Fluid question

[KICKSTART]

I didnt want to apppear insensitive by tagging this onto Bajanne's thread , but i do wonder how can you get fluid overloaded , well to such a point that its actually critical, while on Hemo ? I can believe it can happen on PD (it did to me) but how can it go unnoticed when you are at dialysis/being weighed etc etc every other day ?

[Hanify]

I wondered that too Kickstart.  Good question.

[willowtreewren]

It has to do with that old dry weight issue that keeps coming up. If your dry weight is actually less than what they say, not enough fluid will be pulled off during dialysis.

Remember that Jbeany kept challenging her dry weight because she was actively trying (and succeeding) to lose weight? She had them pull off more than they wanted. Since she did not crash, she was correct in challenging her dry weight.

I think that any time you change clinics like that, the techs do not know you and if you aren't assertive or just don't know, trying to establish a good dry weight can be very tricky.

It is really sad about Bajanne's friend. A senseless death.

Aleta

[Rerun]

I've seen it several times with people who are extremely noncompliant.  They dialyze for 3 hours and have 7 kilos to take off.  Well, it just can't be done, so they say they will get the rest off next time and they come in with 8 kilos on.  See how that kind of repetitive noncompliance can get you into trouble?  They should come in for an extra session but they don't.

[RichardMEL]

exactly.

I have seen this too.

People who just drink normally(as they used to) and don't care(or don't realise) how serious it is. Then they come in unaable to breathe and things are SO MUCH WORSE because by that point they're in serious trouble!! It's then that much harder to get that fluid out of them because there's so much to take, and by that stage it's affecting the heart AND lungs. That stuff scares the crap out of me. I mean cramps and crashing are bad, and that's one thing - but this is a whole other level of bad.

However I have seen it. We used to have a guy who would constantly come in over weight(fluid).. like he just didn't care. My brother saw him once walk out of dialysis and straight into the fast food shop and pile down chicken and chips (mmmmmm salt). Now that is totally his choice (and yes, I had a burger last night oops!  ) but I think this particular person didn't want to admit to himself how serious his situation was, even though he had type 2 diabetes from obesity, kidney failure and he was going blind from the diabetes.... maybe there was only so much he could handle and wanted to "pretend" he had a normal lifestyle by just eating and drinking what he pleased.

So he'd come in, and he'd have 6 or 7 kilos to take off in 5 hours. Of course he might cramp, and he would DEFINITELY complain and be so obnoxious that he would be taken off early. Result he was lucky if he got 3 litres taken off. So he leaves 2 or 3l over already, and of course drinks...... and well you see how that goes.

He moved to a private unit but I've heard he's much better now which is great for him - I was very worried he'd pass away sooner than later.

While in my mind I just can't contemplate of putting on 5+kg between treatments I think that is because I try to be very disciplined with my drinking, and I weigh myself several times a day at home to keep track, and I have my own goal of 2kg between treatments which I pretty much keep (woohoo!). It's NOT easy at times, but I know that if I don't anything could happen from cramps to crashing to.. well some sort of overload.

There are times when I look at a 600ml bottle of ice water and I think "I could guzzle you in 30 seconds flat!" but I also know this would be a very BAD thing to do.

So I bide my time until the day I *will* be able to do that, and laugh and grin at the freedom

[aharris2]

not necessarily "exactly"... While there are certainly instances of the "self inflicted injury", there is also the injury caused by inappropriate determination of target ending weight (dry weight or whatever)

Early on, before we understood, my brother was hospitalized with a fluid overload. As opposed to going for his dry weight, the techs were looking at what he had come off at "last time" and going for that. Between the errors in subtraction in determining the amount to be removed and the errors in recording ending weight, he gradually built up a fluid overload. The kiss of "death" was a 2 kilo error on top of the gradual buildup. They removed the minimum because they thought he had put nothing on. It was the last session before New Years and the 3 day break. On New Years Day, we ended up in the emergency room.  After a brief hospitalization, we asked questions at the unit (that's how we determined how the overload developed.) We learned and we took charge. It took us a month, 0.5 kilos at a time to get to a good dry weight. Since that time we have always told them the target ending weight... and checked their math!

