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    Caricato da

    Carlos Hernández
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    40

    Caricato da

    Carlos Hernández

    Copyright:

    © All Rights Reserved
    Scarica in formato TXT, PDF, TXT o leggi online su Scribd
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    di 181

    var title_f0_40_640="Medication esophagitis Endosc";

    var content_f0_40_640=[" <div id=\"graphicsToolbar\">",


    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=GAST
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    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
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    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=GAST
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    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
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    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Medication-induced esophagitis",
    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " Characteristic endoscopic appearance of medication-induced esophagitis showing
    a discrete ulcer in the distal esophagus with normal appearing adjacent mucosa.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of James B McGee, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_40_640=null;
    var title_f0_40_641="Pulm AVM CT I";
    var content_f0_40_641=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PULM
    %2F62261&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=PULM
    %2F62261&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Arteriovenous malformation in right lower lobe in patient who developed a
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    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " A CT scan confirms a tangle of vessels in right lower lobe and draining vein
    coursing towards left atrium.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Paul Stark, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_641=[""].join("\n");
    var outline_f0_40_641=null;
    var title_f0_40_642="Viral conjunctivitis";
    var content_f0_40_642=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " Viral conjunctivitis typically presents as injection, watery or mucoserous
    discharge, and a burning, sandy, or gritty feeling in one eye.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced with permission from: Trobe JD. The Eyes Have It: An interactive
    teaching and assessment program on vision care. WK Kellog Eye Center, University of
    Michigan. Copyright &copy; Jonathan D Trobe, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_642=[""].join("\n");
    var outline_f0_40_642=null;
    var title_f0_40_643="Barium swallow PI";
    var content_f0_40_643=[" <div id=\"graphicsToolbar\">",
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    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PI
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    " <a class=\"icontxt textLink\" href=\"?imageKey=PI
    %2F69107&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
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    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 510px\">",
    " <div class=\"ttl\">",
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    " </div>",
    " <div class=\"lgnd\">",
    " This figure shows an actual x-ray of someone with achalasia. You can see that
    the lower esophagus is enlarged compared to the upper part, and that the lower
    esophageal sphincter is very narrow. The damaged lower esophageal sphincter makes
    it hard for food and fluid to pass into the stomach.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
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    var title_f0_40_644="Lodoxamide tromethamine: Patient drug information";
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    " <div id=\"drugTitle\">",
    " Lodoxamide tromethamine: Patient drug information",
    " </div>",
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    " Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
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    " (For additional information",
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    " <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F189444\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: U.S.",
    " </span>",
    " <ul>",
    " <li>",
    " Alomide&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F189445\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " Brand Names: Canada",
    " </span>",
    " <ul>",
    " <li>",
    " Alomide&reg;",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yya-os drugH1Div\" id=\"F10016839\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What is this drug used for?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2691836",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " It is used to treat eye swelling.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt coi-os drugH1Div\" id=\"F10016838\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What do I need to tell my doctor before I take this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2702403",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have an allergy to lodoxamide or any other part of this drug.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2705171",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you are allergic to any drugs, foods, or other substances. Tell your
    doctor about the allergy and what signs you had, like rash; hives; itching;
    shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
    any other signs.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yye-os drugH1Div\" id=\"F10016843\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some things I need to know or do while I take this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699677",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep a list of all your drugs (prescription, natural products, vitamins,
    OTC) with you. Give this list to your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696947",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not use this drug to treat contact lens irritation.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696717",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Check all drugs you are taking with your doctor. This drug may not mix well
    with some other drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697641",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Tell your doctor if you are pregnant or plan on getting pregnant. You will
    need to talk about the benefits and risks of using this drug while you are
    pregnant.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697636",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Tell your doctor if you are breast-feeding. You will need to talk about any
    risks to your baby.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyf-os drugH1Div\" id=\"F10016844\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some side effects of this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698119",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Headache.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698045",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Eye irritation.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2697908",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Blurred eyesight.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F10016846\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What are some side effects that I need to call my doctor about right away?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698721",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you think there has been an overdose, call 1-800-222-1222 (the American
    Association of Poison Control Centers), your local poison control center
    (file://www.aapcc.org), or emergency room (ER) right away.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699066",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Signs of an allergic reaction, like rash; hives; itching; red, swollen,
    blistered, or peeling skin with or without fever; wheezing; tightness in the chest
    or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
    mouth, face, lips, tongue, or throat.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699086",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Sudden change in eyesight, eye pain, or irritation.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698603",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Any rash.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2698977",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Side effect or health problem is not better or you are feeling worse.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F10016841\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " How is this drug best taken?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2694913",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " For the eye only.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2695783",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Take out contact lenses before using this drug. Lenses may be put back in
    15 minutes after this drug is given. Do not put contacts back in if your eyes are
    irritated or infected.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2694779",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not touch the container tip to the eye, lid, or other skin.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696124",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Tilt your head back and drop drug into the eye.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2694401",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " After use, keep your eyes closed. Put pressure on the inside corner of the
    eye. Do this for 1 to 2 minutes. This keeps the drug in your eye.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2695618",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Space each eye drug by 5 minutes.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyd-os drugH1Div\" id=\"F10016842\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " What do I do if I miss a dose?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696583",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Use a missed dose as soon as you think about it.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696496",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If it is close to the time for your next dose, skip the missed dose and go
    back to your normal time.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2696485",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not use 2 doses or extra doses.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyi-os drugH1Div\" id=\"F10016847\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " How do I store and/or throw out this drug?",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699336",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Store at room temperature.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b498:s2699166",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not use if solution changes color.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " <div class=\"ord-stmt yyj-os drugH1Div\" id=\"F10016848\"
    xmlns=\"file://www.w3.org/1999/xhtml\">",
    " <span class=\"drugH1\">",
    " General drug facts",
    " </span>",
    " <ul class=\"statements\" style=\"list-style-type:none;\">",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699675",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If your symptoms or health problems do not get better or if they become
    worse, call your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699673",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Do not share your drugs with others and do not take anyone else's drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699678",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep all drugs out of the reach of children and pets.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699709",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " If you have any questions about this drug, please talk with your doctor,
    pharmacist, or other health care provider.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s3302581",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " In Canada, take any unused drugs to the pharmacy. Also, visit
    file://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/disposal-defaire-eng.php#th to learn about
    the right way to get rid of unused drugs.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699677",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Keep a list of all your drugs (prescription, natural products, vitamins,
    OTC) with you. Give this list to your doctor.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699671",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " These are not all of the side effects that may occur. If you have questions
    about side effects, call your doctor. Call your doctor for medical advice about
    side effects.",
    " </span>",
    " </li>",
    " <li class=\"statement\">",
    " <span class=\"attributes\" style=\"display:none;\">",
    " <span class=\"entity\">",
    " &bull;",
    " </span>",
    " <span class=\"link\">",
    " urn:lims:b259:s2699683",
    " </span>",
    " </span>",
    " <span class=\"content\">",
    " Talk with the doctor before starting any new drug, including prescription
    or OTC, natural products, or vitamins.",
    " </span>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 12060 Version 33.0",
    " </div>",
    " </div>",
    " <div id=\"footer\">",
    " <div id=\"supportFooter\">",
    " <span class=\"sfInfo\">",
    " &copy; 2013 UpToDate, Inc. All rights reserved.",
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    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_footer\">",
    " Subscription and License Agreement",
    " </a>",
    " <span class=\"sfInfo\">",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " Release: 21.6- C21.56",
    " </span>",
    " <br/>",
    " <span class=\"sfInfo\">",
    " Licensed to:",
    " <span class=\"emphasis\">",
    " AsanBook Dig. Med. Lib.",
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    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " Support Tag: [1004-125.39.66.147-73EAED37C4-S244013.14]",
    " <br/>",
    " </span>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_40_644=[" <div id=\"toggleOutline\">",
    " <a href=\"#\" title=\"Collapse Topic Outline\">",
    " <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
    " </a>",
    " </div>",
    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F189444\">",
    " Brand Names: U.S.",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F189445\">",
    " Brand Names: Canada",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016839\">",
    " What is this drug used for?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016838\">",
    " What do I need to tell my doctor before I take this drug?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016843\">",
    " What are some things I need to know or do while I take this drug?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016844\">",
    " What are some side effects of this drug?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016846\">",
    " What are some side effects that I need to call my doctor about right away?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016841\">",
    " How is this drug best taken?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016842\">",
    " What do I do if I miss a dose?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016847\">",
    " How do I store and/or throw out this drug?",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#F10016848\">",
    " General drug facts",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <a class=\"drug drug_general\" href=\"UTD.htm?5/27/5555?
