Still rounding on 8 patients yesterday. We are on call again today, but plan multiple discharges today.
A reader posed a good question yesterday in my discussion about bumetanide and furosemide. The reader championed torsamide. That loop diuretic might be the best, but it is not available at the VA or on the WalMart $4 list. The comment makes some good points.
Looking at the lab tests on our patient with cirrhosis, yesterday he had hyponatremia and urine osms > 500. I have not seen this explicitly discussed in the literature, but I make the following observations:
- Hyponatremia is a very bad prognostic sign – Hyponatremia and Mortality among Patients on the Liver-Transplant Waiting List
- Hyponatremia occurs due to decreased intra-arterial volume, despite increased plasma volume – Decreased Effective Blood Volume in Edematous Disorders: What Does This Mean?
- We discussed the possible use of Tolvaptan in this situation – but remembered that it cost $177 per pill!
- We offered palliative care to this patient, he is not ready to accept this strategy.
Today we will focus on the treatment of our patient with achalasia. He had a failed botox treatment last week, although he had success in the past. First thing this a.m. I will discuss options with our GI consultants.
We are treating his serious infection successfully, but we need to help him get oral nutrition.
{ 3 comments… read them below or add one }
Does hyponatremia occur because of decreased intravascular volume or do they often coexist ? Cause and effect or common cause?
And what is decreased intravascular volume anyway? It can't be directly measured unless you have massive acute fluid losses. IT's a pretty nebulous concept in the chronic state.
I have always thought edematous states like cirhossis result from avid sodium retention and an excess of total body sodium. For whatever reason, portal pressure, decreased oncotic pressure, this fluid is not retained in the vascular space creating edema and ascites..
Many patients have an increased sense of thirst, you often have to hide water from them, (?angiotensin system) and so you are faced with a total body excess of sodium, undeniable and an intravascular excess of free water.
Absent correcting the liver problem the only real treatment is sodium restriction, mild diuresis (so as not to aggravate the liver problem) and water restriction.
Thoughts?
Palliative care discussed when there are potential therapeutic options available?
wtf?
what was his serum sodium?