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Outpatient Ultrafiltration to Prevent Hospital Readmission During Covid 19
Pandemic in Diuretic Intolerant Patient: Case Study
#MMPMIDC7527182
Livorsi-Moore J
; Malick O
; Valika A
J Card Fail
2020[Oct]; 26
(10
): S104-5
PMIDC7527182
show ga
INTRODUCTION: Heart Failure (HF) is the leading cause of hospitalization among
adults greater than 65 years of age in the U.S. and results in over 1,000,000
hospitalizations annually. Despite advances in medical therapeutics, mortality
remains high. Adjustments in workflow across hospital systems have been
instituted to reduce HF hospitalizations. Ambulatory HF clinics have helped in
this regard. In the current COVID-19 pandemic, the need to minimize utilization
of hospital resources and limit patient hospital admissions is paramount.
Inpatient ultrafiltration (UF) has been utilized to improve congestion in
patients with acute decompensated heart failure (ADHF). Less is known of
outpatient utilization of UF in the ambulatory HF patient. We present a case of
outpatient UF to reduce congestion in an ambulatory HF patient to minimize
hospitalization in the era of COVID-19 pandemic. CASE: A 70-year-old female with
HF preserved ejection fraction, combined pre and post pulmonary capillary
hypertension, with chronic dyspnea on continuous home oxygen, who presented to
the HF clinic. The patient had previous multiple hospitalizations due to
recurrent congestion, with therapies limited by dermatologic biopsy proven
allergy to sulfa based diuretics. She had failed various diuretic regimens with
recurrent desquamating whole body rash. She had recurrent weight gain during the
COVID-19 pandemic, and again was refractory to outpatient therapies. Given her
co-morbidities, she was deemed high risk for COVID-19 exposure. A decision to
proceed with outpatient UF was made. The day of outpatient HF clinic visit, we
placed a brachial dual lumen 16-gauge extended length catheter. A heparin drip
was initiated thirty minutes prior to the start of UF per protocol. Baseline
serum creatinine was 1.24 mg/dl and estimated GFR was 44. Initial outpatient
session was performed over a total of 4-hours with isolated veno-venous UF
utilizing the Aquadex Flex Flow system at a rate of 200 cc/hr fluid removal. The
patient completed a total of 4 sessions, and total fluid removal was 4950mL.
(Table 1) The patient had immediate improvement in symptoms. DISCUSSION: UF is a
method of decongestion that can be used as an alternative to loop diuretics.
Simplified UF devices can utilize peripheral venous access, low blood flows, and
small extracorporeal blood volume. Previous experience with intermittent
outpatient UF utilizing peritoneal dialysis and hemofiltration has been reported,
though not widely utilized. This is the first case to report the use of the
Aquadex Flex Flow system to provide outpatient UF therapies in the COVID-19 era.
CONCLUSIONS: Pre-existing cardiac and pulmonary disease, including congestive HF,
increase risk of serious complications from exposure to SARS-COVID-2 virus. We
report a novel case of minimizing exposure risk of a congested HF patient using
outpatient isolated veno-venous UF in the ambulatory setting.
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