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grepmeded's profile
GrepMed
GrepMed
GrepMed
@grepmeded

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GrepMed

@grepmeded

Image Based Medical Reference: Sharing crowd-sourced checklists, algorithms, decision aids, #PhysicalExam #POCUS, and more - by @GeraldMDMD + @k00bideh

Sacramento, CA
grepmed.com
Joined March 2018

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    1. Zaven Sargsyan‏ @sargsyanz Mar 6
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      What’s a stronger regimen of furosemide, 40 daily or 20 bid? I ask this question often on rounds. The answer: it depends. Understanding what it depends ON is really helpful for dosing decisions. Let’s explore. #tweetorial 1/

      79 replies 901 retweets 2,845 likes
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    2. Zaven Sargsyan‏ @sargsyanz Mar 6
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      It’s helpful to think of therapeutic effect as “episodes of diuresis” adding up to total diuresis. A single “good” dose of a loop will result in excretion of about 250mEq (~6g) of Na in about 2-3L of urine. For furosemide, this occurs over ~6 hours. https://tinyurl.com/uyxkl7f  2/

      5 replies 24 retweets 154 likes
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    3. Zaven Sargsyan‏ @sargsyanz Mar 6
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      This is the dose-response curve for loop diuretics (roughly applies to each episode / dose). The sigmoidal shape, similar to hgb-dissociation curve, means: - at doses left of the steep part, nothing happens - once you get past steep part, increasing dose more doesn’t do much 3/pic.twitter.com/CFz8CpFo2T

      1 reply 10 retweets 98 likes
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    4. Zaven Sargsyan‏ @sargsyanz Mar 6
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      These are called the threshold effect and ceiling effect, and the variable answer to the original question is all about these phenomena. The “depends” is “depends on what the threshold dose is in this particular patient.” 4/pic.twitter.com/zFpFcXQw8K

      1 reply 6 retweets 76 likes
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    5. Zaven Sargsyan‏ @sargsyanz Mar 6
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      If threshold in this patient is <20, then: 40 daily: 2.5L once = 2.5L total 20 bid: 2L twice = 4L total 20 bid is stronger. 5/pic.twitter.com/CQ5OMBqzcF

      5 replies 6 retweets 89 likes
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    6. Zaven Sargsyan‏ @sargsyanz Mar 6
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      But if threshold in this patient is >20 (but <40), then: 40 daily: 2.5L once = 2.5L total 20 bid: scant twice = scant total 40 daily is stronger. 6/pic.twitter.com/bv3srh9WKd

      1 reply 3 retweets 64 likes
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    7. Zaven Sargsyan‏ @sargsyanz Mar 6
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      Let’s practice applying this: Patient A is on 40IV bid in the hospital. Daily UOP is 1.5 liters. How do you adjust? 7/

      1 reply 2 retweets 39 likes
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    8. Zaven Sargsyan‏ @sargsyanz Mar 6
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      40 clearly wasn’t reaching threshold (<<750 cc out per dose). Adding an additional episode of (non-)diuresis won’t help. Better to increase dose and actually make each episode of diuresis effective. 8/

      1 reply 3 retweets 55 likes
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    9. Zaven Sargsyan‏ @sargsyanz Mar 6
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      Patient B is on 40 IV bid, UOP is about 4000 per day. But they’re tolerating it well and have a long ways to go, and you’d like to augment diuresis further. How do you adjust? 9/

      2 replies 2 retweets 38 likes
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    10. Zaven Sargsyan‏ @sargsyanz Mar 6
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      I would keep dose 40, make it tid. Each dose is probably causing almost 2L out, and increasing dose further may have marginal effect. Better to add a third episode of diuresis. (Why no metolazone? If you can get away without it, do so. 10/ https://tinyurl.com/upq3mmu  )

      3 replies 2 retweets 56 likes
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      GrepMed‏ @grepmeded Mar 6
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      Replying to @sargsyanz

      very interesting article, thank you- I’m never really quite sure what I’m doing with metolazone... was not aware it had such bad associated effects relative to loop alone.

      2:24 PM - 6 Mar 2020
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      • Zaven Sargsyan
      2 replies 0 retweets 1 like
        1. Zaven Sargsyan‏ @sargsyanz Mar 6
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          Replying to @grepmeded

          It’s a retrospective study, so hard to say it’s not just confounded by indication. But empirically too, electrolyte losses and fluid shifts can be so rapid with the combination that if I don’t have to use it, I don’t. But if really loop refractory, it can be savior.

          0 replies 0 retweets 3 likes
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        1. dwyhajlo‏ @dwyhajlo Mar 6
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          Replying to @grepmeded @sargsyanz

          Adjunctive thiazides are great when you need them, it’s just that they’re usually not needed quite as frequently as they’re given.

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