    source=related_link\">",
    " Lodoxamide tromethamine: Drug information",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_40_645="Chorioamnionitis light";
    var content_f0_40_645=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=OBGYN
    %2F54320&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=OBGYN
    %2F54320&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Chorioamnionitis",
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    " </div>",
    " <div class=\"lgnd\">",
    " Light micrograph illustrating leukocytes extending through the full thickness
    of choriamniotic membrane.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Drucilla J Roberts, MD.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_645=[""].join("\n");
    var outline_f0_40_645=null;
    var title_f0_40_646="Brain MRI 8 month old with Krabbe disease";
    var content_f0_40_646=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=NEURO
    %2F64081&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=2\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
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    " Print",
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    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
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    " Email",
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Brain MRI of an 8 month old infant with Krabbe disease",
    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " Brain MRI of an infant age 8 months showing classic cerebellar/dentate
    abnormalities (A). There is increased signal involving the periventricular and deep
    cerebral white matter (B and C).",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Courtesy of Dr. Patricia Duffner.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    var outline_f0_40_646=null;
    var title_f0_40_647="Confluent and reticulated papillomatosis";
    var content_f0_40_647=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=DERM
    %2F66671&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
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    title=\"Print this page\"/>",
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    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
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    " Email",
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    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 470px\">",
    " <div class=\"ttl\">",
    " Confluent and reticulated papillomatosis of Gougerot and Carteaud",
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    " </div>",
    " <div class=\"lgnd\">",
    " Hyperpigmented, scaly papules and plaques on the trunk, which become
    reticulated toward the periphery are present.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Figure used with permission from Andrew Montemarano, DO. Reproduced from:
    Wolff, K, Goldsmith, LA, Katz, S, et al. Fitzpatrick's Dermatology in General
    Medicine, 7th ed, McGraw-Hill Professional 2008. Copyright &copy; 2008 Andrew
    Montemarano, DO.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
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    var title_f0_40_648="ACR relative radiation 1";
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    " <a class=\"etacLink\" href=\"#\">",
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    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 619px\">",
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    " </div>",
    " <div class=\"reference\">",
    " References:",
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    " <li>",
    " National Council on Radiation Protection and Measurements. Exposure of the
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    " <li>",
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    " <li>",
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    " </li>",
    " <li>",
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    " </li>",
    " <li>",
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    " <li>",
    " ACR practice guideline for imaging pregnant or potentially pregnant
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    " </li>",
    " </ol>",
    " American College of Radiology Appropriateness Criteria.",
    " </br>",
    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " A frontal chest radiograph on a 45-year-old woman with recurrent left
    hemothorax secondary to metastatic leiomyosarcoma of the uterus. There is a large
    collection of blood (verified by pleural tap) in the left hemithorax with
    displacement of mediastinal structures to the right. After embolization, she
    improved clinically with less accumulation of blood in the left hemithorax.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 560px\">",
    " <div class=\"ttl\">",
    " Angiogram",
    " </div>",
    " <div class=\"cntnt\" style=\"width: 540px; height: 405px; background-image:
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    0FVBRRXC/iPagkoKwUUUUigooooA//Z);\">",
    " </div>",
    " <div class=\"lgnd\">",
    " Angiogram showing one of the left intercostal arteries supplying a metastatic
    tumor with neovascularization (arrows).",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\" style=\"width: 560px\">",
    " <div class=\"ttl\">",
    " Postembolization angiogram of one of the left intercostal arteries",
    " </div>",
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    " </div>",
    " <div class=\"lgnd\">",
    " Occlusion of the left intercostal artery (arrow) after embolization is
    demonstrated.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_649=[""].join("\n");
    var outline_f0_40_649=null;
    var title_f0_40_650="Treatment of refractory edema in adults";
    var content_f0_40_650=[" <noscript>",
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    " <div id=\"topicContent\">",
    " <div id=\"topicTitle\">",
    " Treatment of refractory edema in adults",
    " </div>",
    " <div id=\"topicContributors\">",
    " <div>",
    " <a id=\"authors\">",
    " </a>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/40/650/contributors\">",
    " Author",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/40/650/contributors\">",
    " D Craig Brater, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/40/650/contributors\">",
    " Section Editors",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/40/650/contributors\">",
    " Richard H Sterns, MD",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/40/650/contributors\">",
    " Michael Emmett, MD",
    " </a>",
    " <br/>",
    " </div>",
    " <div>",
    " <a class=\"contributor contributor_credentials contributorType\"
    href=\"UTD.htm?0/40/650/contributors\">",
    " Deputy Editor",
    " </a>",
    " <br/>",
    " <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
    0/40/650/contributors\">",
    " John P Forman, MD, MSc",
    " </a>",
    " <br/>",
    " </div>",
    " </div>",
    " <div id=\"disclosures\">",
    " <a href=\"UTD.htm?0/40/650/contributor-disclosure\" target=\"_blank\">",
    " Disclosures",
    " </a>",
    " </div>",
    " <div id=\"reviewProcess\">",
    " <span>",
    " All topics are updated as new evidence becomes available and our",
    " </span>",
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    " peer review process",
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    " is complete.",
    " </span>",
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    " <div id=\"literatureReviewDate\">",
    " <span class=\"emphasis\">",
    " Literature review current through:",
    " </span>",
    " Oct 2013.",
    " <span class=\"pipeSpace\">",
    " |",
    " </span>",
    " <span class=\"emphasis\">",
    " This topic last updated:",
    " </span>",
    " Apr 9, 2013.",
    " </div>",
    " <div id=\"topicText\">",
    " <p class=\"headingAnchor\" id=\"H1\">",
    " <span class=\"h1\">",
    " INTRODUCTION",
    " </span>",
    " &nbsp;&mdash;&nbsp;Generalized edema can occur in a variety of disorders,
    including heart failure, cirrhosis (where ascites is usually most prominent), the
    nephrotic syndrome, and renal failure; when massive, the excess fluid accumulation
    is called anasarca. Edematous patients generally respond to the combination of
    dietary sodium restriction and diuretic therapy, usually with a loop diuretic. Some
    patients, however, are resistant to this regimen.",
    " </p>",
    " <p>",
    " A variety of factors can account for persistent fluid retention, including
    inadequate diuretic dose or frequency, excess sodium intake, delayed intestinal
    absorption of oral diuretics, decreased diuretic excretion into the urine, and
    increased sodium reabsorption at sites in the nephron other than those inhibited by
    the diuretic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1-4\">",
    " 1-4",
    " </a>",
    " ]. Nonsteroidal antiinflammatory drugs, which reduce the synthesis of
    vasodilator and natriuretic prostaglandins, can impair diuretic responsiveness.
    Thus, these agents should be discontinued, if possible, in edematous patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/4,5\">",
    " 4,5",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " The treatment of refractory edema in adults will be reviewed here. The initial
    therapy of edema, treatment of the different major edematous states, the clinical
    manifestations and diagnosis of edema in adults, and the evaluation and management
    of edema in children are discussed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?29/50/30503?
    source=see_link\">",
    " \"General principles of the treatment of edema in adults\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?3/55/3962?
    source=see_link\">",
    " \"Use of diuretics in patients with heart failure\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/44/19145?
    source=see_link\">",
    " \"Initial therapy of ascites in patients with cirrhosis\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/40/35465?
    source=see_link\">",
    " \"Treatment of diuretic-resistant ascites in patients with cirrhosis\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/10/36008?
    source=see_link\">",
    " \"Pathophysiology and treatment of edema in patients with the nephrotic
    syndrome\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?33/36/34375?
    source=see_link\">",
    " \"Clinical manifestations and diagnosis of edema in adults\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?7/7/7288?
    source=see_link\">",
    " \"Evaluation and management of edema in children\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H2\">",
    " <span class=\"h1\">",
    " CHOICE OF DIURETIC",
    " </span>",
    " &nbsp;&mdash;&nbsp;Edematous patients are typically treated with one of the
    sulfonamide-based loop diuretics &ndash;",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " ,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " , and",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " .",
    " <a class=\"drug drug_general\" href=\"UTD.htm?7/10/7334?source=see_link\">",
    " Ethacrynic acid",
    " </a>",
    " , which is not a sulfonamide, is rarely used because it may be more ototoxic
    than the sulfonamide diuretics in high doses and its relative insolubility makes it
    complicated to administer intravenously.",
    " </p>",
    " <p>",
    " The primary indication for the use of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?7/10/7334?source=see_link\">",
    " ethacrynic acid",
    " </a>",
    " is in patients who are allergic to sulfonamide-based diuretics, including
    thiazide diuretics. There is minimal evidence of allergic cross-reactivity between
    sulfonamide antimicrobials and non-antimicrobials. Thus, patients with a history of
    allergy to sulfonamide antimicrobial drugs would be expected to tolerate non-
    antimicrobial sulfonamides such as loop diuretics. Allergic reactions that do occur
    appear to be related to a predisposition to allergic reactions rather than
    sulfonamide cross-reactivity [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/6\">",
    " 6",
    " </a>",
    " ]. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?23/2/23594?
    source=see_link&amp;anchor=H22#H22\">",
    " \"Sulfonamide allergy in non HIV-infected patients\", section on 'Between
    sulfonamide antimicrobials and non-antimicrobials'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H3\">",
    " <span class=\"h1\">",
    " BASIC PRINCIPLES OF DIURETIC DOSING",
    " </span>",
    " &nbsp;&mdash;&nbsp;The approach to diuretic dosing in all patients, including
    those with refractory edema, should consider each of the following factors [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/2-4\">",
    " 2-4",
    " </a>",
    " ]. These issues, including diuretic-induced side effects and equivalency doses
    among the diuretics, are discussed in detail separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/48/40710?
    source=see_link\">",
    " \"Loop diuretics: Maximum effective dose and major side effects\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H4\">",
    " <span class=\"h2\">",
    " Determine the effective dose",
    " </span>",
    " &nbsp;&mdash;&nbsp;Diuretics have a dose-response curve, with no natriuresis
    seen until a threshold rate of drug excretion is attained (",
    " <a class=\"graphic graphic_figure graphicRef67654 \" href=\"UTD.htm?
    16/36/16973\">",
    " figure 1",
    " </a>",
    " ). If, for example, a patient does not respond to 40 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " , the dose may not have exceeded this threshold. Thus, the single dose should
    be increased to 60 or 80 mg, rather than giving the 40 mg dose twice a day. Once a
    single effective dose has been determined, it should be administered multiple times
    per day, the frequency of which is individualized to the diuretic needs of the
    patient. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/48/40710?
    source=see_link\">",
    " \"Loop diuretics: Maximum effective dose and major side effects\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H5\">",
    " <span class=\"h2\">",
    " Oral versus intravenous therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with refractory edema have usually failed oral
    therapy. Some patients with severe or unstable heart failure require initial
    intravenous therapy, since decreased intestinal perfusion, reduced intestinal
    motility, and perhaps mucosal edema can reduce the rate of diuretic absorption and
    therefore reduce the rate of diuretic delivery into the tubular lumen by as much as
    50 to 70 percent. This reduced delivery of diuretic into the renal tubule may be
    insufficient to cause natriuresis, as discussed above [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/7,8\">",
    " 7,8",
    " </a>",
    " ]. The defect in diuretic absorption is often reversible, resulting in more
    effective oral therapy following removal of some of the edema fluid with
    intravenous diuretics and stabilization of cardiac function [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/7\">",
    " 7",
    " </a>",
    " ]. Similar considerations may apply to patients with advanced cirrhosis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/9\">",
    " 9",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " A patient who is resistant to intravenous",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " is not likely to respond to an equivalent intravenous dose of another loop
    diuretic such as",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " . However, there are differences in bioavailability among the oral
    preparations of these drugs. Only about 50 to 60 percent of oral furosemide is
    absorbed. Absorption is well below this level in some edematous patients, and
    absorption may be erratic (range of bioavailability 10 to 100 percent) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1\">",
    " 1",
    " </a>",
    " ]. In such patients, apparent resistance to seemingly adequate doses of oral
    furosemide may be overcome by increasing the dose of furosemide or by switching to
    oral torsemide, which is more predictably absorbed (80 to 90 percent) than
    furosemide and has a longer half-life than furosemide or bumetanide.",
    " </p>",
    " <p>",
    " The potential benefit of oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " therapy was illustrated in an open label, randomized trial in which 234
    patients with chronic heart failure were treated with either oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " (average dose 136&plusmn;122",
    " <span class=\"nowrap\">",
    " mg/day)",
    " </span>",
    " or oral torsemide (average dose 72&plusmn;76",
    " <span class=\"nowrap\">",
    " mg/day)",
    " </span>",
    " [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/10\">",
    " 10",
    " </a>",
    " ]. The primary end point, readmission for heart failure at one year, was
    significantly lower with torsemide (17 versus 32 percent). Torsemide was also
    associated with a significant reduction in fatigue.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H6\">",
    " <span class=\"h1\">",
    " RISK OF OTOTOXICITY",
    " </span>",
    " &nbsp;&mdash;&nbsp;Ototoxicity following the intravenous administration of
    loop diuretics is primarily manifested by decreased hearing, tinnitus, or deafness
    and is most likely to occur with high-dose bolus therapy in patients with renal
    insufficiency or heart failure [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/11-14\">",
    " 11-14",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H7\">",
    " <span class=\"h2\">",
    " Mechanism",
    " </span>",
    " &nbsp;&mdash;&nbsp;The induction of hearing loss is thought to be related to
    the mechanism of action of loop diuretics. Transport in the loop of Henle that is
    mediated by a Na-K-2Cl cotransporter is inhibited by loop diuretics. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?38/13/39128?
