This is the second post in a new series based upon my ward rounds. Yesterday, I discussed learning climate. Today I will discuss an important issue we discussed on rounds – diuretic dose for heart failure.
We have a gentleman with significant heart failure, who came to the hospital with pulmonary edema. He responded nicely to IV furosemide. Until this episode he has not been taking diuretics.
My students and residents know that I have many “rules” or aphorisms. This situation brings out one of my favorites:
The goal of diuretic therapy in heart failure is to render the patient not wet; it is not to dry out the patient.
Let me translate. We want to give enough diuretic therapy to reduce symptoms, but we do not want to have intravascular volume depletion.
How can we tell? When the creatinine starts increasing, we have probably overdiuresed the patient.
When caring for outpatients, I use “sliding scale” diuretics. This patient only has left side symptoms – no edema. Thus, we are telling the patient to only take his diuretic when his exercise tolerance decreases. He now is back to his baseline for walking. If this worsens, then he should take a diuretic dose that day.
Some patients require daily weights to manage their diuretics. Some patients manage their diuretics on the basis of ankle edema. Regardless I try to not use a standard diuretic dose, rather I focus on trying to improve patient symptoms and prevent worsening.
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2 Responses to Diuretic therapy
Steve Lucas
February 2nd, 2008 at 1:51 pm
A Jan. 28th WSJ Health Blog piece highlights how diuretics are also as effective in treating high blood pressure as some newer branded drugs. Cheap, effective and with known side effects, it is always interesting when a doctor prescribes a branded drug, which does not have the desired effect, adds a diuretic, which does bring down a person’s bp, and then sings the praises of the branded drug.
Of course the branded drug rep does bring lunch, pens, clipboards, clocks, ……
Steve Lucas
amy
February 2nd, 2008 at 3:57 pm
Another good way is to go by weight. Each CHF patient has an ideal weight. I tell them to cut the diuretic dose below a certain weight and go up at a certain weight.