Short-term tolerance should be considered when there is a decrease in response after the first dose of a diuretic has been taken. Long-term use of compression garments in conjunction with meticulous skin care and avoidance of blood pressure measurements and other constrictions should be considered in patients with lymphedema.Īnother potential cause of treatment failure is diuretic tolerance. Paracentesis is the treatment of choice in patients with grade 3 ascites and should be used in conjunction with sodium restriction and diuretic therapy. Spironolactone should be used in patients with cirrhosis and grade 2 or 3 ascites to combat hyperaldosteronism. Travel stockings (i.e., “support hose”) should be worn during flights longer than seven hours to prevent edema and DVT. The use of a transjugular intrahepatic portosystemic shunt may be superior to large-volume paracentesis in relieving ascites and prolonging survival. Spironolactone (Aldactone) should be used to decrease morbidity and mortality rates in patients with NYHA class III or IV heart failure. Treatment with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker should be considered in patients with calcium channel blocker–induced pedal edema. Compression garments and range-of-motion exercises may be helpful in patients with this condition. Lymphedema occurs when a protein-rich fluid accumulates in the interstitium. Dihydropyridine-induced edema can be treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. In patients with cirrhosis, ascites is treated with paracentesis and spironolactone. In patients with New York Heart Association class III and IV congestive heart failure, spironolactone has been found to reduce morbidity and mortality rates. Loop diuretics often are used alone or in combination. Leg elevation may be helpful in some patients. Treatment includes sodium restriction, diuretic use, and appropriate management of the underlying disorder. A systematic approach is warranted to determine the underlying diagnosis. Major causes of edema include venous obstruction, increased capillary permeability, and increased plasma volume secondary to sodium and water retention. The kidneys play a key role in regulating extracellular fluid volume by adjusting sodium and water excretion. Edema is the result of an imbalance in the filtration system between the capillary and interstitial spaces.
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