Fluids or Diurese?

Today we discussed a core internist-struggle: To give fluids or not to give fluids, that is the question!  We discussed a case where the differential came down to pneumonia/sepsis vs decompensated heart failure, and the question: treat with IV fluid resuscitation or diurese?

Faculty, I want to make it known that our interns are ready to be senior residents!  They did a fantastic job at identifying key history, physical exam, radiographic, and serologic findings to aid in their decision making and treatment plan.

Some learning points identified were the following:

1. There is a value of a PA and lateral chest xray instead of a single-view portable to evaluate for pneumonia vs pulmonary edema.  This helped the team identify Kerley lines, evaluate a possible retro-cardiac consolidation, and determine the presence of small effusions.

2. The physical exam, especially the presence of a 3rd heart sound and elevated JVP, are imperative in this evaluation.  Here is a nice table of the likelihood ratios for dyspnea due to heart failure.

3. Captopril dosing and conversion between it and lisinopril is about 5:1 in total daily dosing.  Here is a review by New Zealand's Pharmaceutical Management Agency on how to convert the two doses.

4. Broad DDx of shock/hypotension:
        Distributive: Septic, anaphylactic, neurogenic, adrenal insufficiency, cirrhosis
        Cardiogenic: MI, HF
        Obstructive: PE, tamponade, pneumothorax, abdominal compartment syndrome
        Hypovolemic: blood loss, overdiuresis, significantly low PO intake

Since you are probably curious... the patient was diuresed and clinically improved.