and fluids. When the processes that regulate these are out of whack, bad things happen.

As I recently reported, surgeons at Johns Hopkins Hospital, Baltimore, have documented that excess fluid retention in patients who have just undergone heart surgery was the most common factor driving these patients back to the hospital during the 30 days after their index discharge. Dr. John V. Conte Jr., a Johns Hopkins cardiac surgeon, told me that patients often retain 5-10 pounds of excess fluid during the weeks immediately following heart surgery, and if they have trouble voiding this tsunami that can accumulate in their chest from pleural effusions, they develop acute problems, most notably difficulty breathing.

Brocken Inaglory/Wikimedia Commons/CC-ASA 4.0

As a consequence, heart surgery patients with the highest risk for complications from fluid overload following their operation include those with severe chronic lung disease and those who develop acute renal failure postoperatively.

Problems with postsurgical fluid balance that lead to rehospitalization sound remarkably like the fluid-balance issue that also drives rehospitalization in patients with hard-to-control heart failure. Acute decompensation episodes in heart failure patients are triggered by fluid overload that manifests as severe dyspnea (and peripheral edema) that sends patients to the hospital. Patients with kidney dysfunction in addition to heart failure are particularly vulnerable to decompensation events.

“Fluid is an issue for both heart failure and heart surgery patients. Fluid is the common pathway to readmissions,” Dr. Conte noted when I spoke with him recently.

The parallels between the two disorders run deeper. To combat fluid overload, both types of patients need aggressive diuresis. Results from at least some studies also suggest that heart failure patients benefit clinically and also need fewer hospitalizations when they are closely monitored at home to provide early warning of incipient fluid overload that can be nipped by prompt treatment. The same approach may also help cut rehospitalization rates in recent heart surgery patients; Dr. Conte plans to soon test this strategy in a formal study.

Another parallel is that improved fluid management in these patients when they are at home may also help the hospitals that initially treat them by reducing the hospitals’ risk from financial penalties imposed by the Centers for Medicare & Medicaid Services. In fiscal year 2017, which starts in July 2016, CMS adds 30-day rehospitalization following coronary artery bypass grafting to its short list of hospital readmission types that can generate a monetary penalty from the agency’s Readmissions Reduction Program when a hospital’s numbers exceed national norms.

The CMS plans to soon start penalizing for seven types of excess rehospitalizations and the fact that two of the seven result in large part from deranged fluid balance shows just how important successful fluid management is these days, both to patients and to the hospitals and clinicians that treat them.

On Twitter @mitchelzoler

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