Ascities and SBP Flashcards
What causes ascites?
- decreased oncotic pressure
- low albumin leads to fluid shift from intra to extravascular
- increased renin and aldosterone
- anti-diuretic horomone activation
How can ascites be prevented?
- maintain protein intake in early liver disease
- mild salt restriction (2-3g / day)
What is the weight loss goal for ascites?
0.5 kg daily through diuresis
What is the starting ratio for Spironolactone: furosemide?
100mg : 40mg
What are SEs with Spironolactone?
- hyperkalemia
- gynecomastia
- gastritis
What are SEs with Furosemide?
- hypokalemia
- hyperuricemia
- orthostasis
- tinnitus (high-dose)
What dose adjustments should be made if the patient has hyperkalemia and low BP?
decrease Spironolactone
What dose adjustments should be made if the patient has hyperkalemia and high BP?
increase Furosemide
What dose adjustments should be made if the patient has hypokalemia and low BP?
decrease Furosemide
What dose adjustments should be made if the patient has hypokalemia and high BP?
increase Spirinolactone
Why are Furosemide and Spironolactone used in combination?
- balance K+
- block kidneys from retaining sodium so diuresis works better
What agents should be used for refractory ascites?
- Midodrine with high dose diuretics
- large-volume paracentesis
- TIPS
What is the MOA of Midodrine?
alpha-1 agonist
What are SEs with Midodrine?
itching
urinary retention
paresthesia
HTN
What are the complications with paracentesis?
nicked artery/veins
ascitic fluid leak
infection
hypotension –> hyporenal syndrome
When is albumin replacement recommended?
anything more than 5L removes
What is the proper dose of albumin?
8g/L
What medications should be avoided with ascites to prevent hepatorenal failure?
NSAIDs
Aminoglycosides
What is required for primary SBP prophylaxis?
low ascitic fluid protein
AND
impaired renal function or
BUN >25 or
serum sodium <130 or
liver failure
What is required for secondary SBP prophylaxis?
SPB diagnosis and liver disease
What agents are used for SBP prophylaxis?
Cipro
Norfloxacin (Canada)
Bactrim (quinolone resistance/allergy)
How is SBP diagnosed?
PMN > 250
OR any bacterial growth in ascitic fluid
What agents are used for community-acquired SBP?
Cefotaxime
Ceftriaxone
(quinolones if allergy)
What agents are used for nosocomial SBP?
Zosyn
Cefepime
Carbapenem
(covers pseudomonas)
add vanco if MRSA
When is albumin given for SBP?
days 1 and 3