    source=see_link\">",
    " \"Mechanism of action of diuretics\"",
    " </a>",
    " .) A secretory isoform of this cotransporter is present in the inner ear and
    plays an important role in the composition of endolymph. A mouse model in which
    this transporter was inactivated led to reduced endolymph secretion, structural
    damage to the inner ear, and deafness and imbalance [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/15,16\">",
    " 15,16",
    " </a>",
    " ].",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H8\">",
    " <span class=\"h2\">",
    " Importance of dose and rate of administration",
    " </span>",
    " &nbsp;&mdash;&nbsp;Ototoxicity, which can lead to transient (most lasting 30
    minutes to 24 hours) or permanent deafness, is primarily seen in patients treated
    with high intravenous or oral doses of loop diuretics. In a review of 29 cases of
    deafness associated with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " therapy that were reported to the Food and Drug Administration soon after the
    drug was approved, intravenous furosemide was administered in 17 patients, at an
    overall rate above 4",
    " <span class=\"nowrap\">",
    " mg/min",
    " </span>",
    " (240",
    " <span class=\"nowrap\">",
    " mg/h),",
    " </span>",
    " with total doses given over one to nine days ranging in most patients from 200
    mg to 21.6 g [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/11\">",
    " 11",
    " </a>",
    " ]. Therapy was usually more prolonged in patients treated with oral therapy
    (range 2 to 365 days), with doses ranging from 80 to 600",
    " <span class=\"nowrap\">",
    " mg/day.",
    " </span>",
    " </p>",
    " <p>",
    " The",
    " risk of ototoxicity is increased in patients with acute or chronic kidney
    disease or those taking other potential ototoxins such as",
    " <a class=\"drug drug_general\" href=\"UTD.htm?7/10/7334?source=see_link\">",
    " ethacrynic acid",
    " </a>",
    " or an aminoglycoside antibiotic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/11\">",
    " 11",
    " </a>",
    " ]. As an example, deafness, which may be permanent, has been reported in
    patients with acute renal failure receiving the equivalent of 80 to 160",
    " <span class=\"nowrap\">",
    " mg/h",
    " </span>",
    " (2 to 4",
    " <span class=\"nowrap\">",
    " g/day)",
    " </span>",
    " of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " &nbsp;[",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/14\">",
    " 14",
    " </a>",
    " ]. In addition, patients concurrently treated with an aminoglycoside may
    develop ototoxicity at lower loop diuretic doses.",
    " </p>",
    " <p>",
    " When giving intravenous loop diuretics at high doses, the risk of ototoxicity
    may be reduced by a continuous intravenous infusion rather than bolus therapy. This
    was suggested in a randomized, crossover trial of 20 patients with severe heart
    failure who were treated with an eight-hour continuous infusion of high dose",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " (250 to 2000 mg, mean 690 mg) or the same dose given as a single intravenous
    bolus [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/12\">",
    " 12",
    " </a>",
    " ]. All five episodes of reversible hearing loss occurred with bolus therapy,
    which was associated with a significantly higher maximum serum furosemide
    concentration (95 versus 24",
    " <span class=\"nowrap\">",
    " microg/mL",
    " </span>",
    " with the continuous infusion).",
    " </p>",
    " <p>",
    " Similar findings were noted in a subsequent meta-analysis of eight trials
    involving 254 patients with heart failure in whom a continuous infusion was
    associated with a significantly lower rate of ototoxicity, defined as hearing loss
    or tinnitus (relative risk 0.06, 95% CI 0.01-0.44) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/13\">",
    " 13",
    " </a>",
    " ]. In addition to being safer, a continuous infusion may produce a greater
    diuresis. (See",
    " <a class=\"local\" href=\"#H14\">",
    " 'Continuous infusion'",
    " </a>",
    " below.)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H9\">",
    " <span class=\"h1\">",
    " PATHOGENESIS AND MANAGEMENT OF REFRACTORY EDEMA",
    " </span>",
    " &nbsp;&mdash;&nbsp;The approach to initial diuretic therapy (typically with
    loop diuretics) and subsequent dose adjustments if the initial response is
    inadequate is discussed separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/48/40710?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Loop diuretics: Maximum effective dose and major side effects\", section on
    'Maximum effective dose'",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Three main factors contribute to edema that is refractory to usual oral or
    intravenous loop diuretic therapy:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " A high sodium intake.",
    " </li>",
    " <li>",
    " Decreased diuretic secretion into the tubular lumen, which is the site of
    action of the diuretic.",
    " </li>",
    " <li>",
    " Increased tubular sodium reabsorption at sites other than the loop of Henle.
    In addition, a high salt intake should be excluded.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H10\">",
    " <span class=\"h2\">",
    " Exclude high salt intake",
    " </span>",
    " &nbsp;&mdash;&nbsp;Maintenance of a high salt intake can prevent net fluid
    loss even if there is an adequate diuresis. As the diuretic effect wanes, there is
    postdiuretic sodium retention due to the recovery of sodium reabsorption in the
    loop of Henle plus continued increased sodium reabsorption at other sites in the
    nephron [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/17,18\">",
    " 17,18",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H17\">",
    " 'Enhanced tubular sodium reabsorption'",
    " </a>",
    " below.)",
    " </p>",
    " <p>",
    " If salt intake is high, postdiuretic sodium retention can counteract part or
    all of the diuresis that occurred while the diuretic was active. The postdiuretic
    effect is minimized with dietary salt restriction.",
    " </p>",
    " <p>",
    " To estimate salt intake, a 24-hour urine should be collected in patients with
    refractory edema whose daily weight is stable or increasing. A value above 100 meq
    per day indicates that noncompliance with sodium restriction may be in part
    responsible for the apparent resistance to therapy. (See",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?20/41/21151?
    source=see_link\">",
    " \"Patient information: Collection of a 24-hour urine specimen (Beyond the
    Basics)\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H11\">",
    " <span class=\"h2\">",
    " Decreased loop diuretic secretion",
    " </span>",
    " &nbsp;&mdash;&nbsp;Loop diuretics are highly (&ge;95 percent) protein bound.
    As a result, they primarily enter the tubular lumen by secretion in the proximal
    tubule, not by glomerular filtration.",
    " </p>",
    " <p>",
    " Patients who do not respond to usual loop diuretic therapy may be resistant
    because of decreased diuretic secretion into the tubular lumen. As examples,
    decreased renal perfusion in heart failure (due to the reduced cardiac output) and
    cirrhosis (due to renal vasoconstriction) and competitive inhibition of tubular
    secretion in renal failure may contribute to impaired diuretic secretion. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/48/40710?
    source=see_link\">",
    " \"Loop diuretics: Maximum effective dose and major side effects\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Patients with nephrotic syndrome may also be unresponsive to diuretics because
    of decreased tubular secretion. Because loop diuretics are highly protein bound,
    hypoalbuminemia associated with the nephrotic syndrome may reduce the delivery of
    diuretic to the renal tubule. In addition, filtered albumin in nephrotic patients
    may bind loop diuretics in the tubular lumen, thereby interfering with their
    function. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/10/36008?
    source=see_link&amp;anchor=H12#H12\">",
    " \"Pathophysiology and treatment of edema in patients with the nephrotic
    syndrome\", section on 'Treatment'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H12\">",
    " <span class=\"h3\">",
    " Maximum effective dose of loop diuretics",
    " </span>",
    " &nbsp;&mdash;&nbsp;Impaired diuretic secretion can be at least partially
    overcome by increasing the diuretic dose to the maximum effective dose. The maximum
    effective dose, which has been derived empirically, represents the dose at which
    loop sodium chloride transport is presumably completely inhibited [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1,3\">",
    " 1,3",
    " </a>",
    " ]. The maximum effective dose in different edematous disorders is discussed in
    detail elsewhere. Administering higher doses will produce little or no further
    diuresis but may increase the risk of side effects (see",
    " <a class=\"medical medical_review\" href=\"UTD.htm?39/48/40710?
    source=see_link&amp;anchor=H2#H2\">",
    " \"Loop diuretics: Maximum effective dose and major side effects\", section on
    'Maximum effective dose'",
    " </a>",
    " ).",
    " </p>",
    " <p>",
    " The following data on the maximally effective loop diuretic dose are based
    upon",
    " <strong>",
    " intravenous",
    " </strong>",
    " therapy in patients with a relatively normal glomerular filtration rate (GFR)
    and varies with the underlying disease [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1,3\">",
    " 1,3",
    " </a>",
    " ]:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In heart failure &mdash; 40 to 80 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " , 1 to 2 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " , or 20 to 40 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " . (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?3/55/3962?
    source=see_link\">",
    " \"Use of diuretics in patients with heart failure\"",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " In cirrhosis &mdash; 40 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " , 1 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " , or 10 to 20 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " . (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?18/44/19145?
    source=see_link&amp;anchor=H8#H8\">",
    " \"Initial therapy of ascites in patients with cirrhosis\", section on
    'Diuretic therapy'",
    " </a>",
    " .)",
    " </li>",
    " <li>",
    " In nephrotic syndrome &mdash; 80 to 120 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " , 2 to 3 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " , or 40 to 60 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " . (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/10/36008?
    source=see_link\">",
    " \"Pathophysiology and treatment of edema in patients with the nephrotic
    syndrome\"",
    " </a>",
    " .)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H13\">",
    " <span class=\"h3\">",
    " Application to refractory edema",
    " </span>",
    " &nbsp;&mdash;&nbsp;Most patients with refractory edema do not have normal
    renal function and higher doses are necessary when the GFR is substantially
    reduced. In addition, the extrarenal clearance of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " is increased in renal insufficiency. As a result, the normal ratio of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " -to-bumetanide dose falls from 40:1 to about 20:1 [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/19\">",
    " 19",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " Among patients with a substantially reduced GFR, it is difficult to be as
    precise with the maximum effective dose, since a variety of factors can be
    important including the degree of reduction in GFR and possibly other comorbid
    conditions. As a result, dosing recommendations in the literature differ. We
    suggest the following maximum intravenous doses in patients with refractory edema;
    the dose is usually given over 20 to 30 minutes:",
    " </p>",
    " <p>",
    " <ul class=\"bulletCompact-block\">",
    " <li>",
    " 160 to 200 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " </li>",
    " <li>",
    " 8 to 10 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " </li>",
    " <li>",
    " 50 to 100 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " In comparison, the 2009 American College of",
    " <span class=\"nowrap\">",
    " Cardiology/American",
    " </span>",
    " Heart Association",
    " <span class=\"nowrap\">",
    " (ACC/AHA)",
    " </span>",
    " guideline on heart failure recommended for patients with severe heart failure
    the same maximum intravenous dose for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " , a lower dose for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " (4 and 8 mg), and a higher dose for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " (100 to 200 mg) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/20\">",
    " 20",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " With respect to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " , we would adhere to the lower maximum doses in most patients, but the higher
    dose in the",
    " <span class=\"nowrap\">",
    " ACC/AHA",
    " </span>",
    " guideline may be tried in patients who do not respond to this dose and the
    other modalities described below (eg, a continuous infusion or the addition of a
    thiazide diuretic). One concern with higher doses in general is possible
    ototoxicity, particularly with bolus therapy or concurrent administration of an
    aminoglycoside.",
    " </p>",
    " <p>",
    " Bolus intravenous",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " doses of 160 to 200 mg (and equivalent doses of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " and",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " ) occasionally cause transient tinnitus. This effect can be minimized by
    giving the dose more slowly [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1\">",
    " 1",
    " </a>",
    " ]. As noted, ototoxicity is most common when high doses of a loop diuretic are
    given rapidly at rates above 4",
    " <span class=\"nowrap\">",
    " mg/min.",
    " </span>",
    " (See",
    " <a class=\"local\" href=\"#H8\">",
    " 'Importance of dose and rate of administration'",
    " </a>",
    " above.)",
    " </p>",
    " <p>",
    " Application of the above intravenous doses to",
    " <strong>",
    " oral",
    " </strong>",
    " dosing varies among the loop diuretics. The dose should usually be doubled for
    oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " , since its mean bioavailability is only about 50 percent. However, there is
    substantial interpatient and intrapatient variability in the bioavailability of
    oral furosemide, making it difficult to give a fixed ratio that would apply to all
    patients. A twofold higher dose than the intravenous dose is a reasonable starting
    point when switching to oral therapy, with further dose adjustments being
    determined by the diuretic response. In outpatients, the efficacy of therapy can be
    monitored by having daily weights called into the physician's office.",
    " </p>",
    " <p>",
    " In contrast, the intravenous and oral doses are similar in patients treated
    with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?source=see_link\">",
    " torsemide",
    " </a>",
    " , which have higher rates of oral bioavailability than",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " (70 to 95 percent and 80 to 90 percent, respectively). Careful monitoring is
    still required since there is substantial variability in response.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H14\">",
    " <span class=\"h3\">",
    " Continuous infusion",
    " </span>",
    " &nbsp;&mdash;&nbsp;Continuous infusion and bolus loop diuretic therapy appear
    to have similar efficacy. The physiologic rationale for a continuous intravenous
    infusion compared with bolus therapy is related to maintenance of an effective rate
    of drug excretion and therefore of inhibition of sodium chloride reabsorption in
    the loop of Henle over time (",
    " <a class=\"graphic graphic_figure graphicRef67654 \" href=\"UTD.htm?
