Pennsylvania Academy of Family Physicians Foundation & UPMC 43rd Refresher Course in Family Medicine CME Conference March 10-13, 2016

Transcription

1 Pennsylvania Academy of Family Physicians Foundation & UPMC 43rd Refresher Course in Family Medicine CME Conference March 10-13, 2016 Disclosures: A Swell Talk on Edema Laura Novak, MD Speaker has no disclosures and there are no conflicts of interest. The speaker has attested that their presentation will be free of all commercial bias toward a specific company and its products. The speaker indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices.

2 Water, Water Everywhere L Novak Disclosure The speaker has no conflict of interest, financial agreement, or working affiliation with any group or organization. 2 Objectives Be able to describe and assess peripheral edema Be familiar with appropriate diagnostic testing Discuss effective management based on the etiology of edema I have no conflicts of interest to report 3 1

3 30 minutes to cover edema Dozens of causes Dozens of treatments So we aren t going to cover everything but will focus on the more common causes (no picnic) 4 We ll start with the basics Fluid circulation 2 systems Vascular Lymphatic 5 There s a lot going on in there 6 2

4 Regulated by : Fluid Volume Absorption in the gut Excretion by the kidney Antidiuretic hormone Multiple ion pumps 7 Fluid Balance Fluid is filtered out into tissue by Arterial pressure Intravascular volume Fluid is drawn back into circulation by Protein concentration in blood Local tissue pressure Microscopic pores 8 Disruption of Fluid Balance Increased circulating volume Back pressure from obstruction Decreased protein concentration Inflammation and leaking 9 3

5 Edema Palpable fluid in the periphery Clinically apparent at 2 L (Circulating volume is ~ 5 L) 10 Etiologies can overlap A morbidly obese patient may have Diastolic CHF ( HFpEF ) Pulmonary HT Sleep apnea AND Venous insufficiency BUT: 11 We will discuss them as separate entities 12 4

6 The first questions to ask Bilateral or unilateral Generalized or localized Normal or increased circulatory volume Bilateral and generalized edema Common systemic causes: Cardiac Right sided HF Pulmonary HT Renal disease Cirrhosis 15 5

7 Cardiac Failure Perceived decreased cardiac output The body retains fluid to correct the deficit Left sided HF pulmonary edema Right sided HF peripheral edema Can have both types 16 Right-sided failure Increased pulmonary artery pressure Increased jugular venous distention Peripheral edema 17 Jugular venous distention An indirect measure of right heart pressure Exam has limits, but is helpful when high 18 6

8 Lay the patient at a 45 degree angle. Turn their head away from you. Look for a > 3 cm column of venous blood (external jugular) 19 Confirmatory CHF Testing Echocardiogram Distinguishes systolic(hfref) / diastolic (HFpEF) Can find pulmonary hypertension BNP (b-type natiuretic peptide) Marker of ventricular stretch Most helpful in inpatient settings Elevated in renal failure (so don t use) 20 Treatment for CHF Salt restriction, medications, risk factor reduction but: We will discuss diuresis Goal is to: Decrease excess intravascular volume Which draws edema in from periphery BUT must maintain cardiac output Warm and dry 21 7

9 Good News! 22 Loop Diuretics Loop diuretics are the strongest diuretics Three common loop diuretics All are equally effective at equipotent doses Furosemide (Lasix) - 40 mg po ($ 4) Bumetanide (Bumex) - 1 mg po ($20) Torsemide (Demadex) - 20 mg po ($35) (In most situations,change dose before brand) 23 Dosing Minimal effective dose Found by therapeutic trial Like a light switch If a given dose is not effective, using it bid will not increase efficacy 24 8

10 All can be given IV Dosing Furosemide IV is unique more potent than po 20 mg IV = 40 mg po The others are not 25 Side effects Low potassium and Mg Hypotension Increased BUN / Cr Patients avoid taking loops due to frequency / incontinence 26 Thiazides Weak diuretics Not used for diuresis, BUT Can be used in combination with loops in resistant edema Blocks reabsorption of salt and water further down the nephron 27 9

11 Any thiazide* Co-administration Give at the same time (or 30 min earlier) 2x diuresis but significant potassium loss Use sparingly (and stop HCTZ for HTN when the pt starts a loop) (* eg HCTZ, Chlorthalidone, metolazone (Zaroxolyn)) 28 Potassium sparing diuretics Spironolactone Weak diuretic Used in CHF but not for diuresis Renin-angiotensin system 29 Diuresis in CHF Daily or bid loop at an effective level Try to achieve a dry weight Obtain daily weights. Call if weight increases by ~ 3 pounds Ask what tipped the patient out of balance Increase diuretic short term 30 10

12 Edema in renal disease Fluid overload from Renal failure Nephrotic syndrome (severe protein loss) As there is intravascular fluid overload, diuresis can be tried until disease specific treatments begin 31 Cirrhosis There are many causes for cirrhotic liver failure Appropriate circulating volume with third spacing Diuresis needs to be cautious spironolactone +/- furosemide 100mg/40mg ratio 32 For most patients, Bilateral generalized edema should be treated with diuresis and treatment of the underlying disease 33 11

