DIURETICS How do they work? What do they do? WHEN DO I USE THEM? How do I use them?
DEFINITION OF EDEMA The Accumulation of Abnormal Amounts of Extravascular, Extracellular Fluid. ANASARCA:  Severe, widely ...
TYPES OF EDEMA LOCALIZED GENERALIZED <ul><li>Inflammation </li></ul><ul><li>Lymphatic Obstruction </li></ul><ul><li>Venous...
MECHANISMS OF EDEMA FORMATION  IS P cap  cap P IS  alance of Starling Forces (Capillary Permeability)  nterstitial Spa...
CARDIAC EDEMA Diagnosis <ul><li>History of Heart Disease </li></ul><ul><li>Evidence of Pulmonary Edema </li></ul><ul><ul><...
CARDIAC EDEMA Pathophysiology HEART DISEASE Left Ventricular Dysfunction Right Ventricular Dysfunction Increased Pulmonary...
HEPATIC EDEMA Diagnosis <ul><li>History of Liver Disease </li></ul><ul><li>Diminished CrCl (Normal Serum Cr) </li></ul><ul...
LIVER  DISEASE Neurohumoral Activation (Increased “Volume Hormones”) Liver Cirrhosis Increased Pressure in Hepatic Sinusoi...
RENAL EDEMA Diagnosis History of Renal Disease <ul><li>Evidence of Albumin Loss </li></ul><ul><ul><li>Narrow, pale transve...
RENAL EDEMA Diagnosis <ul><li>Nephrotic Syndrome </li></ul><ul><ul><li>Hyaline Casts </li></ul></ul><ul><ul><li>Oval Fat B...
RENAL EDEMA Pathophysiology RENAL DISEASE Urinary Loss of Albumin Reduced GFR Hypoalbuminemia Altered Starling Forces Syst...
CARDIAC Dependent Edema HEPATIC RENAL Proteinuria Facial Edema Ascites Hypoalbuminemia Severe Absent Absent Absent/Mild Se...
IDIOPATHIC EDEMA Diagnosis <ul><li>Women of Childbearing Age </li></ul><ul><li>Associated with Eating Disorders </li></ul>...
IDIOPATHIC EDEMA Pathophysiology  IS P cap  cap P IS  alance of Starling Forces (Capillary Permeability)  nterstitial ...
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Part III - When Do I Use Them

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Part III - When Do I Use Them