    16/36/16973\">",
    " figure 1",
    " </a>",
    " ). In contrast, bolus therapy is associated with initially higher and then
    lower rates of diuretic excretion; as a result, sodium excretion may be at near
    maximal levels for the first two hours but then gradually falls until the next dose
    is given (",
    " <a class=\"graphic graphic_figure graphicRef75714 \" href=\"UTD.htm?
    31/33/32285\">",
    " figure 2",
    " </a>",
    " ). (See",
    " <a class=\"local\" href=\"#H8\">",
    " 'Importance of dose and rate of administration'",
    " </a>",
    " above.)",
    " </p>",
    " <p>",
    " The efficacy of a continuous intravenous infusion compared with intravenous
    bolus therapy has been evaluated in randomized trials. A continuous intravenous
    infusion is safer (less ototoxicity) than bolus injections of loop diuretics but
    clear evidence of greater diuretic efficacy is lacking, at least in patients with
    acute decompensated heart failure (ADHF). The following observations illustrate the
    range of findings:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " The value of a continuous infusion of a loop diuretic compared to
    intermittent bolus injections was evaluated in a systematic review of eight trials
    that included 254 patients with ADHF [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/21\">",
    " 21",
    " </a>",
    " ]. The urine output was significantly higher with a continuous infusion,
    although the difference was modest (mean difference 271 mL per 24 hours). However,
    the trials were small and heterogeneous and the apparent benefit was largely driven
    by a trial of 107 patients in which hypertonic saline was given only to patients
    receiving continuous therapy. Continuous infusion was associated with significantly
    lower rates of ototoxicity (tinnitus and hearing loss). The authors concluded that
    the available data were insufficient to permit definitive recommendations. (See",
    " <a class=\"local\" href=\"#H8\">",
    " 'Importance of dose and rate of administration'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The best data come from the DOSE trial, published after the above meta-
    analysis [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/22\">",
    " 22",
    " </a>",
    " ]. The trial randomly assigned 308 patients with ADHF to receive",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " administered intravenously via either a bolus every 12 hours or continuous
    infusion and at either a low dose (equivalent to the patient&rsquo;s previous oral
    dose) or a high dose (2.5 times the previous oral dose). The efficacy endpoint was
    the global assessment of symptoms over the course of 72 hours and the safety
    endpoint was change in serum creatinine from baseline to 72 hours. Worsening renal
    function was defined as increase in the serum creatinine &gt;0.3",
    " <span class=\"nowrap\">",
    " mg/dL",
    " </span>",
    " [&gt;26.5",
    " <span class=\"nowrap\">",
    " micromol/L]",
    " </span>",
    " at any time during the 72 hours after randomization.",
    " <br/>",
    " <br/>",
    " The following findings were noted:",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " There was",
    " <strong>",
    " no",
    " </strong>",
    " significant difference in efficacy or safety endpoints for bolus versus
    continuous infusion. Patients assigned to intravenous bolus therapy were more
    likely to require a dose increase at 48 hours; as a result, the total dose of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " over 72 hours was higher in the bolus group compared with the continuous
    infusion group, a difference that was not statistically different (592 versus 480
    mg, P=0.06).",
    " </li>",
    " <li>",
    " High-dose",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " , compared with low-dose furosemide, produced greater net fluid loss, weight
    loss, and relief from dyspnea but also more frequent worsening of renal function
    (23 versus 14 percent). There was no significant difference in patients&rsquo;
    global assessment of symptoms in the high-dose compared with low-dose group
    (P=0.06); the mean change in the serum creatinine was less than 0.1",
    " <span class=\"nowrap\">",
    " mg/dL",
    " </span>",
    " (9",
    " <span class=\"nowrap\">",
    " micromol/L)",
    " </span>",
    " in both groups.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In a trial of eight patients with severe stable chronic kidney disease (mean
    creatinine clearance 17",
    " <span class=\"nowrap\">",
    " mL/min),",
    " </span>",
    " a continuous infusion of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " (12 mg over 12 hours [1 mg of which was given as a loading dose]) was
    compared with two 6 mg boluses given at 0 and 6 hours [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/23\">",
    " 23",
    " </a>",
    " ]. The 1 mg loading dose was given over three minutes and the 6 mg boluses
    were given over five minutes. The continuous infusion was associated with a
    significant 30 percent increase in sodium excretion during the study period (mean
    236 versus 188 meq) (",
    " <a class=\"graphic graphic_figure graphicRef75714 \" href=\"UTD.htm?
    31/33/32285\">",
    " figure 2",
    " </a>",
    " ). Total urinary bumetanide excretion during the study period was similar in
    the two groups.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " In summary, at least in patients with ADHF, a continuous infusion and bolus
    loop diuretic therapy appear to have similar efficacy.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H19940053\">",
    " <span class=\"h4\">",
    " Regimen",
    " </span>",
    " &nbsp;&mdash;&nbsp;Use of a continuous infusion requires that the patient be
    responsive to loop diuretics. Thus, a continuous infusion should",
    " <strong>",
    " not",
    " </strong>",
    " be tried in patients who have not responded to the maximum bolus doses
    described above, since bolus therapy results in higher initial serum concentrations
    and therefore higher initial rates of urinary diuretic excretion than a continuous
    infusion [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/12\">",
    " 12",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " If the patient has received one or more intravenous boluses within the
    previous few hours, then an infusion can be started without a loading dose. If this
    has not occurred, an intravenous loading dose of 40 to 80 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " is given over five minutes.",
    " </p>",
    " <p>",
    " After the loading dose, the starting infusion rate with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " varies with the level of renal function:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " If the patient has severe renal insufficiency (estimated glomerular
    filtration rate less than 30",
    " <span class=\"nowrap\">",
    " mL/min),",
    " </span>",
    " we suggest an initial",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " infusion rate of 20",
    " <span class=\"nowrap\">",
    " mg/h.",
    " </span>",
    " If the diuresis is not sustained, a second bolus is given followed by a
    higher infusion rate of 40",
    " <span class=\"nowrap\">",
    " mg/h.",
    " </span>",
    " The equivalent dose is 1",
    " <span class=\"nowrap\">",
    " mg/h,",
    " </span>",
    " increasing to 2",
    " <span class=\"nowrap\">",
    " mg/h",
    " </span>",
    " for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " and 10",
    " <span class=\"nowrap\">",
    " mg/h,",
    " </span>",
    " increasing to 20",
    " <span class=\"nowrap\">",
    " mg/h",
    " </span>",
    " for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " .",
    " </li>",
    " <li>",
    " If the patient has normal or near normal renal function, we suggest an
    initial",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " infusion rate of 5",
    " <span class=\"nowrap\">",
    " mg/h.",
    " </span>",
    " If the diuresis is not sustained, a second bolus is given followed by a
    higher infusion rate of 10",
    " <span class=\"nowrap\">",
    " mg/h",
    " </span>",
    " infusion.",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " Higher infusion rates of up to 240",
    " <span class=\"nowrap\">",
    " mg/h",
    " </span>",
    " are reported in the literature. The risk of ototoxicity and other side effects
    associated with these infusion rates must be weighed against alternative strategies
    such as the addition of a thiazide-type diuretic or fluid removal via
    ultrafiltration, as described below. We do not recommend these higher doses. (See",
    " <a class=\"local\" href=\"#H18\">",
    " 'Thiazide plus loop diuretics'",
    " </a>",
    " below and",
    " <a class=\"local\" href=\"#H20\">",
    " 'Ultrafiltration'",
    " </a>",
    " below.)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H15\">",
    " <span class=\"h3\">",
    " Posture",
    " </span>",
    " &nbsp;&mdash;&nbsp;Diuretic responsiveness can be influenced by posture,
    although the effects of posture have not been specifically studied in patients with
    refractory edema. Patients with heart failure, for example, cannot increase cardiac
    output normally with assumption of an upright position. As a result, renal
    perfusion and presumably urinary diuretic delivery further diminish. In addition,
    renal salt and water reabsorption increase.",
    " </p>",
    " <p>",
    " The efficacy of assuming a supine position was evaluated in a randomized trial
    of six patients with heart failure and six with cirrhosis and ascites [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/24\">",
    " 24",
    " </a>",
    " ]. After staying in bed overnight, the patients were treated with 1 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?source=see_link\">",
    " bumetanide",
    " </a>",
    " intravenously and then assigned to either continued bed rest or normal daily
    activity for the next six hours. The procedure was repeated two days later when
    each patient was assigned to the opposite group. The supine position was associated
    with significantly higher mean creatinine clearance (100 versus 66",
    " <span class=\"nowrap\">",
    " mL/min)",
    " </span>",
    " and diuretic response (1133 versus 626 mL at six hours). The upright position
    was associated with significant increases in plasma norepinephrine, renin, and
    aldosterone.",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H16\">",
    " <span class=\"h3\">",
    " Infusion with albumin",
    " </span>",
    " &nbsp;&mdash;&nbsp;Some patients with hypoalbuminemia are relatively resistant
    to conventional diuretic therapy. It has been proposed that these patients may
    respond to the administration of 40 to 80 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " mixed with 6.25 to 12.5 g of salt-poor albumin. Infusion of the furosemide-
    albumin complex is thought to increase diuretic delivery to the kidney by keeping
    furosemide within the vascular space. In an initial report, this approach led to a
    substantial increase in sodium excretion in some patients [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/25\">",
    " 25",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " However, a subsequent study in patients with nephrotic syndrome (mean plasma
    albumin 3.0",
    " <span class=\"nowrap\">",
    " g/dL)",
    " </span>",
    " found that a mixture of loop diuretic and albumin (60 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " infused in 200 mL of a 20 percent albumin solution) produced only a modest
    increase in sodium excretion compared with furosemide alone without an increase in
    the rate of furosemide excretion [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/26\">",
    " 26",
    " </a>",
    " ]. Furthermore, the increase in sodium excretion was roughly equivalent to the
    amount of sodium contained in the colloid solution, suggesting that volume
    expansion was a likely explanation for the enhanced natriuresis.",
    " </p>",
    " <p>",
    " A similar lack of efficacy of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " plus albumin infusion has been demonstrated in hypoalbuminemic patients with
    cirrhosis (mean plasma albumin 3.0",
    " <span class=\"nowrap\">",
    " g/dL)",
    " </span>",
    " [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/27\">",
    " 27",
    " </a>",
    " ]. Compared with furosemide alone, combination therapy did not increase the
    rate of either furosemide or sodium excretion.",
    " </p>",
    " <p>",
    " It is possible that infusion of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " or other loop diuretic plus albumin would be effective in patients with
    refractory edema and severe hypoalbuminemia (plasma albumin less than 2.0",
    " <span class=\"nowrap\">",
    " g/dL).",
    " </span>",
    " However, this has not been studied. General issues related to the management
    of edema in patients with nephrotic syndrome are discussed in detail elsewhere.