Noncompliance is not the only issue.

[willowtreewren]

I agree, Alene.

And to make matters worse, if there is non-compliance on top of figuring the wrong dry weight, it can go bad very fast.

 

[petey]

not necessarily "exactly"... While there are certainly instances of the "self inflicted injury", there is also the injury caused by inappropriate determination of target ending weight (dry weight or whatever)

Early on, before we understood, my brother was hospitalized with a fluid overload. As opposed to going for his dry weight, the techs were looking at what he had come off at "last time" and going for that. Between the errors in subtraction in determining the amount to be removed and the errors in recording ending weight, he gradually built up a fluid overload. The kiss of "death" was a 2 kilo error on top of the gradual buildup. They removed the minimum because they thought he had put nothing on. It was the last session before New Years and the 3 day break. On New Years Day, we ended up in the emergency room.  After a brief hospitalization, we asked questions at the unit (that's how we determined how the overload developed.) We learned and we took charge. It took us a month, 0.5 kilos at a time to get to a good dry weight. Since that time we have always told them the target ending weight... and checked their math!

Noncompliance is not the only issue.

Alene's right.  If a person is losing weight (but not a great deal at a time -- but a pound or two this week, a pound or two next, etc.) but their dry weight is not adjusted accordingly, fluid overload can happen.  It builds up quicker than you realize -- and before you can realize it.  While your actual weight is going down, it APPEARS that  you're only putting on a kilo or two between treatments.  That may not be accurate -- if your weight drops just two pounds, that's an extra kilo, and your dry weight should be dropped or "challenged" as they call it in center.

Stay aware of your dry weight, yes.  But, also, know your own body -- what you eat, what you don't eat, if you're sick, anything that would cause your actual weight to go up or down.  Just a couple of pounds makes a huge difference.  Then, make sure the clinic hears you when you say, "Challenge my dry weight" or "Up my dry weight."  Knowledge is power -- and it could save your life, too!

[RichardMEL]

yes, ok, that's obviously also true. I didn't mean to sound like noncompliance was the only issue.

I also agree it is important to know your body and to check what the techs are doing. I always compute my own UF target and check with theirs. every so often there's an error, but it's not usually serious. I also keep note of my food intake and take that into account because I don't want to be putting on or taking off dry weight - I try to keep it fairly static.

I agree that because dry weight calculations are at best a guess it's difficult to get it right and it's a constantly shifting thing given real body weight can come and go.

I guess I was focusing on non compliance in my mind the most because that is something that we, as patients, can control ourselves - it is a choice.

[KICKSTART]

Ah i understand now  If you came into our unit with 5 kg !! to pull off they wouldnt even attempt it. They would put you in hospital , monitor your fluid intake and restrict it big time ! I guess im lucky with regards the dry weight issue as my nurses do listen to me. I go on what we call the Loop and basically if the fluid is there it will take it off , if it isnt it wont ! (and it also spreads it out over the 4 hours , which is far kinder on the system)

[Chris]

I use to keep a stat book of what I ate and drank since I kept track of my blood sugars along with my weights before and after dialysis and for some reason bp through the dialysis session.

I had fluid overload once, but forgot cause. I know I had a hospital stay though.

