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 distributed pitting edema.

TYPES OF EDEMA GENERALIZED LOCALIZED CARDIAC HEPATIC Inflammation RENAL NEPHROTIC SYNDROME ACUTE GN CRF IDIOPATHIC Other Cyclic Myxedema Vasodilator-induced Pregnancy-induced Capillary leak syndrome Inflammation Lymphatic Obstruction Venous Obstruction Thrombophlebitis

(Capillary Permeability) MECHANISMS OF EDEMA FORMATION PIS alance of Starling Forces cap Pcap IS (Capillary Permeability) nterstitial Space Filtration < or = Lymphatic Drainage Filtration > Lymphatic Drainage odema DEMA

CARDIAC EDEMA Diagnosis History of Heart Disease Evidence of Pulmonary Edema Orthopnea SOB Exertional Dyspnea Evidence of Volume Expansion Hepatic Congestion Hepatojugular Reflux Ventricular Gallop Rhythm

CARDIAC EDEMA Pathophysiology HEART DISEASE Left Ventricular Dysfunction Right Ventricular Dysfunction Hypotension Increased Pulmonary Venous Pressure Renal Na Retention Pulmonary Edema Systemic Edema

HEPATIC EDEMA Diagnosis History of Liver Disease Diminished CrCl (Normal Serum Cr) Evidence of Chronic Liver Disease Spider Angiomata Palmar Erythema Jaundice Hypoalbuminemia Evidence of Portal Hypertension Venous Pattern on Abdominal Wall Esophogeal Varices Ascites

HEPATIC EDEMA Pathophysiology LIVER DISEASE HEPATIC EDEMA Pathophysiology Liver Cirrhosis Increased Pressure in Hepatic Sinusoids Neurohumoral Activation (Increased “Volume Hormones”) Exudation of Fluid Into Peritoneal Cavity Functional Renal Insufficiency (Hepatorenal Syndrome) Ascites Renal Na Retention Systemic Edema

RENAL EDEMA Diagnosis History of Renal Disease Evidence of Albumin Loss Narrow, pale transverse bands in nail beds Proteinuria (3+ to 4+) Hypoalbuminuria Renal Imaging Enlarged Kidneys Nephrotic Syndrome or AGN Shrunken Kidneys CRF

Urinalysis RENAL EDEMA Diagnosis Nephrotic Syndrome Hyaline Casts Oval Fat Bodies Lipid Droplets/Casts Acute Glomerulonephritis Hematuria Erythrocyte Casts Leukocyte Casts Pyuria Chronic Renal Failure Broad Waxy Casts Urinalysis

RENAL EDEMA Pathophysiology RENAL DISEASE NEPHROTIC PATHWAY NEPHRITIC PATHWAY Reduced GFR Urinary Loss of Albumin Hypoalbuminemia Renal Na Retention Altered Starling Forces Systemic Edema

Severe Moderate Mild Absent Absent Severe/Moderate Absent/Mild Severe CARDIAC HEPATIC RENAL Dependent Edema Severe Moderate Mild Facial Edema Absent Absent Severe/Moderate Ascites Absent/Mild Severe Absent/Mild Hypoalbuminemia Absent Moderate/Mild Severe Proteinuria Absent/Trace Absent/Trace Severe

 IDIOPATHIC EDEMA Diagnosis Women of Childbearing Age Associated with Eating Disorders Dependent Edema Facial Edema Abdominal Bloating

   IDIOPATHIC EDEMA Pathophysiology PIS cap Pcap IS alance of Starling Forces  cap Pcap  IS  (Capillary Permeability) nterstitial Space Filtration > Lymphatic Drainage DEMA