    (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/10/36008?
    source=see_link\">",
    " \"Pathophysiology and treatment of edema in patients with the nephrotic
    syndrome\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H17\">",
    " <span class=\"h2\">",
    " Enhanced tubular sodium reabsorption",
    " </span>",
    " &nbsp;&mdash;&nbsp;Some patients have partial or relatively complete
    resistance to a loop diuretic, despite adequate urinary delivery, as evidenced by a
    decreased natriuresis (compared with normals) at a given rate of diuretic excretion
    (",
    " <a class=\"graphic graphic_figure graphicRef67654 \" href=\"UTD.htm?
    16/36/16973\">",
    " figure 1",
    " </a>",
    " ). This problem is often due to increased tubular sodium reabsorption in
    nephron segments other than the loop of Henle [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1,17\">",
    " 1,17",
    " </a>",
    " ]. The decreased response to the action of a diuretic that results from
    increased sodium reabsorption in other nephron segments has been called the
    diuretic braking phenomenon [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/28\">",
    " 28",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " This phenomenon may be mediated by sodium reabsorption in various other
    nephron segments:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In the proximal tubule, due to enhanced activity of angiotensin II and
    norepinephrine [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/29\">",
    " 29",
    " </a>",
    " ]",
    " </li>",
    " <li>",
    " In the distal tubule, due to flow-dependent hypertrophy resulting from
    chronic loop diuretic therapy, which increases sodium delivery and reabsorption in
    this segment. The hypertrophy increases sodium reabsorption (",
    " <a class=\"graphic graphic_figure graphicRef53198 \" href=\"UTD.htm?
    27/35/28221\">",
    " figure 3",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/28,30\">",
    " 28,30",
    " </a>",
    " ]",
    " </li>",
    " <li>",
    " In the collecting tubules, due to increased mineralocorticoid activity [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/2-4\">",
    " 2-4",
    " </a>",
    " ].",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " The neurohumoral activation occurs both as part of the primary disease (as in
    heart failure or cirrhosis) and as a consequence of diuretic-induced salt and water
    loss. One consequence of activating compensatory sodium-retaining mechanisms as
    soon as the extracellular fluid volume falls is that the maximum response to an
    intravenous diuretic occurs with the",
    " <strong>",
    " first dose",
    " </strong>",
    " , even with a continuous infusion, and the natriuresis begins to diminish
    within the first 12 hours (",
    " <a class=\"graphic graphic_figure graphicRef75714 \" href=\"UTD.htm?
    31/33/32285\">",
    " figure 2",
    " </a>",
    " ) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/1,23\">",
    " 1,23",
    " </a>",
    " ]. Similar findings are seen with oral diuretic therapy, assuming no defect in
    drug absorption. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?6/45/6868?
    source=see_link\">",
    " \"Time course of loop and thiazide diuretic-induced electrolyte
    complications\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " Two strategies may be helpful in overcoming the increase in sodium
    reabsorption in nephron segments not inhibited by the loop diuretic. The efficacy
    of either of these strategies is enhanced with concurrent sodium restriction;
    diuretics only",
    " <strong>",
    " transiently reverse",
    " </strong>",
    " the sodium-avid state and substantial sodium retention can occur when the
    diuretic effect wears off [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/30\">",
    " 30",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " If the patient has a partial but inadequate diuretic response to once daily
    bolus therapy, the loop diuretic dose can be repeated twice or even three times a
    day.",
    " </li>",
    " <li>",
    " A thiazide diuretic can be added.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H18\">",
    " <span class=\"h3\">",
    " Thiazide plus loop diuretics",
    " </span>",
    " &nbsp;&mdash;&nbsp;Sodium reabsorption can be blocked in the distal tubule by
    the concurrent administration of a thiazide diuretic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/4,31-33\">",
    " 4,31-33",
    " </a>",
    " ]. The distal tubule reabsorbs about 75 to 80 percent of the sodium delivered
    out of the loop of Henle. Administration of a loop diuretic increases distal sodium
    delivery and therefore sodium reabsorption in the distal tubule, an effect mediated
    in part by increased activity of the thiazide-sensitive sodium-chloride
    cotransporter in the luminal membrane of the distal tubule cells [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/31\">",
    " 31",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " The efficacy of adding a thiazide diuretic was illustrated in a study of five
    patients who had an inadequate response to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?source=see_link\">",
    " furosemide",
    " </a>",
    " in doses of 160 to 240",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " (given in divided doses three to four times daily) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/32\">",
    " 32",
    " </a>",
    " ]. All had significant chronic kidney disease with the serum creatinine
    ranging from 2.3 to 4.9",
    " <span class=\"nowrap\">",
    " mg/dL",
    " </span>",
    " (203 to 433",
    " <span class=\"nowrap\">",
    " micromol/L).",
    " </span>",
    " Increasing the furosemide dose to 320 to 480",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " produced only a modest increase in urine output. In contrast, the addition
    of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " (25 to 50 mg twice daily) was associated with a marked diuresis and a
    significant reduction in weight.",
    " </p>",
    " <p>",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/2/35878?source=see_link\">",
    " Chlorothiazide",
    " </a>",
    " is the only thiazide diuretic that can be given intravenously (500 to 1000 mg
    once or twice daily) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/20\">",
    " 20",
    " </a>",
    " ]. However, the availability of intravenous chlorothiazide may be limited. An
    oral preparation, such as",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?1/32/1542?source=see_link\">",
    " metolazone",
    " </a>",
    " , is an alternative for acute therapy and can be used chronically.",
    " </p>",
    " <p>",
    " It has been suggested that",
    " <a class=\"drug drug_general\" href=\"UTD.htm?1/32/1542?source=see_link\">",
    " metolazone",
    " </a>",
    " is the oral thiazide diuretic of choice in patients with refractory edema and
    advanced renal failure (GFR below 20",
    " <span class=\"nowrap\">",
    " mL/min),",
    " </span>",
    " since other thiazide-type drugs were thought to be ineffective in this setting
    [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/34\">",
    " 34",
    " </a>",
    " ]. However, the study that led to this conclusion used extremely high doses of
    metolazone (20 to 150 mg, the equivalent of 200 to 1500 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " ). There is at present no convincing evidence that metolazone has any unique
    efficacy when comparable doses are given, although it does have the advantage of
    once daily dosing [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/4\">",
    " 4",
    " </a>",
    " ]. Furthermore, a thiazide diuretic may be effective in patients with renal
    failure at usual doses when given with a loop diuretic [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/32,33\">",
    " 32,33",
    " </a>",
    " ].",
    " </p>",
    " <p>",
    " The timing of combination therapy depends upon the route by which the
    diuretics are given. The drugs can be administered at the same time if given by the
    same route (intravenous or oral). If, however, a thiazide diuretic such as",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " is given orally in patients treated with an intravenous loop diuretic, the
    thiazide diuretic should precede the loop diuretic by two to five hours, since the
    peak effect of the thiazide is four to six hours after ingestion.",
    " </p>",
    " <p>",
    " Combination therapy can lead to a marked diuresis in which daily sodium and
    potassium losses can be greater than 300 meq and 200 meq, respectively [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/33,35\">",
    " 33,35",
    " </a>",
    " ]. As a result, careful initial monitoring of fluid and electrolyte balance is
    essential.",
    " </p>",
    " <p>",
    " A potassium-sparing diuretic (eg,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?37/12/38085?source=see_link\">",
    " amiloride",
    " </a>",
    " or, particularly in heart failure, an aldosterone antagonist) can also be
    added. However, these diuretics are more useful in preventing potassium wasting
    significantly increasing the diuresis. In patients who have developed a low or low-
    normal serum potassium with loop diuretic therapy alone, it is reasonable to start
    a potassium-sparing diuretic before the addition of a thiazide diuretic. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?38/13/39128?
    source=see_link&amp;anchor=H8#H8\">",
    " \"Mechanism of action of diuretics\", section on 'Time course of diuresis'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/54/28521?
    source=see_link\">",
    " \"Use of aldosterone antagonists in heart failure\"",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H19\">",
    " <span class=\"h3\">",
    " Use of dopamine",
    " </span>",
    " &nbsp;&mdash;&nbsp;It has been proposed that the natriuretic and renal
    vasodilator activity of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42310?source=see_link\">",
    " dopamine",
    " </a>",
    " can be used to potentiate the effect of diuretics in patients with resistant
    edema. However, a significant benefit from intravenous dopamine has",
    " <strong>",
    " not",
    " </strong>",
    " been confirmed. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?43/25/44435?
    source=see_link\">",
    " \"Renal actions of dopamine\"",
    " </a>",
    " .)",
    " </p>",
    " <p>",
    " There are few data on this subject. One report evaluated six patients with
    stable heart failure (New York Heart Association class II and III) [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/36\">",
    " 36",
    " </a>",
    " ]. The following results were obtained:",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Baseline sodium excretion increased from 7 to 37 meq per three hours with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42310?
    source=see_link\">",
    " dopamine",
    " </a>",
    " (1 to 3",
    " <span class=\"nowrap\">",
    " microg/kg",
    " </span>",
    " per min as tolerated).",
    " </li>",
    " <li>",
    " A",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " infusion produced a much larger natriuresis (277 meq per three hours) than",
    " <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42310?
    source=see_link\">",
    " dopamine",
    " </a>",
    " given alone.",
    " </li>",
    " <li>",
    " The addition of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42310?
    source=see_link\">",
    " dopamine",
    " </a>",
    " to",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " had no effect.",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H20\">",
    " <span class=\"h2\">",
    " Ultrafiltration",
    " </span>",
    " &nbsp;&mdash;&nbsp;Some patients with advanced heart failure or renal failure
    do not respond to any of the above modalities. In this setting, the excess fluid
    can be removed by dialysis or ultrafiltration. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?33/56/34698?