[MomInDialysis]

This happened last night.  Mom wound up in emergency with congestive heart failure.  She had a heart attack and is doing well now, thank you Jesus.  Here's what happened.
We lowered her fluid draw to . 5 for the past 2 weeks (6 dialysis sessions), her dry wt fluctuated 87 - 89 every session, some days 87 in some days 88, next session 87, next session 88-89.  It has done this for the past 15 months so no one was concerned.
Saturday her dry wt was 90 and the center said oh it is probably because you ate today.  Seemed weird, but OK.  well, her wt out was 90.  90 in 90 out no concern  OK.   well that 90 was a concern and so was the 89 from the 2 previous dialysis sessions.  She was retaining fluids in her lungs, causing pressure on the heart.  There is a number, the VPM, I think that is what they called it.  Hers is 200 normally, last night it was 1700.  This is the pressure the heart is under when pumping.  not good.
Good came out of this though.  We now know what her target wt is, we now know that the fluid draw should change based on her dry wt in( it has not been getting changed in the past by the techs or docs) until we changed it to .5 for no fluid removal.  Her fluid removal should have been being adjusted and it was not.  IT WILL BE NOW!  Silver linings are nice, but sometimes their acquisition path sucks.
She is doing great and getting better each hour.   One more stone negotiated on this rough river.

[RichardMEL]

I have always been taught that real body weight gain does NOT happen in between sessions but over time - so pushing dry weight up 1 or 2 kilos between sessions would never be advisable - even if your real body weight has crept up 200g-300g due to eating a massive meal or something most of that would probably come off over time, unless you really were putting on the body weight. I would NEVER change the dry weight up like that just to suit how I was coming off.. that seems very wrong to me and discounting the fluid - as obviously what happened.

I am sorry for what happened to your mom - clearly much tighter control needs to be had over what the unit is doing and to not just accept what they say or do. I would never vary my dry weight that much over a short period of time like 2 weeks. The most I ever change between sessions is .2 (although one time I did go down by 0.5, but only because I put on very little so was confident I could take the extra fluid off, and I wanted to get by dry weight down because it had been put up to satisfy a theory that was wrong).

I hope she will be OK!

[Lillupie]

I have actually seen someone at hemo come in the clinic with 18 kilos on. I personally do not gain weight between days on PD as I did on hemo.
As you can see I really dont like hemo.
 

[Melissa]

OMG, 18 kilos?  That is insane....for real?
I can not imagine.
I have had lots of issues with fluid overload because I lose weight quickly, so I have to always ask to be challenged a bit.  Even if I am a small amount over, like a 1/4 kilo, it adds up and I can end up in the hospital before I know it, because we were trying to stick to a number.   Now I know what I feel like when I  need to take more off and am not afraid to ask for more.
Thankfully, since my kidney was removed my weight has been stable, and I might have even gained a kilo!
 

[calypso]

Don't they listen to your heart and lungs, take your blood pressure and feel your ankles so fluid overload doesn't become critical? They do at my clinic.

[RichardMEL]

Don't they listen to your heart and lungs, take your blood pressure and feel your ankles so fluid overload doesn't become critical? They do at my clinic.

not in my unit. We do the blood pressures of course, but not the other stuff. I think though if folks came in complaining of breathing problems, etc they might take it further and do that. We also do BVM's to see if people are too wet or dry also and that helps.

I've never had my heart or lungs listened to in the unit - only by the neph every 3 months.

[MomInDialysis]

Don't they listen to your heart and lungs, take your blood pressure and feel your ankles so fluid overload doesn't become critical? They do at my clinic.

This is what was so strange for Mom when this happened.  She had just had dialysis that day, but we were not taking any fluids off other than rinse back.  They listened to her lungs, and took her blood pressure every 30 minutes as always.  I was with her the entire time at dialysis and watched them do it.  No one caught it.  Her ankles were not swollen, there was no puffiness anywhere, except around her heart and in her lungs.     My xray vision wasn't working that day and I didn't see it coming.

[Lillupie]

that is insane!!! My unit would check your breathing each and every time with each and every patient! wow

Lisa

Don't they listen to your heart and lungs, take your blood pressure and feel your ankles so fluid overload doesn't become critical? They do at my clinic.

not in my unit. We do the blood pressures of course, but not the other stuff. I think though if folks came in complaining of breathing problems, etc they might take it further and do that. We also do BVM's to see if people are too wet or dry also and that helps.

I've never had my heart or lungs listened to in the unit - only by the neph every 3 months.