Managing fluid overload in patients who have been identified as having end stage heart failure is key to quality of life
These patients often present with:
- really heavy legs, often weeping fluid
- worsening mobility
- severe breathlessness
- anorexia and insomnia
The aim of management is to promote diuresis and comfort and avoid unnecessary hospital admission if possible.
Key clinical features for a clinician to assess in the community
- Extensive peripheral oedema, raised JVP, possible ascites, pulmonary crepitations
- Daily weight is the most reliable marker of fluid retention - a gain of more than 1–2 kg over 1–2 days indicates accumulation
- If possible check baseline U&E and creatinine - worsening renal function requires caution with diuretic escalation (but comfort is the priority and blood tests shouldn't delay treatment)
- Review for reversible contributors: dietary salt excess, medication non-adherence, concurrent infection, or NSAIDs
An initial approach to treatment
- Optimise oral diuretics first - these can be given in liquid form if swallowing is difficult
- If worsening fluid overload on oral Furosemide, consider switching to oral Bumetanide which is better absorbed through an oedematous bowel wall (40 mg oral Furosemide = 1 mg oral Bumetanide)
- Add Bendroflumethiazide 2.5 mg three times weekly, keeping an eye on blood pressure
- Involve the community heart failure team early - they can advise on diuretic titration and subcut Furosemide initiation
- Consider fluid restriction to <1.5 litres
- Review medications that can be stopped
Specialist care
- If Bendroflumethiazide is ineffective oral Metolazone 2.5 mg twice weekly may help
- Metolazone needs careful monitoring of blood pressure and electrolytes (particularly potassium)
- When oral treatment fails subcut Furosemide in a syringe pump is an effective treatment to keep patients at home. The suggested 24 hour subcut dose of Furosemide is usually twice the total daily oral dose
Top tips
- Switching from Furosemide to Bumetanide can restore diuretic response when gut oedema is limiting oral absorption - try this before escalating to subcut or IV treatment
- Subcut Furosemide is an evidence-based alternative to IV in the community
- Daily weighing is the most practical monitoring tool - make a clear action plan with the patient and carer for what to do if weight rises
- Do not continue to check U&E if worsening renal function would not change your management - this causes distress without benefit
- Monitor the syringe pump site for signs of inflammation and resite if needed
- Consider catheterisation if increased diuresis is really disruptive to sleep
- Encourage the patient to avoid added salt - this can make a real difference