    source=see_link&amp;anchor=H26#H26\">",
    " \"Treatment of acute decompensated heart failure: Components of therapy\",
    section on 'Ultrafiltration'",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?37/39/38516?
    source=see_link&amp;anchor=H5#H5\">",
    " \"Continuous renal replacement therapies: Overview\", section on
    'Hemofiltration'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H21\">",
    " <span class=\"h1\">",
    " APPROACH TO REFRACTORY EDEMA",
    " </span>",
    " &nbsp;&mdash;&nbsp;The preceding observations permit the following sequential
    approach to patients with refractory edema. The first step is exclusion of a high
    salt intake by obtaining a 24-hour urine collection. A value above 100 meq per day
    probably indicates an adequate diuretic response and the likelihood that
    noncompliance with sodium restriction is at least in part responsible for the
    apparent resistance to therapy. (See",
    " <a class=\"local\" href=\"#H10\">",
    " 'Exclude high salt intake'",
    " </a>",
    " above.)",
    " </p>",
    " <p>",
    " The following discussion primarily applies to patients who have heart
    failure",
    " <span class=\"nowrap\">",
    " and/or",
    " </span>",
    " substantially impaired renal function. The treatment of diuretic resistance in
    patients with cirrhosis and the management of nephrotic edema are discussed
    separately. (See",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/40/35465?
    source=see_link\">",
    " \"Treatment of diuretic-resistant ascites in patients with cirrhosis\"",
    " </a>",
    " and",
    " <a class=\"medical medical_review\" href=\"UTD.htm?35/10/36008?
    source=see_link&amp;anchor=H12#H12\">",
    " \"Pathophysiology and treatment of edema in patients with the nephrotic
    syndrome\", section on 'Treatment'",
    " </a>",
    " .)",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H22\">",
    " <span class=\"h2\">",
    " Oral therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Patients with stable edema not requiring hospitalization
    are treated initially with oral diuretics.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " In patients who do not have an adequate response to initial oral loop
    diuretic therapy, the dose should be gradually increased until either a clinically
    significant diuresis is attained or the maximum effective dose has been reached.
    This dose is similar to the maximum effective intravenous dose for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " (8 to 10 mg) and",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " (50 to 100 mg) because of high bioavailability. In contrast, only about 50
    percent of oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " is absorbed (range 10 to 100 percent with interpatient and intrapatient
    variability); as result, the maximum effective oral dose is approximately twice
    that of the maximally effective intravenous dose (ie, 320 to 400 mg rather than 160
    to 200 mg). (See",
    " <a class=\"local\" href=\"#H5\">",
    " 'Oral versus intravenous therapy'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H12\">",
    " 'Maximum effective dose of loop diuretics'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " When the diuretic response to oral loop diuretics is partial but inadequate,
    it may be improved by giving the same dose two or three times per day.",
    " </li>",
    " <li>",
    " Patients who have not responded to a maximum effective oral dose of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " (320 to 400 mg) may have impaired gastrointestinal absorption of the drug.
    In such settings, it is reasonable to switch to oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " , which is more predictably absorbed (80 to 90 percent) than furosemide and
    has a longer half-life than furosemide or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " . If this agent is effective, resuming furosemide, which is less expensive,
    but at a higher dose may be an acceptable strategy.",
    " </li>",
    " <li>",
    " Among patients who do not have an adequate response to the maximum effective
    oral dose of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " (100 to 200 mg), an oral thiazide diuretic may be added to block distal
    reabsorption of sodium. The effective dose has not been established in patients
    with refractory edema. A reasonable approach is to start",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " at a dose of 25 to 50 mg twice daily and then increase the dose, if needed,
    to a maximum of 200",
    " <span class=\"nowrap\">",
    " mg/day",
    " </span>",
    " [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/32\">",
    " 32",
    " </a>",
    " ]. An alternative is to start",
    " <a class=\"drug drug_general\" href=\"UTD.htm?1/32/1542?source=see_link\">",
    " metolazone",
    " </a>",
    " 5 to 10 mg with a maximum dose of 20 mg once daily [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/20\">",
    " 20",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H18\">",
    " 'Thiazide plus loop diuretics'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Some patients with severe or unstable heart failure or advanced cirrhosis
    benefit from initial intravenous therapy, since decreased intestinal perfusion,
    reduced intestinal motility, and perhaps mucosal edema can reduce the rate of
    diuretic absorption and therefore the rate of diuretic delivery into the renal
    tubular lumen. These defects in diuretic absorption are often reversible. Thus,
    oral diuretic therapy may become much more effective following removal of some of
    the edema fluid with intravenous diuretics. Patients who are treated with an
    intravenous diuretic because they have not responded to oral therapy can therefore
    be given a repeat trial of oral therapy once the edema has been reduced. (See",
    " <a class=\"local\" href=\"#H5\">",
    " 'Oral versus intravenous therapy'",
    " </a>",
    " above.)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H23\">",
    " <span class=\"h2\">",
    " Intravenous therapy",
    " </span>",
    " &nbsp;&mdash;&nbsp;Intravenous therapy is required in patients with
    potentially life-threatening edema (mostly acute pulmonary edema), in patients who
    are hospitalized and cannot take oral therapy, and in patients who have not
    responded to oral therapy as described in the preceding section.",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Patients with refractory edema generally have impaired renal function and,
    as noted above, the maximum effective doses of intravenous loop diuretics are 160
    to 200 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " , 8 to 10 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " , and 50 to 100 mg of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " . (See",
    " <a class=\"local\" href=\"#H12\">",
    " 'Maximum effective dose of loop diuretics'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " There are no data related to the optimal time over which a single
    intravenous dose of a loop diuretic should be administered that applies to all
    doses. The following approach seems reasonable; the doses are given for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " and should be adjusted as noted above for",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " and",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " :",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"hyphen-block\">",
    " <li>",
    " 20 to 40 mg over 5 minutes",
    " </li>",
    " <li>",
    " 60 to 120 mg over 20 minutes",
    " </li>",
    " <li>",
    " 160 to 200 mg over 40 to 50 minutes (4",
    " <span class=\"nowrap\">",
    " mg/min)",
    " </span>",
    " </li>",
    " </ul>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Patients who do not respond to a given dose are unlikely to benefit from
    repeated administration of the same dose, and patients who do not have an adequate
    response to a maximal dose of one intravenous loop diuretic are unlikely to respond
    to another loop diuretic.",
    " </li>",
    " <li>",
    " Patients who have a partial but inadequate diuresis with bolus therapy can
    be treated with two or even three daily doses, if necessary. Another approach is
    concurrent administration of a thiazide diuretic to block distal sodium chloride
    reabsorption.",
    " <a class=\"drug drug_general\" href=\"UTD.htm?35/2/35878?
    source=see_link\">",
    " Chlorothiazide",
    " </a>",
    " (500 to 1000 mg once or twice daily), which may have limited availability,
    is the only intravenous thiazide preparation. Oral alternatives include",
    " <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8263?source=see_link\">",
    " hydrochlorothiazide",
    " </a>",
    " (25 to 50 mg twice daily to a maximum dose of 200",
    " <span class=\"nowrap\">",
    " mg/day)",
    " </span>",
    " or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?1/32/1542?source=see_link\">",
    " metolazone",
    " </a>",
    " (5 to 10 mg to maximum dose of 20 mg once daily).",
    " <br/>",
    " <br/>",
    " Combination therapy, must be given with careful initial monitoring, since a
    marked diuresis can occur in which daily sodium and potassium losses can be greater
    than 300 meq and 200 meq, respectively [",
    " <a class=\"abstract\" href=\"UTD.htm?0/40/650/abstract/33,35\">",
    " 33,35",
    " </a>",
    " ]. (See",
    " <a class=\"local\" href=\"#H18\">",
    " 'Thiazide plus loop diuretics'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " A potassium-sparing diuretic can also be added, more to prevent potassium
    wasting than to significantly increase the diuresis.",
    " </li>",
    " <li>",
    " Patients who do not have an adequate response to intravenous bolus loop
    diuretic therapy may benefit from a continuous intravenous infusion, which can
    maintain an optimal rate of loop diuretic secretion into the tubular lumen and
    therefore of inhibition of sodium chloride reabsorption in the loop of Henle.
    (See",
    " <a class=\"local\" href=\"#H14\">",
    " 'Continuous infusion'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Among hospitalized patients, maintaining the supine position may increase
    diuretic responsiveness. In contrast, efficacy is unproven for an infusion of a
    loop diuretic with albumin or the use of",
    " <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42310?
    source=see_link\">",
    " dopamine",
    " </a>",
    " . (See",
    " <a class=\"local\" href=\"#H15\">",
    " 'Posture'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H16\">",
    " 'Infusion with albumin'",
    " </a>",
    " above and",
    " <a class=\"local\" href=\"#H19\">",
    " 'Use of dopamine'",
    " </a>",
    " above.).",
    " </li>",
    " <li>",
    " Patients with advanced heart failure or renal failure who do not respond to
    any of the above modalities can be treated with dialysis or ultrafiltration. (See",
    " <a class=\"local\" href=\"#H20\">",
    " 'Ultrafiltration'",
    " </a>",
    " above.)",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
    " <span class=\"h1\">",
    " INFORMATION FOR PATIENTS",
    " </span>",
    " &nbsp;&mdash;&nbsp;UpToDate offers two types of patient education materials,
    &ldquo;The Basics&rdquo; and &ldquo;Beyond the Basics.&rdquo; The Basics patient
    education pieces are written in plain language, at the 5",
    " <sup>",
    " th",
    " </sup>",
    " to 6",
    " <sup>",
    " th",
    " </sup>",
    " grade reading level, and they answer the four or five key questions a patient
    might have about a given condition. These articles are best for patients who want a
    general overview and who prefer short, easy-to-read materials. Beyond the Basics
    patient education pieces are longer, more sophisticated, and more detailed. These
    articles are written at the 10",
    " <sup>",
    " th",
    " </sup>",
    " to 12",
    " <sup>",
    " th",
    " </sup>",
    " grade reading level and are best for patients who want in-depth information
    and are comfortable with some medical jargon.",
    " </p>",
    " <p>",
    " Here are the patient education articles that are relevant to this topic. We
    encourage you to print or e-mail these topics to your patients. (You can also
    locate patient education articles on a variety of subjects by searching on
    &ldquo;patient info&rdquo; and the keyword(s) of interest.)",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Beyond the Basics topic (see",
    " <a class=\"medical medical_patient\" href=\"UTD.htm?31/53/32594?