13 There are other, less obvious causes of generalized edema 34 Idiopathic edema Obstructive sleep apnea (OSA) Frequent cause of idiopathic edema Edema can be seen with or without pulmonary HT CPAP may reverse edema 35 Dieting Use of diuretics for weight loss or water retention Sets up a cycle of use - rebound - use Don t prescribe / Wean 36 12

14 Medications The timing is the clue Vasodilators Nifedipine (Procardia) Amlodipine (Norvasc) Glitazones pioglitazone (Actos) rosiglitazone (Avandia) NSAIDs Treatment- a trial off meds 37 Change in direction 38 Localized edema - bilateral Chronic venous stasis Gradual accumulation of fluid in the legs from back pressure and venous reflux Over time the legs develop pitting, hemosiderin deposits, eczematous changes, deformity, scarring and ulceration The chronic redness can mimic cellulitis 39 13

15 Pitting Management There is no generalized fluid overload Intravascular volume is normal Try to avoid diuretics Elevation Feet above heart for 30 minutes twice a day So not a recliner Not MOST recliners 42 14

16 Compression hose Graduated compression mm Hg for most (moderate) mm Hg if severe (firm-extra firm) (Ted hose 8-10) 43 Compression Hose OTC ($20) or Rx ( $$) Knee high Open or closed toe Small, med, large Can custom-size ($$$) Eg Jobst Can get OTC on Amazon What can t you get on Amazon? 44 Hard to put on Zippers ($70) Stocking applicators ($25) Again, Amazon Have an expert in your office 45 15

17 Compression Stockings Don t use in Peripheral Vascular Disease screen with ABI if at risk 46 Exercise In one study, 1/3 of patients with chronic venous stasis didn t have one 10 min walk per week Chair exercise Circling and flexing feet 47 Horse chestnut The active ingredients have been found to decrease edema and pain in several small studies BUT: They are coumarin derivatives and can t be given with warfarin They interact with most diabetes drugs and antiplatelet meds 48 16

18 Venous ablation 49 Emollients Skin care Vaseline, Aquaphor Hydrocortisone cream if there are eczematous changes If ulceration develops Intensify treatment Consider a wound care clinic 50 Diuretics When edema becomes severe enough, we usually add diuretics But don t stop promoting the mechanical treatments 51 17

19 Lymphedema Disrupted lymph system Obesity vs obstruction vs trauma Hard to distinguish from venous stasis In early stages, it pits and swells. With time, the skin thickens and there is more rigidity and less pitting The skin near the toes won t tent (Stemmer s sign) Stemmer s sign 54 18

20 Treatment Diuretics don t mobilize lymph spaces Treatment : 2-4 weeks of: Compression wraps Decongestive massage Pumping Followed by compression stockings Low compliance High rebound Lipedema Fat deposits Spares ankles and feet 57 19

21 58 Unilateral edema DVT (deep vein thrombosis) Baker s cyst (popliteal synovial cyst) Obstruction 59 DVT/ VTE Thrombus in the deep venous system Risks trauma, immobilization, travel, cancer, hormones Exam: Unilateral swelling, pain, warmth Homan s sign (pain with dorsiflexion of foot) is not helpful if positive or negative 60 20

22 Diagnosis In low probability patients, use a risk assessment tool (there are many) and a d-dimer blood test In higher probability patients, use ultrasound 61 Well s Risk Assessment 62 D-dimer Thrombin breakdown product Useful if negative, not helpful if positive Don t order in post-op patients Use age adjusted normals If risk assessment tool is low and d-dimer is negative, you don t need an ultrasound Risk scales miss some patients. When in doubt, image the patient 63 21

23 Duplex scanning Two tests: Ultrasound for compressibility Color doppler for flow Limited by: Obesity Hard to distinguish new clot from old clot 64 Ultrasound - compressibility 65 Color doppler flow 66 22

24 Treatment Choice Chest Supplement 2016 recommends : Start with an oral Xa inhibitor Apixaban and rivaroxaban don t need bridged Dabigatrin and edoxaban need LMWH first Outpatient treatment when possible Compression stockings are no longer recommended unless there s symptomatic postthrombotic syndrome 67 Orals Rivaroxiban (Xarelto) Apixaban (Eliquis) Eboxaban (Savaysa) Dabigatran (Pradaxa) $300/month Vs hospital stay or INRs No reversibility at this time 68 Length of treatment Provoked? -3 mo Unprovoked? 3 mo then risk assess Recurrent no end point Cancer - LMWH 3 mo then reassess 69 23

25 Reassess Risk of bleeding (3-5%) vs risk of recurrence (up to 20 % for unprovoked clots) More data D dimer off meds or repeat duplex Risk scales (HERDOO) Aspirin post anticoagulation if unprovoked 70 Baker s cyst Synovial bursal cyst Best seen with a straight leg Best felt with a bent leg Can confirm with Ultrasound if needed Treatment Observation Drainage +/- steroids High recurrence rate 71 Baker s cyst 72 24

26 Edema from Obstruction External compression of the vein by nodes, tumor, constriction Look for the source 73 Summary Systemic,generalized edema should be treated by addressing the disease process and appropriate diuresis Chronic venous stasis and lymphedema should be treated with compression before diuretics In real life, many diseases overlap