  1. 1. DIURETICS How do they work? What do they do? WHEN DO I USE THEM? How do I use them?
  2. 2. DEFINITION OF EDEMA The Accumulation of Abnormal Amounts of Extravascular, Extracellular Fluid. ANASARCA: Severe, widely distributed pitting edema.
  3. 3. TYPES OF EDEMA LOCALIZED GENERALIZED <ul><li>Inflammation </li></ul><ul><li>Lymphatic Obstruction </li></ul><ul><li>Venous Obstruction </li></ul><ul><li>Thrombophlebitis </li></ul><ul><li>CARDIAC </li></ul><ul><li>HEPATIC </li></ul><ul><li>RENAL </li></ul><ul><ul><li>NEPHROTIC SYNDROME </li></ul></ul><ul><ul><li>ACUTE GN </li></ul></ul><ul><ul><li>CRF </li></ul></ul><ul><li>IDIOPATHIC </li></ul><ul><li>Other </li></ul><ul><ul><li>Cyclic </li></ul></ul><ul><ul><li>Myxedema </li></ul></ul><ul><ul><li>Vasodilator-induced </li></ul></ul><ul><ul><li>Pregnancy-induced </li></ul></ul><ul><ul><li>Capillary leak syndrome </li></ul></ul>
  4. 4. MECHANISMS OF EDEMA FORMATION  IS P cap  cap P IS  alance of Starling Forces (Capillary Permeability)  nterstitial Space Filtration < or = Lymphatic Drainage Filtration > Lymphatic Drainage  o  dema  DEMA
  5. 5. CARDIAC EDEMA Diagnosis <ul><li>History of Heart Disease </li></ul><ul><li>Evidence of Pulmonary Edema </li></ul><ul><ul><li>Orthopnea </li></ul></ul><ul><ul><li>SOB </li></ul></ul><ul><ul><li>Exertional Dyspnea </li></ul></ul><ul><li>Evidence of Volume Expansion </li></ul><ul><ul><li>Hepatic Congestion </li></ul></ul><ul><ul><li>Hepatojugular Reflux </li></ul></ul><ul><li>Ventricular Gallop Rhythm </li></ul>
  6. 6. CARDIAC EDEMA Pathophysiology HEART DISEASE Left Ventricular Dysfunction Right Ventricular Dysfunction Increased Pulmonary Venous Pressure Pulmonary Edema Systemic Edema Hypotension Renal Na Retention
  7. 7. HEPATIC EDEMA Diagnosis <ul><li>History of Liver Disease </li></ul><ul><li>Diminished CrCl (Normal Serum Cr) </li></ul><ul><li>Evidence of Chronic Liver Disease </li></ul><ul><ul><li>Spider Angiomata </li></ul></ul><ul><ul><li>Palmar Erythema </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Hypoalbuminemia </li></ul></ul><ul><li>Evidence of Portal Hypertension </li></ul><ul><ul><li>Venous Pattern on Abdominal Wall </li></ul></ul><ul><ul><li>Esophogeal Varices </li></ul></ul><ul><ul><li>Ascites </li></ul></ul>
  8. 8. LIVER DISEASE Neurohumoral Activation (Increased “Volume Hormones”) Liver Cirrhosis Increased Pressure in Hepatic Sinusoids Exudation of Fluid Into Peritoneal Cavity Systemic Edema Ascites Renal Na Retention HEPATIC EDEMA Pathophysiology Functional Renal Insufficiency (Hepatorenal Syndrome)
  9. 9. RENAL EDEMA Diagnosis History of Renal Disease <ul><li>Evidence of Albumin Loss </li></ul><ul><ul><li>Narrow, pale transverse bands in nail beds </li></ul></ul><ul><ul><li>Proteinuria (3+ to 4+) </li></ul></ul><ul><ul><li>Hypoalbuminuria </li></ul></ul><ul><li>Renal Imaging </li></ul><ul><ul><li>Enlarged Kidneys Nephrotic Syndrome or AGN </li></ul></ul><ul><ul><li>Shrunken Kidneys CRF </li></ul></ul>
  10. 10. RENAL EDEMA Diagnosis <ul><li>Nephrotic Syndrome </li></ul><ul><ul><li>Hyaline Casts </li></ul></ul><ul><ul><li>Oval Fat Bodies </li></ul></ul><ul><ul><li>Lipid Droplets/Casts </li></ul></ul><ul><li>Acute Glomerulonephritis </li></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Erythrocyte Casts </li></ul></ul><ul><ul><li>Leukocyte Casts </li></ul></ul><ul><ul><li>Pyuria </li></ul></ul><ul><li>Chronic Renal Failure </li></ul><ul><ul><li>Broad Waxy Casts </li></ul></ul>Urinalysis
  11. 11. RENAL EDEMA Pathophysiology RENAL DISEASE Urinary Loss of Albumin Reduced GFR Hypoalbuminemia Altered Starling Forces Systemic Edema Renal Na Retention NEPHROTIC PATHWAY NEPHRITIC PATHWAY
  12. 12. CARDIAC Dependent Edema HEPATIC RENAL Proteinuria Facial Edema Ascites Hypoalbuminemia Severe Absent Absent Absent/Mild Severe Absent/Mild Severe Moderate/Mild Absent Absent/Trace Absent/Trace Severe/Moderate Moderate Mild Severe
  13. 13. IDIOPATHIC EDEMA Diagnosis <ul><li>Women of Childbearing Age </li></ul><ul><li>Associated with Eating Disorders </li></ul><ul><li>Dependent Edema </li></ul><ul><li>Facial Edema </li></ul><ul><li>Abdominal Bloating </li></ul>
  14. 14. IDIOPATHIC EDEMA Pathophysiology  IS P cap  cap P IS  alance of Starling Forces (Capillary Permeability)  nterstitial Space    Filtration > Lymphatic Drainage  DEMA

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