    source=see_link\">",
    " \"Patient information: Edema (swelling) (Beyond the Basics)\"",
    " </a>",
    " ).",
    " </li>",
    " </ul>",
    " </p>",
    " <p class=\"headingAnchor\" id=\"H17558105\">",
    " <span class=\"h1\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </span>",
    " </p>",
    " <p>",
    " <ul class=\"bullet-block\">",
    " <li>",
    " Edematous patients are typically treated with one of the sulfonamide-based
    loop diuretics, including",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " ,",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " , and",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " . The nonsulfonamide diuretic",
    " <a class=\"drug drug_general\" href=\"UTD.htm?7/10/7334?source=see_link\">",
    " ethacrynic acid",
    " </a>",
    " may be used in patients who are allergic to sulfonamide-based diuretics, but
    is not considered a first-line agent because it may be more ototoxic than the
    sulfonamide diuretics in high doses and its relative insolubility makes it
    difficult to administer intravenously. (See",
    " <a class=\"local\" href=\"#H2\">",
    " 'Choice of diuretic'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " The basic approach to diuretic dosing includes determination of the minimum
    effective dose and selection of oral versus intravenous therapy. Patients with
    refractory edema may require initial intravenous therapy, since decreased
    intestinal perfusion, reduced intestinal motility, and mucosal edema significantly
    decrease the rate of diuretic absorption. (See",
    " <a class=\"local\" href=\"#H3\">",
    " 'Basic principles of diuretic dosing'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " There are differences in bioavailability among the oral preparations of loop
    diuretics. Oral",
    " <a class=\"drug drug_general\" href=\"UTD.htm?28/13/28886?
    source=see_link\">",
    " torsemide",
    " </a>",
    " is more predictably absorbed than",
    " <a class=\"drug drug_general\" href=\"UTD.htm?27/52/28488?
    source=see_link\">",
    " furosemide",
    " </a>",
    " and has a longer half-life than furosemide or",
    " <a class=\"drug drug_general\" href=\"UTD.htm?42/9/43158?
    source=see_link\">",
    " bumetanide",
    " </a>",
    " . (See",
    " <a class=\"local\" href=\"#H5\">",
    " 'Oral versus intravenous therapy'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Ototoxicity is observed in patients treated with high intravenous or oral
    doses of loop diuretics; the risk is increased in patients with acute or chronic
    kidney disease, those taking other potential ototoxins, and possibly with",
    " <a class=\"drug drug_general\" href=\"UTD.htm?7/10/7334?source=see_link\">",
    " ethacrynic acid",
    " </a>",
    " . The risk is reduced by a continuous intravenous infusion rather than bolus
    therapy. (See",
    " <a class=\"local\" href=\"#H6\">",
    " 'Risk of ototoxicity'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Factors that contribute to resistance to oral or intravenous loop diuretics
    include decreased diuretic secretion into the tubular lumen, and increased tubular
    sodium reabsorption at sites other than the loop of Henle. Impaired diuretic
    secretion can be partially overcome using the maximum effective dose, which has
    been determined empirically. The increase in sodium reabsorption in nephron
    segments not inhibited by the loop diuretic may be overcome by repeating the
    diuretic dose twice or three times daily, providing the patient has at least a
    partial response to the diuretic, and by adding a thiazide diuretic. (See",
    " <a class=\"local\" href=\"#H9\">",
    " 'Pathogenesis and management of refractory edema'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Maintenance of a high salt intake can prevent net fluid loss even if there
    is an adequate diuresis. (See",
    " <a class=\"local\" href=\"#H10\">",
    " 'Exclude high salt intake'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Patients with refractory edema may be treated with a sequential approach
    that is determined by the response to initial doses of diuretics. (See",
    " <a class=\"local\" href=\"#H21\">",
    " 'Approach to refractory edema'",
    " </a>",
    " above.)",
    " </li>",
    " <li>",
    " Patients with advanced heart failure or renal failure who do not respond to
    any of the above modalities can be treated with dialysis or ultrafiltration. (See",
    " <a class=\"local\" href=\"#H20\">",
    " 'Ultrafiltration'",
    " </a>",
    " above.)",
    " </li>",
    " </ul>",
    " </p>",
    " </div>",
    " <div id=\"topicAgreement\">",
    " Use of UpToDate is subject to the",
    " <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
    target=\"_blank\">",
    " Subscription and License Agreement",
    " </a>",
    " .",
    " </div>",
    " <div class=\"headingAnchor\" id=\"references\">",
    " <h1>",
    " REFERENCES",
    " </h1>",
    " <ol id=\"reference\">",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/1\">",
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    " Ellison DH. Diuretic drugs and the treatment of edema: from clinic to bench
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    " Brater DC. Analysis of the effect of indomethacin on the response to
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    " Brater DC, Day B, Burdette A, Anderson S. Bumetanide and furosemide in heart
    failure. Kidney Int 1984; 26:183.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/8\">",
    " Kr&auml;mer BK, Schweda F, Riegger GA. Diuretic treatment and diuretic
    resistance in heart failure. Am J Med 1999; 106:90.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/9\">",
    " Fredrick MJ, Pound DC, Hall SD, Brater DC. Furosemide absorption in patients
    with cirrhosis. Clin Pharmacol Ther 1991; 49:241.",
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    " Murray MD, Deer MM, Ferguson JA, et al. Open-label randomized trial of
    torsemide compared with furosemide therapy for patients with heart failure. Am J
    Med 2001; 111:513.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/11\">",
    " Gallagher KL, Jones JK. Furosemide-induced ototoxicity. Ann Intern Med 1979;
    91:744.",
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    " Dormans TP, van Meyel JJ, Gerlag PG, et al. Diuretic efficacy of high dose
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    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/13\">",
    " Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus
    injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev
    2004; :CD003178.",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/14\">",
    " Brown CB, Ogg CS, Cameron JS. High dose frusemide in acute renal failure: a
    controlled trial. Clin Nephrol 1981; 15:90.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/15\">",
    " Delpire E, Lu J, England R, et al. Deafness and imbalance associated with
    inactivation of the secretory Na-K-2Cl co-transporter. Nat Genet 1999; 22:192.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/16\">",
    " Flagella M, Clarke LL, Miller ML, et al. Mice lacking the basolateral Na-K-
    2Cl cotransporter have impaired epithelial chloride secretion and are profoundly
    deaf. J Biol Chem 1999; 274:26946.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/17\">",
    " Ellison DH. The physiologic basis of diuretic synergism: its role in
    treating diuretic resistance. Ann Intern Med 1991; 114:886.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/18\">",
    " Wilcox CS, Mitch WE, Kelly RA, et al. Response of the kidney to furosemide.
    I. Effects of salt intake and renal compensation. J Lab Clin Med 1983; 102:450.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/19\">",
    " Voelker JR, Cartwright-Brown D, Anderson S, et al. Comparison of loop
    diuretics in patients with chronic renal insufficiency. Kidney Int 1987; 32:572.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/20\">",
    " Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into
    the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in
    Adults: a report of the American College of Cardiology Foundation/American Heart
    Association Task Force on Practice Guidelines: developed in collaboration with the
    International Society for Heart and Lung Transplantation. Circulation 2009;
    119:e391.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/21\">",
    " Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus
    injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev
    2005; :CD003178.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/22\">",
    " Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with
    acute decompensated heart failure. N Engl J Med 2011; 364:797.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/23\">",
    " Rudy DW, Voelker JR, Greene PK, et al. Loop diuretics for chronic renal
    insufficiency: a continuous infusion is more efficacious than bolus therapy. Ann
    Intern Med 1991; 115:360.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/24\">",
    " Ring-Larsen H, Henriksen JH, Wilken C, et al. Diuretic treatment in
    decompensated cirrhosis and congestive heart failure: effect of posture. Br Med J
    (Clin Res Ed) 1986; 292:1351.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/25\">",
    " Inoue M, Okajima K, Itoh K, et al. Mechanism of furosemide resistance in
    analbuminemic rats and hypoalbuminemic patients. Kidney Int 1987; 32:198.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/26\">",
    " Fliser D, Zurbr&uuml;ggen I, Mutschler E, et al. Coadministration of albumin
    and furosemide in patients with the nephrotic syndrome. Kidney Int 1999; 55:629.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/27\">",
    " Chalasani N, Gorski JC, Horlander JC Sr, et al. Effects of
    albumin/furosemide mixtures on responses to furosemide in hypoalbuminemic patients.
    J Am Soc Nephrol 2001; 12:1010.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/28\">",
    " Loon NR, Wilcox CS, Unwin RJ. Mechanism of impaired natriuretic response to
    furosemide during prolonged therapy. Kidney Int 1989; 36:682.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/29\">",
    " Wald H, Scherzer P, Popovtzer MM. Na,K-ATPase in isolated nephron segments
    in rats with experimental heart failure. Circ Res 1991; 68:1051.",
    " </a>",
    " </li>",
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    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/30\">",
    " Almeshari K, Ahlstrom NG, Capraro FE, Wilcox CS. A volume-independent
    component to postdiuretic sodium retention in humans. J Am Soc Nephrol 1993;
    3:1878.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/31\">",
    " Abdallah JG, Schrier RW, Edelstein C, et al. Loop diuretic infusion
    increases thiazide-sensitive Na(+)/Cl(-)-cotransporter abundance: role of
    aldosterone. J Am Soc Nephrol 2001; 12:1335.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/32\">",
    " Wollam GL, Tarazi RC, Bravo EL, Dustan HP. Diuretic potency of combined
    hydrochlorothiazide and furosemide therapy in patients with azotemia. Am J Med
    1982; 72:929.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/33\">",
    " Fliser D, Schr&ouml;ter M, Neubeck M, Ritz E. Coadministration of thiazides
    increases the efficacy of loop diuretics even in patients with advanced renal
    failure. Kidney Int 1994; 46:482.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/34\">",
    " Dargie HJ, Allison ME, Kennedy AC, Gray MJ. High dosage metolazone in
    chronic renal failure. Br Med J 1972; 4:196.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/35\">",
    " Oster JR, Epstein M, Smoller S. Combined therapy with thiazide-type and loop
    diuretic agents for resistant sodium retention. Ann Intern Med 1983; 99:405.",
    " </a>",
    " </li>",
    " <li>",
    " <a class=\"nounderline abstract\" href=\"UTD.htm?0/40/650/abstract/36\">",
    " Vargo DL, Brater DC, Rudy DW, Swan SK. Dopamine does not enhance furosemide-
    induced natriuresis in patients with congestive heart failure. J Am Soc Nephrol
    1996; 7:1032.",
    " </a>",
    " </li>",
    " </ol>",
    " </div>",
    " <div id=\"topicVersionRevision\">",
    " Topic 2324 Version 13.0",
    " </div>",
    " </div>",
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    var outline_f0_40_650=[" <div id=\"toggleOutline\">",
    " <a href=\"#\" title=\"Collapse Topic Outline\">",
    " <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
    " </a>",
    " </div>",
    " <div id=\"innerOutline\">",
    " <h1>",
    " TOPIC OUTLINE",
    " </h1>",
    " <div id=\"outline\">",
    " <ul>",
    " <li>",
    " <a class=\"sr_button\" href=\"#H17558105\" id=\"summRecButton\">",
    " <span>",
    " SUMMARY &amp; RECOMMENDATIONS",
    " </span>",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H1\">",
    " INTRODUCTION",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H2\">",
    " CHOICE OF DIURETIC",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H3\">",
    " BASIC PRINCIPLES OF DIURETIC DOSING",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H4\">",
    " Determine the effective dose",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H5\">",
    " Oral versus intravenous therapy",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H6\">",
    " RISK OF OTOTOXICITY",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H7\">",
    " Mechanism",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H8\">",
    " Importance of dose and rate of administration",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H9\">",
    " PATHOGENESIS AND MANAGEMENT OF REFRACTORY EDEMA",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H10\">",
    " Exclude high salt intake",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H11\">",
    " Decreased loop diuretic secretion",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H12\">",
    " - Maximum effective dose of loop diuretics",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H13\">",
    " - Application to refractory edema",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H14\">",
    " - Continuous infusion",
    " </a>",
    " </li>",
    " <li class=\"bulletItem2\">",
    " <a class=\"outlineLink\" href=\"#H19940053\">",
    " Regimen",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H15\">",
    " - Posture",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H16\">",
    " - Infusion with albumin",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H17\">",
    " Enhanced tubular sodium reabsorption",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H18\">",
    " - Thiazide plus loop diuretics",
    " </a>",
    " </li>",
    " <li class=\"dashItem\">",
    " <a class=\"outlineLink\" href=\"#H19\">",
    " - Use of dopamine",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H20\">",
    " Ultrafiltration",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H21\">",
    " APPROACH TO REFRACTORY EDEMA",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H22\">",
    " Oral therapy",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"outlineLink\" href=\"#H23\">",
    " Intravenous therapy",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#PATIENT_INFORMATION\">",
    " INFORMATION FOR PATIENTS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"outlineLink\" href=\"#H17558105\">",
    " SUMMARY AND RECOMMENDATIONS",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a href=\"#references\">",
    " REFERENCES",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " <div class=\"openRelatedGraphics\" id=\"NEPH/2324\" rel=\"outline_link\">",
    " GRAPHICS",
    " <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
    " View All",
    " </a>",
    " </div>",
    " </h1>",
    " <div id=\"relatedGraphics\">",
    " <ul>",
    " <li class=\"plainItem\">",
    " <div class=\"openRelatedGraphics\" id=\"NEPH/2324|FIG\">",
    " <a href=\"#\" title=\"FIGURES\">",
    " FIGURES",
    " </a>",
    " </div>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?16/36/16973\"
    title=\"figure 1\">",
    " Loop diuretic dose response",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?31/33/32285\"
    title=\"figure 2\">",
    " First dose diuretic response",
    " </a>",
    " </li>",
    " <li class=\"bulletItem\">",
    " <a class=\"graphic graphic_figure\" href=\"UTD.htm?27/35/28221\"
    title=\"figure 3\">",
    " Distal response to furosemide",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " <h1>",
    " RELATED TOPICS",
    " </h1>",
    " <div id=\"relatedTopics\">",
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    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?33/56/34698?
