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Orthostatic Sodium Retention

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101. Lower Gastrointestinal Bleeding (Treatment)

, and urine output. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL. Next: Resuscitation and Initial Assessment The 2016 American Academy of Family Physicians (AAFP) guidelines recommend the following for the initial evaluation, risk stratifcation, and hemodynamic resuscitation [ ] : Obtain a focused history, physical examination, and laboratory studies at time of patient presentation (to determine bleeding severity and potential (...) postural changes with dyspnea, tachypnea, and tachycardia. An orthostatic drop in systolic blood pressure of more than 10 mm Hg or an increase in heart rate of more than 10 beats per minute is indicative of at least 15% of blood volume loss. Severe postural dizziness with a postural pulse increase of at least 30 beats per minute is a sensitive and specific indicator of acute blood loss of more than 630 mL. [ ] A hematocrit level of less than 18% or a decrease of about 6% is indicative of significant

2014 eMedicine.com

102. Geriatric Rehabilitation (Treatment)

physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP (...) ] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive

2014 eMedicine.com

103. Multiple System Atrophy (Treatment)

No data Table 9. Drugs Used to Manage Orthostatic Hypotension in MSA Class Drug Description or Mechanism Corticosteroids Fludrocortisone (Florinef) Mineralocorticoid; sodium retention, primarily in extravascular compartment, causes tissue edema to venous capacitance bed in lower extremity. With this edema, venous bed accommodates decreased volume of blood in an upright posture (high doses, late effect); increases sensitivity to norepinephrine (even with small doses) Sympathomimetic amines Midodrine (...) . Clinicopathologic Correlations Clinical Symptom Pathologic Findings and Location of Damage or Cell Loss Orthostatic hypotension Primary preganglionic damage of intermediolateral cell columns Urinary incontinence (not retention) Preganglionic cell loss in spinal cord (intermediolateral cell columns), related to detrusor hyperreflexia caused mainly by loss of inhibitory input to pontine micturition center (rather than to external urethral sphincter denervation alone) Urinary retention caused by detrusor atonia

2014 eMedicine.com

104. Migraine Headache: Pediatric Perspective (Treatment)

Postdrome Premonitory Migraine with aura (previously known as classic migraine) and migraine without aura (previously known as common migraine) each have a premonitory phase, or prodrome, which may precede the headache phase by up to 24 hours. During this phase, the following features may occur: Irritability Elation or sadness Talkativeness or social withdrawal Increased or decreased appetite Food craving or anorexia Water retention Sleep disturbances These premonitions are often more pronounced (...) , nystagmus, gait unsteadiness, limb incoordination, and dysarthria. Genetic abnormalities have been identified; CACNA1A gene mutations (coding for calcium channel) on chromosome 19 in FHM1; mutations in the ATP1A2 gene (coding for a K/Na-ATPase) on chromosome 1 in FHM2; and mutations in the SCN1A gene (coding for a sodium channel) on chromosome 2 in FHM3. [ ] Consider structural lesions, vasculitis, cerebral hemorrhage, brain tumor, mitochondrial myopathy, encephalopathy, and lactic acidosis

2014 eMedicine.com

105. Nephrosclerosis (Treatment)

dilation by blocking arterial wall calcium uptake Effective in severe hypertension (minoxidil is better than hydralazine) Minoxidil most potent vasodilator available for oral use No dose adjustment in renal failure Best used in combination with a diuretic plus a beta-blocker Adverse effects are as follows: Reflex activation of sympathetic nervous system (headache, tachycardia) Activation of renin-angiotensin system (sodium retention) Loop diuretic possibly required to control edema Hirsutism (minoxidil (...) ) T-wave inversion in approximately 50% of patients on minoxidil Central-acting alpha-2 agonists Effects and indications are as follows: Methyldopa drug of choice in pregnancy Hypertensive emergency (clonidine) Clonidine useful when patient has migraine in association with hypertension Adverse effects are as follows: Sedation Orthostatic hypotension Dry mouth, skin irritation (clonidine patch) Rebound hypertension upon abrupt discontinuation Possible Coombs-positive hemolytic anemia

