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Orthostatic Sodium Retention

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121. 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

122. Diabetic Neuropathy (Treatment)

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 (...) such as vacuum devices or intracavernosal papaverine injections may be tried. Referral to a urologist is suggested. Orthostatic hypotension Symptomatic orthostatic hypotension can be troubling in patients with diabetic neuropathy. Increasing the dietary fluid and salt intake, along with use of compression stockings, may help. If these modalities do not improve symptoms, then medication may help. [ ] Gustatory sweating Glycopyrrolate is an antimuscarinic compound that can be used for the treatment

2014 eMedicine.com

123. Diabetic Neuropathy (Treatment)

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 (...) such as vacuum devices or intracavernosal papaverine injections may be tried. Referral to a urologist is suggested. Orthostatic hypotension Symptomatic orthostatic hypotension can be troubling in patients with diabetic neuropathy. Increasing the dietary fluid and salt intake, along with use of compression stockings, may help. If these modalities do not improve symptoms, then medication may help. [ ] Gustatory sweating Glycopyrrolate is an antimuscarinic compound that can be used for the treatment

2014 eMedicine.com

124. Diabetes Mellitus, Type 2 (Treatment)

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

125. Diabetes Mellitus, Type 1 (Treatment)

or parasympathetic chains and produce myriad manifestations. [ , ] Patients likely to seek care in the ED are those with diabetic gastroparesis and vomiting, severe diarrhea, bladder dysfunction and urinary retention, or symptomatic orthostatic hypotension. Treatment of gastroparesis is symptomatic, and symptoms tend to wax and wane. Patients with gastroparesis may benefit from metoclopramide or erythromycin. Before these therapies are started, the degree of dehydration and metabolic imbalance must be assessed (...) , and other serious causes of vomiting must be excluded. In severe cases, gastric pacing has been used. Patients with disabling orthostatic hypotension may be treated with salt tablets, support stockings, or fludrocortisone. Alleviating the functional abnormalities associated with the autonomic neuropathy is often difficult and frustrating for both doctor and patient. (See and .) Diabetic foot disease Patients with diabetes who present with wounds, infections, or ulcers of the foot should be treated

2014 eMedicine.com

126. 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

127. Cauda Equina and Conus Medullaris Syndromes (Treatment)

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

128. Cardiovascular Concerns in Spinal Cord Injury (Treatment)

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

129. Assistive Devices to Improve Independence (Treatment)

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 (...) , female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension. Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of studies suggest

2014 eMedicine.com

131. 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

132. 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 (...) compression, bending forward, and placing 1 foot on a chair, can be effective in preventing episodes of orthostatic hypotension. Wearing an external support garment that comes to the waist improves venous return and preload to the heart during standing but loses effectiveness if the patient also wears it while supine. Increased salt and fluid intake and tilted sleeping with the head elevated increase the circulatory plasma volume. Postprandial hypotension Small, frequent meals attenuate BP drop after

2014 eMedicine.com

133. Hypertension (Treatment)

) inhibition was more effective than dual blockade (ACE inhibitor [ACEI] and angiotensin II receptor blocker [ARB]) in reducing both proteinuria and BP in nondiabetic patients with modest chronic kidney disease. Furthermore, a low-sodium diet added to dual therapy yielded additional reductions in both BP and proteinuria, emphasizing the beneficial effect of dietary salt reduction in the management of hypertensive patients with renal insufficiency. The DASH eating plan encompasses a diet rich in fruits (...) using newer techniques. [ ] Consultations Consultations with a nutritionist and exercise specialist are often helpful in changing lifestyle and initiating weight loss. Consultation with a hypertension specialist is indicated for management of secondary hypertension attributable to a specific cause. Next: Nonpharmacologic Therapy Dietary changes A number of studies have documented an association between sodium chloride intake and BP. The effect of sodium chloride is particularly important

2014 eMedicine.com

134. 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 (...) fluid dynamics: back to the future. J Am Soc Nephrol . 2011 Dec. 22(12):2166-81. . Sterns HR. Renal function and disorders of water and sodium balance. ACP Medicine: A Publication of the American College of Physicians . New York, NY: WebMD; 2005. 10.1-10.19. Boone M, Deen PM. Physiology and pathophysiology of the vasopressin-regulated renal water reabsorption. Pflugers Arch . 2008 Sep. 456(6):1005-24. . . Loh JA, Verbalis JG. Disorders of water and salt metabolism associated with pituitary disease

2014 eMedicine.com

135. Paraneoplastic Autonomic Neuropathy (Treatment)

and salt intake. Equipment aids may be helpful; these include tight support stockings, abdominal binders or antigravity suits for symptomatic hypotension, and bladder catheterization for urinary retention. Dietary fiber and enemas may help improve bowel motility and decrease straining during defecation. Patients with decreased sweating should limit their physical activity, particularly in hot weather. Sponging with water during activity may help prevent overheating. Large meals may exacerbate (...) and salt intake is of potential value for orthostatic hypotension. A fiber-rich diet can help some gastric dysmotility symptoms. Previous References Graus F, Delattre JY, Antoine JC, et al. Recommended diagnostic criteria for paraneoplastic neurological syndromes. J Neurol Neurosurg Psychiatry . 2004 Aug. 75(8):1135-40. . Anderson NE, Rosenblum MK, Graus F. Autoantibodies in paraneoplastic syndromes associated with small-cell lung cancer. Neurology . 1988 Sep. 38(9):1391-8. . Elrington GM, Murray NM

2014 eMedicine.com

136. Proteinuria (Treatment)

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 (...) studies have reported statins to be renoprotective and decrease levels of proteinuria. [ , ] Dyslipidemia usually improves once the proteinuria resolves or immunosuppression is started. Previous Next: Diet Sodium restriction The glomerular capillary pressure can increase in the presense of high sodium intake. Vegter et al found that for nondiabetic patients with chronic kidney disease, high dietary salt (>14 g daily) appeared to blunt the antiproteinuric effect of ACE inhibitor therapy and increase

2014 eMedicine.com

137. 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

138. Portal Hypertension (Treatment)

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

140. 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

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