To Bolus or Not to Bolus: A Case Demonstrating the Clinical Challenge of Volume Management in Pancreatitis for Patients with ESKD

Introduction: Conditions typically treated with volume expansion (sepsis, DKA, acute pancreatitis, prehydration for procedures, etc.) are commonplace in clinical practice. Existing guidelines for these conditions in the setting of ESKD are less defined and pose significant clinical challenges. We present a case through which we are establishing protocols for overriding typical dialysis orders in select situations for volume management. Case Description: 69yo male with ESKD on HD presented to ER with abdominal pain and nausea. Lipase elevation confirmed acute pancreatitis diagnosis. He was given normal saline in the ER per guidelines for pancreatitis. Soon after that, he was admitted to ICU for severe hypertension with systolic blood pressure over 220mmHg likely due to volume overload. Nephrology consulted for acute dialysis. He arrived to ICU 2.5kg above his dry weight with evidence of volume overload on chest X-Ray, physical exam (peripheral edema), and distended inferior vena cava on ultrasound evaluation. HD was done with ultrafiltration target reduced to 1 kg over his dry weight to maintain some relative volume expansion. No further IV fluids were administered. The following morning, he weighed 1kg above dry weight; his pain had resolved, and blood pressure was controlled. He transferred to the floor and resumed usual HD schedule. Discussion: Conditions usually managed with IVF are at high risk for iatrogenic volume overload in the setting of ESKD and require careful judgement. Effective circulatory volume should be targeted as the goal of resuscitation rather than protocolized volume targets using detailed exam, history, and bedside PoC ultrasound. Ultrafiltration goals need to be tailored individually, especially when total weight exceeds a patient’s baseline dry weight and evidence for abnormal fluid distribution is present. Accounting for residual urine output is also vital. Appropriate volume resuscitation and removal depend on careful bedside assessment. The table outlines our proposed protocol.