2014 eMedicine.com

106. Gynecologic Pain (Treatment)

improvement in patients with IC who were treated with amitriptyline. [ ] Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. [ ] Pentosan polysulfate sodium (PPS) (Elmiron) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective (...) a reproductive age woman presents with pelivic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients. Abdominal examination

2014 eMedicine.com

107. Esophageal Varices (Treatment)

can reduce arterial blood pressure and promote the activation of endogenous vasoactive systems that may lead to sodium and water retention. Although ISMN has been demonstrated to reduce HVPG markedly in acute administration, it provides significantly less reduction after long-term administration (due to probable development of patient tolerance). Combination therapy Although many authorities recommended a combination therapy of pharmacologic treatment and EVL as the first-line treatment (...) procedures, and liver transplantation. Decompressive shunts and devascularization procedures are mainly rescue therapies. Management of patients with liver cirrhosis and ascites but without variceal hemorrhage includes a low-sodium diet and diuretics. Nasogastric tube In patients with hemodynamically significant upper gastrointestinal (GI) tract bleeding, a nasogastric tube should remain in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently through

2014 eMedicine.com

108. Hypernatremia (Treatment)

the man's serum sodium, D 5 W will be used. Thus, the retention of 1 L of D 5 W will reduce his serum sodium by (0 - 165) ÷ (35 + 1) = -4.6 mmol. The goal is to reduce his serum sodium by no more than 10 mmol/L in a 24-hour period. Thus, (10 ÷ 4.6) = 2.17 L of solution is required. About 1-1.5 L will be added for obligatory water loss to make a total of up to 3.67 L of D 5 W over 24 hours, or 153 cc/h. A clinically important study by Lindner and colleagues found that all the above formulae correlated (...) Treatment & Management Updated: Dec 06, 2018 Author: Ivo Lukitsch, MD; Chief Editor: Vecihi Batuman, MD, FASN Share Email Print Feedback Close Sections Sections Hypernatremia Treatment Medical Care The goals of management in hypernatremia are as follows [ ] : Recognition of the symptoms, when present Identification of the underlying cause(s) Correction of volume disturbances Correction of hypertonicity Correcting the hypertonicity requires a careful decrease in serum sodium and plasma osmolality

2014 eMedicine.com

109. Proteinuria (Follow-up)

syndrome. Treatment with a loop diuretic or a combination of diuretics such as a thiazide and loop diuretic produces diuresis in most patients. The addition of albumin may improve natriuresis in patients with refractory salt and water retention, but the potential benefits must be weighed against the cost and risks of albumin infusion, which include the possibility of exacerbating fluid overload. Anticoagulants Patients with proteinuria tend to be hypercoagulable due to urinary losses of coagulation (...) of an experimental ETA-selective antagonist, avosentan, in patients with diabetic nephropathy showed a decrease in albuminuria, but with adverse effects including fluid retention and heart failure exacerbation. Atrasentan, another experimental ETA antagonist with a better adverse effect profile than avosentan, has also been shown to reduce proteinuria. [ , ] Vitamin D and proteinuria In animal studies, vitamin D and vitamin D analogues decrease inflammatory mediators and may act as immunosuppressive agents

2014 eMedicine.com

110. Portal Hypertension (Follow-up)

in patients with advanced cirrhosis is that vasodilators can reduce arterial blood pressure and promote the activation of endogenous vasoactive systems that may lead to sodium and water retention. Although ISMN has been demonstrated to reduce HVPG markedly in acute administration, it provides significantly less reduction after long-term administration (due to probable development of patient tolerance). Combination therapy Although many authorities recommended a combination therapy of pharmacologic (...) , devascularization procedures, and liver transplantation. Decompressive shunts and devascularization procedures are mainly rescue therapies. Management of patients with liver cirrhosis and ascites but without variceal hemorrhage includes a low-sodium diet and diuretics. Nasogastric tube In patients with hemodynamically significant upper gastrointestinal (GI) tract bleeding, a nasogastric tube should remain in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently

2014 eMedicine.com

111. Lower Gastrointestinal Bleeding (Follow-up)

, and urine output. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL. Next: Resuscitation and Initial Assessment The 2016 American Academy of Family Physicians (AAFP) guidelines recommend the following for the initial evaluation, risk stratifcation, and hemodynamic resuscitation [ ] : Obtain a focused history, physical examination, and laboratory studies at time of patient presentation (to determine bleeding severity and potential (...) postural changes with dyspnea, tachypnea, and tachycardia. An orthostatic drop in systolic blood pressure of more than 10 mm Hg or an increase in heart rate of more than 10 beats per minute is indicative of at least 15% of blood volume loss. Severe postural dizziness with a postural pulse increase of at least 30 beats per minute is a sensitive and specific indicator of acute blood loss of more than 630 mL. [ ] A hematocrit level of less than 18% or a decrease of about 6% is indicative of significant

2014 eMedicine.com

113. Multiple System Atrophy (Follow-up)

No data Table 9. Drugs Used to Manage Orthostatic Hypotension in MSA Class Drug Description or Mechanism Corticosteroids Fludrocortisone (Florinef) Mineralocorticoid; sodium retention, primarily in extravascular compartment, causes tissue edema to venous capacitance bed in lower extremity. With this edema, venous bed accommodates decreased volume of blood in an upright posture (high doses, late effect); increases sensitivity to norepinephrine (even with small doses) Sympathomimetic amines Midodrine (...) . Clinicopathologic Correlations Clinical Symptom Pathologic Findings and Location of Damage or Cell Loss Orthostatic hypotension Primary preganglionic damage of intermediolateral cell columns Urinary incontinence (not retention) Preganglionic cell loss in spinal cord (intermediolateral cell columns), related to detrusor hyperreflexia caused mainly by loss of inhibitory input to pontine micturition center (rather than to external urethral sphincter denervation alone) Urinary retention caused by detrusor atonia

2014 eMedicine.com

114. Migraine Headache: Pediatric Perspective (Follow-up)

Postdrome Premonitory Migraine with aura (previously known as classic migraine) and migraine without aura (previously known as common migraine) each have a premonitory phase, or prodrome, which may precede the headache phase by up to 24 hours. During this phase, the following features may occur: Irritability Elation or sadness Talkativeness or social withdrawal Increased or decreased appetite Food craving or anorexia Water retention Sleep disturbances These premonitions are often more pronounced (...) , nystagmus, gait unsteadiness, limb incoordination, and dysarthria. Genetic abnormalities have been identified; CACNA1A gene mutations (coding for calcium channel) on chromosome 19 in FHM1; mutations in the ATP1A2 gene (coding for a K/Na-ATPase) on chromosome 1 in FHM2; and mutations in the SCN1A gene (coding for a sodium channel) on chromosome 2 in FHM3. [ ] Consider structural lesions, vasculitis, cerebral hemorrhage, brain tumor, mitochondrial myopathy, encephalopathy, and lactic acidosis

2014 eMedicine.com

115. Spinal Cord Trauma and Related Diseases (Follow-up)

hypotension after high lesions resolves, although orthostatic hypotension persists. For lesions above the lumbar/sacral centers for bladder control, the initial urinary retention is replaced by the development of an automatic spastic bladder. Lower lesions lead to permanent atonic bladder (lower motor neuron pattern). In humans, constipation persists and may contribute to delayed gastric emptying. Autonomic hyperreflexia in this phase is characterized by massive firing of sympathetic neurons after (...) extremity areflexia Anesthesia below the affected level Neurogenic shock (ie, hypotension without compensatory tachycardia) Loss of rectal and bladder sphincter tone Urinary and bowel retention leading to abdominal distention, ileus, and delayed gastric emptying Horner syndrome (ie, ipsilateral ptosis, miosis, anhydrosis): This is also present with higher lesions because of interruption of the descending sympathetic pathways originating from the hypothalamus. Lower cervical level injury spares