    source=related_link\">",
    " Treatment of acute decompensated heart failure: Components of therapy",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?34/40/35465?
    source=related_link\">",
    " Treatment of diuretic-resistant ascites in patients with cirrhosis",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?27/54/28521?
    source=related_link\">",
    " Use of aldosterone antagonists in heart failure",
    " </a>",
    " </li>",
    " <li class=\"plainItem\">",
    " <a class=\"medical medical_review\" href=\"UTD.htm?3/55/3962?
    source=related_link\">",
    " Use of diuretics in patients with heart failure",
    " </a>",
    " </li>",
    " </ul>",
    " </div>",
    " </div>"].join("\n");
    var title_f0_40_651="Indications LAVH";
    var content_f0_40_651=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=OBGYN
    %2F51508&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=5\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=OBGYN
    %2F51508&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=5\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
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    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
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    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Indications for laparoscopic assistance to vaginal hysterectomy",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td>",
    " Possible extrauterine disease",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Endometriosis",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Possible adhesive disease",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " History of pelvic inflammatory disease",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Ovarian disease",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " Chronic pelvic pain",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_651=[""].join("\n");
    var outline_f0_40_651=null;
    var title_f0_40_652="Approach to mediastinal nodes";
    var content_f0_40_652=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PULM
    %2F59333&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=4\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=PULM
    %2F59333&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=4\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Anatomic considerations in TBNA of mediastinal lymph nodes",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\">",
    " <tr>",
    " <td class=\"subtitle1\">",
    " Station",
    " </td>",
    " <td class=\"subtitle1\">",
    " Level",
    " </td>",
    " <td class=\"subtitle1\">",
    " Best approach",
    " </td>",
    " <td class=\"subtitle1\">",
    " Pitfalls",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " 7",
    " </td>",
    " <td>",
    " Subcarinal nodes",
    " </td>",
    " <td>",
    " From a point 3-5 mm below on either side of the primary carina, with the
    needle pointed in an inferomedial direction.",
    " </td>",
    " <td>",
    " Direct puncture of a normal looking carina should usually be avoided.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " 4R",
    " </td>",
    " <td>",
    " Right paratracheal lymph nodes",
    " </td>",
    " <td>",
    " From the second or third intercartilaginous space (or 2 cm) proximal to the
    carina at the 1-2 o'clock position.",
    " </td>",
    " <td>",
    " The mediastinal reflection of the pleura and the azygos vein lie at the 3
    o'clock position and should be avoided.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " 4L",
    " </td>",
    " <td>",
    " Left paratracheal nodes",
    " </td>",
    " <td>",
    " From the lateral wall of the left main bronchus at the level of the carina
    at the 9 o'clock position.",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " 10R",
    " </td>",
    " <td>",
    " Right hilar nodes",
    " </td>",
    " <td>",
    " Through the bronchus intermedius at 3 o'clock position, just below the
    level of the right upper lobe bronchus or proximal to the origin of the superior
    segment of the right lower lobe bronchus.",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td>",
    " 10L",
    " </td>",
    " <td>",
    " Left hilar nodes",
    " </td>",
    " <td>",
    " At the origin of the left lower lobe bronchus at the nine o'clock
    position.",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Adapted with permission from Minai, OA, Dasgupta, A, Mehta, AC.
    Transbronchial needle aspiration of central and peripheral lesions. In: Bolliger,
    CT, Mathur, PN (Eds), Progress in Respiratory Research - Interventional
    Bronchoscopy. Karger, Basel, Switzerland, 1999.",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_652=[""].join("\n");
    var outline_f0_40_652=null;
    var title_f0_40_653="Laboratory testing for PHHI";
    var content_f0_40_653=[" <div id=\"graphicsToolbar\">",
    " <div id=\"graphicsCopy\">",
    " &copy;2013 UpToDate",
    " <sup>",
    " &reg;",
    " </sup>",
    " </div>",
    " <div id=\"graphicsLinks\">",
    " <a href=\"?imageKey=PEDS
    %2F64643&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=3\" onclick=\"\">",
    " <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
    title=\"Print this page\"/>",
    " </a>",
    " <a class=\"icontxt textLink\" href=\"?imageKey=PEDS
    %2F64643&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=3\" onclick=\"\"
    title=\"Print this page\">",
    " Print",
    " </a>",
    " <a class=\"etacLink\" href=\"#\">",
    " <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
    title=\"Email graphic(s)\"/>",
    " </a>",
    " <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
    " Email",
    " </a>",
    " </div>",
    " </div>",
    " <div class=\"graphic\">",
    " <div class=\"figure\">",
    " <div class=\"ttl\">",
    " Laboratory testing for persistent hyperinsulinemic hypoglycemia of infancy
    (samples taken during period of hypoglycemia)",
    " </div>",
    " <div class=\"cntnt\">",
    " <table cellspacing=\"0\">",
    " <tbody>",
    " <tr>",
    " <td class=\"subtitle1\">",
    " &nbsp;",
    " </td>",
    " <td class=\"subtitle1\" colspan=\"2\">",
    " Result suggestive of PHHI",
    " </td>",
    " <td class=\"subtitle1\">",
    " Comment",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle2_left\" colspan=\"4\">",
    " Blood",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Glucose",
    " </td>",
    " <td class=\"centered\">",
    " &darr;",
    " </td>",
    " <td>",
    " &lt;40 mg/dL (2.2 mmol/L)",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Insulin",
    " </td>",
    " <td class=\"centered\">",
    " &uarr;",
    " </td>",
    " <td>",
    " &ge;5 mcU/mL (36 pmol/L)",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " C-peptide",
    " </td>",
    " <td class=\"centered\">",
    " &uarr;",
    " </td>",
    " <td>",
    " &ge;0.2 nmol/L (0.6 ng/mL)",
    " </td>",
    " <td>",
    " If C-peptide is low despite hyperinsulinemia, the possibility of exogenous
    administration of insulin should be considered",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Free fatty acids",
    " </td>",
    " <td class=\"centered\">",
    " &darr;",
    " </td>",
    " <td>",
    " &lt;1.0 mmol/L",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Beta-hydroxybutyrate",
    " </td>",
    " <td class=\"centered\">",
    " &darr;",
    " </td>",
    " <td>",
    " &lt;1.5 mmol/L",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Lactic acid",
    " </td>",
    " <td class=\"centered\">",
    " Normal",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Carnitine",
    " </td>",
    " <td class=\"centered\">",
    " Normal",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Ammonia",
    " </td>",
    " <td class=\"centered\">",
    " &uarr; in HIHA form of PHHI",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " Normal in other forms of PHHI",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Growth hormone",
    " </td>",
    " <td class=\"centered\">",
    " &uarr;",
    " </td>",
    " <td>",
    " Usually &gt;10 mcg/L",
    " </td>",
    " <td>",
    " Elevated due to hypoglycemia; this result excludes growth hormone
    deficiency as a cause of hypoglycemia. However, a normal or low value is NOT
    diagnostic of growth hormone deficiency.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Cortisol",
    " </td>",
    " <td class=\"centered\">",
    " &uarr;",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " Elevated due to hypoglycemia; this result excludes cortisol deficiency as
    a cause of hypoglycemia. However, a normal or low value is NOT diagnostic of
    cortisol deficiency.",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"subtitle2_left\" colspan=\"4\">",
    " Urine",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " Ketones",
    " </td>",
    " <td class=\"centered\">",
    " Negative",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " In some cases of PHHI, ketonuria may be present despite an abnormally low
    plasma concentration of ketones, because the renal threshold for ketones is low",
    " </td>",
    " </tr>",
    " <tr>",
    " <td class=\"indent1\">",
    " C-peptide",
    " </td>",
    " <td class=\"centered\">",
    " &uarr;",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " <td>",
    " &nbsp;",
    " </td>",
    " </tr>",
    " </tbody>",
    " </table>",
    " </div>",
    " <div class=\"lgnd\">",
    " <div class=\"footnotes\">",
    " PHHI: persistent hyperinsulinemic hypoglycemia of infancy; HIHA:
    hyperinsulinism-hyperammonemia.",
    " </div>",
    " <div class=\"reference\">",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
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    040lID//2Q==);\">",
    " </div>",
    " <div class=\"lgnd\">",
    " A neti pot is a small pot with a long spout. This woman is using a neti pot to
    rinse out her nose with salt water.",
    " <div class=\"footnotes\">",
    " </div>",
    " <div class=\"reference\">",
    " Reproduced from: U.S. Food and Drug Administration. For Consumers: Is Rinsing
    Your Sinuses Safe? Available at:&nbsp;",
    " <a href=\"file://www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375\"
    style=\"FONT-STYLE: italic\" target=\"_blank\">",
    " file://www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375",
    " </a>",
    " (Accessed October 12, 2012).",
    " </div>",
    " </div>",
    " </div>",
    " </div>",
    "</div>"].join("\n");
    var script_f0_40_655=[""].join("\n");
    var outline_f0_40_655=null;

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