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Classifications, approach and treatment of edema


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Presentation Transcript

edema : 

edema Dr. S. Aswini Kumar. MD Professor of Medicine Govt Medical College Hospital, Thiruvananthapuram Kerala, S. India, e mail :draswini@in.com 1

Mechanism : 

Mechanism 1 2 3 4 5 6 7 8 2

1. Drug Induced edema : 

1. Drug Induced edema Antihypertensive agents Vasodilators Hydralazine Clonidine Amlodipine Steroid hormones Glucocorticoids Prednisolone Betamethasone Deflazacort Anabolic steroids Hormones Sex hormones Oestrogens Progesterons Testesterone Growth hormones Miscellaneous Immunosupressants Cyclosporines Azathioprine Methotrexate 3

2. Idiopathic Edema : 

2. Idiopathic Edema Exclusively in women Unrelated to menstruation Diurnal alteration in edema Diurnal alteration in weight Mechanisms Orthostatic (on standing) Retention of NaCl and H2O Increase in cap. Permeability Fluctuation in severity More in hot climates DD Premenstrual edema Cyclical Retention of NaCl and H2O But related to estrogen Diuretic induced Salt retaining mechanism Overcompensate diuretic effect Acute withdrawal of diuretics Na retaining forces un opposed Fluid and Na retention Edema 4

3. Nutritional edema : 

3. Nutritional edema Diet deficient in protein Parasitic infestation Protozoa Giardia Helminths Malabsorption Tropical sprue Coeliac disease Intestinal lymphoma Bacterial overgrowth Intestinal tuberculosis Post surgical Hypo-protinemia Hypoalbuminemia Hypokalemia Caloric deficit Beriberi heart disease Alcoholism Chronic liver disease Re-feeding edema Paradoxical edema due to Na+ intake Increased insulin release Increased Na + reabsorption 5

4. Localized edema : 

4. Localized edema Inflammation Cellulitis Abscess Ulcer Hypersensitivity Contact Cement Chemicals Bites Mosquito Bugs Venous obstruction Deep vein thrombosis Homan’s sign and Pratt’s sign Thrombophlebitis Over-exertion/Thready veins Varicose veins Incompetence of valves Lymphatic obstruction Acute lymphngitis Filarial Lymphatic resection 6

5. Myxedema : 

5. Myxedema Myxedema Symptom complex in Hypothyroidism with non-pitting edema Weight gain Cold intolerance Hoarseness of voice Thyroidomegaly Signs of hypothyroidism Bradycardia Coarse skin Ankle joint edema Non-pitting nature Pretibial myedema An infiltrative dermopathy of hyperthyroidism Waxy disclored induration of skin Anterior aspect of legs alone Or may spread to dorsum of foot peau d'orange appearance Signs of Hyperthyroidism Tachycardia Warm moist skin High frequency fine tremor Weight loss in spite of appetitie 7

6. Capillary Leak Syndrome : 

6. Capillary Leak Syndrome First described by B. Clarkson in 1960 Symptoms generalized edema low blood pressure (hypotension) hemoconcentration hypoalbuminemia without albuminuria The capillary leak phase (1-4 days) Complications Cardiopulmonary collapse Hypovolemia   Acute tubular necrosis Rhabdomyolysis  Acute Renal Failure Second phase results in the recruitment of the initially extravasated fluid. Intravascular overload polyuria Pulmonary edema Edema may be more severe due to massive fluid supply in the initial phase Causes: Dengue fever, Snake bite, Treatment monitor the patient in order to switch to depletion treatment diuretics or  hemofiltration 8

7. Generalized edema : 

7. Generalized edema Symptoms Dyspnoea Exertional Orthopnoea PND Signs Raised JVP S3 gallop Displaced apex Dyskinetic apex Symptoms Altered appetite Altered taste Restless legs Myoclonus Signs Periorbital edema High BP Nitrogenous fetor Pericardial rub Cardiac Renal Hepatic Symptoms Abd distension Pedal edema Orthopnoea Alcohol abuse Signs Jaundice Spider angioma Palmar erythema Asterexis 9

Approach to edema : 

Approach to edema 10

Approach to edema : 

Approach to edema 11

Investigations : 

Investigations 12

Management - Reversing the underlying disorder : 

Management - Reversing the underlying disorder Establish a diagnosis Cardiac Diuretics give symptom relief Does not improve survival Hepatic Spironolactone/Lopp diuretic Paracentesis in grade III ascites Nephrotic syndrome Sodium restriction Combination of loop_ ald antagonist Nutritional Increasing protein intake Supplementing calories Capillary leak syndrome Miscellaneous Drug induced Change of drug to ACEI or ARB Myxedema Administer thyroxine Local Diuretics of little benefit Angioedema Steroids and antihistamines Use non-pharmacological approaches Rest Exercise Stockings Elevation LL 13

Salt restriction in Edema : 

Salt restriction in Edema Record fluid intake and output Check for body fluid loss Weigh the patient daily Obtain a drug history to check for drugs that promote sodium retention Explain the importance of sodium restriction Teach the patient how to plan a low-sodium diet. Closely monitor the serum sodium levels of high-risk patients Restricting the dietary Sodium Normal requirement Need for control Describe types Restriction needed Supplement with Potassium Items to be deleted Pappad Achaar Fried Snacks Table 14

Site of actions of diuretics : 

Site of actions of diuretics Loop diuretics inhibit the sodium-potassium-chloride co-transporter in the thick ascending limb Thiazide diuretics, These inhibit the sodium-chloride transporter in the distal tubule Potassium-sparing diuretics Some drugs in this class antagonize the actions of aldosterone (aldosterone receptor antagonists) at the distal segment of the distal tubule Carbonic anhydrase inhibitors inhibit the transport of bicarbonate out of the proximal convoluted tubule 15

Management of Edema : 

Management of Edema Proximal diuretics CAH Inhibitors Diamox 250 tid PDE Inhibitors Deriphyllin 100 tid Loop diuretics Frusemide Lasix 40-80 tid Torsemide Tide10-20 tid DCT diuretics Hydrochlorthiazide 12.5 BID Metalazone 2.5-5.0mg BID CCT diuretic Aldosterone Antagonists Spironolactone 25-100mg BD Na Ch blocker- Amiloride 5mg OD 16

Treatment Failure : 

Treatment Failure Diuretic resistance Failure to create Negative Na+ balance In spite of maximum dosage of diuretics And restriction of salt to <2gm/day Eg. Frusemide at a dose of 240mg/day Non-compliance Non-adherence to drug/salt restriction Decreased renal perfusion/T Secretion Low volume, Arterial disease, Drugs Tolerance Chronic administration of loop diuretics Pharmacokinetics Oral Frusemide has erratic absorption Add adrug with different site of action Use short acting – more frequently Or replace with long acting Important Follow up for adverse effects Hypokalemia and hypovolemia Continuous intravenous infusion Frusemide 10-20mg/hour Truly refractory cases Intensive care unit setting 17

Slide 18: 

Thank You 18

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