2014 eMedicine.com

116. Cardiovascular Concerns in Spinal Cord Injury (Follow-up)

in the management of orthostatic hypotension Atropine: Drug of choice for bradycardia but rarely used in rehabilitation settings except during emergencies (phenylephrine and dopamine also can be considered) Alpha-adrenergic agonists: Improve the patient's hemodynamic status by increasing myocardial contractility and heart rate Corticosteroids: Cause sodium and fluid retention, resulting in improvements in symptomatic orthostatic hypotension Sympathomimetics: Augment coronary and cerebral blood flow (...) lead to increased blood pressure. Corticosteroids cause sodium and fluid retention to improve symptomatic orthostatic hypotension, and sympathomimetics augment coronary and cerebral blood flow. Anticholinergics are administered to improve conduction through the atrioventricular (AV) node; this is accomplished by a reduction of vagal tone by way of muscarinic receptor blockade. Previous References Partida E, Mironets E, Hou S, Tom VJ. Cardiovascular dysfunction following spinal cord injury. Neural

2014 eMedicine.com

117. Cauda Equina and Conus Medullaris Syndromes (Follow-up)

therapy. Methylprednisolone should be administered. It treatment must be started within 8 hours of injury. No evidence exists of any benefit if it is started more than 8 hours after injury; on the contrary, late treatment may have detrimental effects. Administration of ganglioside GM1 sodium salt beginning within 72 hours of injury may be beneficial; the dose is 100 mg IV qd for 18-32 days. Tirilazad mesylate (a nonglucocorticoid 21-aminosteroid) has been proven to be of benefit in animals (...) are to maximize the medical, physical, psychological, educational, vocational, and social function of the patient. To maximize medical function, ensure adequate prevention and treatment of possible medical complications already discussed, especially deep venous thrombosis, bladder and bowel problems, and decubitus ulcers Physical therapy Perform range of motion and strengthening exercises, sitting balance, transfer training, and tilt table as tolerated (because of tendency to orthostatic hypotension). Tilt

2014 eMedicine.com

118. Diabetic Neuropathy (Follow-up)

if the drug is clinically appropriate for their patients on a case-by-case basis. Gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management. According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently experience adverse side effects, these are usually tolerable, and serious side (...) that adverse effects can be monitored if possible. Decrease or increase drug dose if indicated. For many of these medications, use for neuropathic pain is off-label; they were approved by the Food and Drug Administration for other indications. Many are in the news for questionable side effects (eg, increased blood pressure and edema from salt retention with fludrocortisones). Nevertheless, multiple clinical studies show benefit for the use of these medications in the treatment of neuropathic pain. Use

2014 eMedicine.com

119. Diabetic Neuropathy (Follow-up)

if the drug is clinically appropriate for their patients on a case-by-case basis. Gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management. According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently experience adverse side effects, these are usually tolerable, and serious side (...) that adverse effects can be monitored if possible. Decrease or increase drug dose if indicated. For many of these medications, use for neuropathic pain is off-label; they were approved by the Food and Drug Administration for other indications. Many are in the news for questionable side effects (eg, increased blood pressure and edema from salt retention with fludrocortisones). Nevertheless, multiple clinical studies show benefit for the use of these medications in the treatment of neuropathic pain. Use

2014 eMedicine.com

120. Diabetes Mellitus, Type 2 (Follow-up)

or insulin secretagogues. [ ] These effects may induce or worsen heart failure in patients with left ventricular compromise and occasionally in patients with normal left ventricular function. TZDs have not been tested in patients with New York Heart Association class III or IV heart failure. Fluid retention from TZDs has been considered resistant to treatment with loop diuretics, because of upregulation of renal epithelial sodium channels. However, a randomized, double-blind, placebo-controlled (...) in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter–2 (SGLT-2) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists A literature review by Alfayez et al indicated that GLP-1 agonists, DPP-4 inhibitors, and SGLT-2

2014 eMedicine.com

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