Acute Decompensated HF Drugs 1 Flashcards
Type 1
Warm and dry
- Patients are okay
Type 2
Warm and wet
- Typically caused by too much sodium or forgot their diuretics
Type 3
Cold and Dry
- Typically hypoperfusion
Type 4
Cold and Wet
Wet =
Congestion
Wet symptoms
Peripheral edema Pulmonary edema: dyspnea, orthopnea, nocturnal dyspnea, rales, wheezing Ascites GI edema: Early satiety/reduced appetite Abdominal fullness Jugular distention Hepatojugular reflex
Define orthopnea
Water goes from your legs to your lungs, making it hard to breath
Cold Symptoms
Reduced Cardiac Output Cold/clammy extremities Renal insufficiency Altered mental status Hypotension Fatigue Narrow pulse pressure
Too much diuretics =
Dry
& vice versa
If your pulmonary artery occlusion pressure (PAOP) is not within 15-18,
You will show signs of edema if it is greater than 18
CI greater than 2.2 =
Hyperperfusion
Diuretics are First Line when?
Warm and Wet
Cold and Wet
** any signs of fluid overload
Diuretics titration
Want to lose 1-1.5 kg/day (1000-1500 mL)
Urine output should increase in 1-2 hours
Monitoring for diuretics
BP K MG Na Ca SCr Urine output Daily weight
Diuretic dosing
Needs to be BID or else the body will start to retain the water later on in the day
Diuretics AE
Hypotension, worsening of renal function, electrolyte abnormalities
Contraction alkalosis
Ototoxicity
If the urine output does not increase,
Double initial IV bolus dose Add continuous infusion Add a thiazide Consider addition of vasodilator or inotrope if hypotensive Last line: ultrafiltration
Thiazides that can be used are
Metolazone
Chlorothiazide
Management of Hypotensive for Diuretics
Reduce the rate of diuresis
May require IV fluid bolus or inotrope if it is severe
Reduce/hold BP meds
Management of worsening renal failure
Slower diuresis
Vasodilators (if BP is okay) or inotrops (if BP is low)
Define contraction alkalosis
Occurs as a result of removing water but not bicabonate from the body so the same amount of bicarb in a smaller volume = alkalosis
Warm and Wet Treatment includes
Vasodilators (nitroglycerin, nitroprusside, nesiritide)
Vasodilators are usefule for
Those patients who failed to respond to IV diuretics
Or who have severe pulmonary congestion with hypoxia ad need for rapid resolution
So mainly for warm and wet patients but can also be used for cold and wet if they have adequate organ perfusion (BP > 110/70)
Nitroglycern Hemodynamic effects
Mostly venous but high doses can do arterial dilation
Na Nitroprusside Hemodynamic effects
Venous and arterial dilators
Nesiritide Hemodynamic effects
Venous and arterial dilator
Rapidly reduces PAOP to relieve congestion
Enhances natriuresis
Titration for Nitroglycerin and Nitroprusside
Relief of pulmonary congestion, increase in diuresis and BP no less than 100/65
Nesiritide
(Natrecor)
is not usually titrated and it has a really long half life
Monitoring for Nitroglycerin
BP
Urine output
May need Swan-Ganz
Monitoring for Na Nitroprusside
BP
Urine Output
Need Swan-Ganz
Thiocyanate levels
Monitoring for Nesiritide
BP
Urine Output
No Swan-Ganz**
Nitroglycerin AE
Hypotension
Reflex tachycardia
Tachyphylaxis
Headache
Nitroprusside AE
Hypotension
Reflex tachycardia
Tachyphylaxis
Cyanide toxicity
Nesiritide AE
Hypotension
tachycardia (continuous EKG)
Acute RF
Expensive
Manage Hypotension for Vasodilators
Reduce the dose but do not stop (must taper)
May d/c nesiritide
What do you treat Cold and Dry ADHP or Cold and Wet ADHP with?
Inotropes
Cold and dry ADHP requires
Patient has optimal PAOP, preload, volume status
Cold and wet ADHP inotrope therapy when
vasodilators are not an option due to hypotension or they failed
Dobutamine Hemodynamic effects
+ inotrope
+ Chronotrope (tachycardia)
Slight vasodilation
Milirinone Hemodynamic effects
+ Inotropic
Few chronotropic changes
+ Vasodilation (possible hypOTN)
Milrinone is preferred if
on a beta blocker
BUT NOT HYPOTENSIVE
Dobutamine is preferred in
frank hypotension
Titration targets to the intropes is:
CI > 2.2
Intropes Monitoring
Continuous EKG for arrhythmias, BP, urine output, new onset chest pain
Dobutamine AE
Arrhythmias Tachycardia Hypotension Myocardial Ischemia Tachyphylaxis
Milirinone AE
Arrhythmias Tachycardia Hypotension Myocardial Ischemia Thrombocytopenia
Long term use of inotropes is associated with
Increased mortality
