Edward Buga

@FH_Verbrugge discusses the top 10 diuretic mistakes at #HR24 . If you prescribe lasix you need to read these key mistakes👇 10 Diuretic mistakes 🧵 #1: Not getting the job finished.. don't stop diuresis too early. If you fail to decongest, outcomes are worse and there is a higher risk of readmission to hospital. #2: Being distracted by serum Creatinine.. rising Cr does NOT indicate dying kidneys!! #3: Giving oral loop diuretics for in-hospital pts. with clear fluid overload (instead of IV diuretics)... When dosing loop diuretics, there is a threshold effect that until above that you get no effect, and then a ceiling effect where any more diuretics don't increase diuresis. #4: Underdosing (loop) diuretics and compensating with increasing maintenance outpatients doses instead. Lasix dose = 1-2 times oral maintenance dose only makes sense IF the maintenance dose was appropriate... might not be the best place to start. Does house of god (book) have it right? Adjust based on GFR. If you have poor kidney function need higher dosing... general gestalt GFR>45 --> 80 IV lasix GFR 30-45--> 120 IV lasix GFR <30 -->120 IV lasix #5: Too infrequent dosing of loop diuretics LaSIX --> lasts six hours. If you dose too infrequently then you get Na resorption in-between diuretic doses. Start BID or TID with Lasix, not once daily! (sometimes even QID) #6: Using loop diuretic drips (No lasix infusions!) Higher plasma-renin activity with diuretic infusions... #7: Failure to recognize fluid overload when cardiac filling pressures are normal / not terribly elevated You can be overloaded with normal filling pressures. Volume does NOT equal pressure. If overload + high filling pressures --> diurese fast If overload + low filling pressures --> diurese slow #8: Mistaking one size fits all for diuretic resistance Steps to treat diuretic resistance: 1. Maximize Loop Diuretic 2. Add thiazide like diuretic (e.g Metolazone) 3. Add other nephro segment blocker (Acetazolamide, Spiro, Empagliflozin, Amiloride) 4. Consider hyperdiuresis (3% saline with diuretics) 5. Consider diuresis #9: Don't be afraid of combination diuretic therapy ADVOR trial: acetazolamide added to loop diuretic improved decongestion. We need to start thinking about multi-modal diuresis! #10: Don't mistake decongestion for dehydration Decongestion is about removing sodium. Positive sodium balance with net fluid loss still portends worse survival (Hodson et al 2019). #echofirst #Cardiology #medtwitter #foamed #foamcc #pocus #physiology The key is in the pee Check urine sodium concentration 1-2 hours post diuretic ... want a urine Na > 100 ideally (<80 is diuretic resistance)