The rotation comes to an end

Today was my last day for this 2 week rotation.  While there are clear personal advantages to a 2 week rotation, I still prefer doing a full month.  My administrative circumstances make a full month very difficult, so I will probably have to compromise with shorter rotations. The month was delightful.  I had wonderful housestaff and students.  They were all as eager to learn as I was to teach. Because I have 2 jobs in two cities, I will still be making rounds for 2-3 days at a time on a regular basis.  The attending rounds feature is a new one, which I will gladly continue if the readership so desires.  I will post episodically until I have another 2 week rotation, if you wish. I taught many small things today.  Perhaps the most important was the reason for diuretic resistance.  This abstract explains diuretic resistance. My quick summary

1. Loop diuretics work on the Na-K-2Cl cotransporter in the ascending limb of the loop of Henle.
2. With chronic "bombardment"  of that site, we have increased flow of urine distally.
3. In the distal tubule, the NaCl exchanger normal reabsorbs a small amount of NaCl.
4. Increased flow past this site, stimulates the number of exchangers produced, and thus with more exchangers, we have more NaCl reabsorption distally, counteracting the effect of the loop diuretic.
5. When patients do not respond to IV loop diuretic at a standard dose (e.g. 100-120 mg of furosemide) then I assume diuretic resistance.
6. Because of the physiology, adding a thiazide diuretic allows diuresis.
7. If the patient needs IV therapy, I use 500 mg of chlorothiazide.  If they can take p.o. meds I personally have always used 5 mg of metolazone, although I understand 50 mg of hydrochlorothiazide also works.
8. I only use the second diuretic to return the volume status to normal.

Remember the goal of diuretic therapy is to keep the patient "not wet", not to make the patient dry.  Most diuretic resistance can be avoided by limiting the amount of diuretic used on a daily basis.