Acute Decompensated HF Drugs 1

Question 1

Type 1

Answer 1

Warm and dry

- Patients are okay

Question 2

Type 2

Answer 2

Warm and wet

- Typically caused by too much sodium or forgot their diuretics

Question 3

Type 3

Answer 3

Cold and Dry

- Typically hypoperfusion

Question 4

Type 4

Answer 4

Cold and Wet

Question 5

Wet =

Answer 5

Congestion

Question 6

Wet symptoms

Answer 6

Peripheral edema
Pulmonary edema: dyspnea, orthopnea, nocturnal dyspnea, rales, wheezing
Ascites
GI edema: Early satiety/reduced appetite
Abdominal fullness
Jugular distention
Hepatojugular reflex

Question 7

Define orthopnea

Answer 7

Water goes from your legs to your lungs, making it hard to breath

Question 8

Cold Symptoms

Answer 8

Reduced Cardiac Output
Cold/clammy extremities
Renal insufficiency
Altered mental status
Hypotension
Fatigue
Narrow pulse pressure

Question 9

Too much diuretics =

Answer 9

Dry

& vice versa

Question 10

If your pulmonary artery occlusion pressure (PAOP) is not within 15-18,

Answer 10

You will show signs of edema if it is greater than 18

Question 11

CI greater than 2.2 =

Answer 11

Hyperperfusion

Question 12

Diuretics are First Line when?

Answer 12

Warm and Wet
Cold and Wet
** any signs of fluid overload

Question 13

Diuretics titration

Answer 13

Want to lose 1-1.5 kg/day (1000-1500 mL)

Urine output should increase in 1-2 hours

Question 14

Monitoring for diuretics

Answer 14

BP
K
MG
Na
Ca
SCr
Urine output 
Daily weight

Question 15

Diuretic dosing

Answer 15

Needs to be BID or else the body will start to retain the water later on in the day

Question 16

Diuretics AE

Answer 16

Hypotension, worsening of renal function, electrolyte abnormalities
Contraction alkalosis
Ototoxicity

Question 17

If the urine output does not increase,

Answer 17

Double initial IV bolus dose
Add continuous infusion
Add a thiazide
Consider addition of vasodilator or inotrope if hypotensive
Last line: ultrafiltration

Question 18

Thiazides that can be used are

Answer 18

Metolazone

Chlorothiazide

Question 19

Management of Hypotensive for Diuretics

Answer 19

Reduce the rate of diuresis
May require IV fluid bolus or inotrope if it is severe
Reduce/hold BP meds

Question 20

Management of worsening renal failure

Answer 20

Slower diuresis

Vasodilators (if BP is okay) or inotrops (if BP is low)

Question 21

Define contraction alkalosis

Answer 21

Occurs as a result of removing water but not bicabonate from the body so the same amount of bicarb in a smaller volume = alkalosis

Question 22

Warm and Wet Treatment includes

Answer 22

Vasodilators (nitroglycerin, nitroprusside, nesiritide)

Question 23

Vasodilators are usefule for

Answer 23

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)

Question 24

Nitroglycern Hemodynamic effects

Answer 24

Mostly venous but high doses can do arterial dilation

Question 25

Na Nitroprusside Hemodynamic effects

Answer 25

Venous and arterial dilators

Question 26

Nesiritide Hemodynamic effects

Answer 26

Venous and arterial dilator Rapidly reduces PAOP to relieve congestion Enhances natriuresis

Question 27

Titration for Nitroglycerin and Nitroprusside

Answer 27

Relief of pulmonary congestion, increase in diuresis and BP no less than 100/65

Question 28

Nesiritide

Answer 28

(Natrecor) | is not usually titrated and it has a really long half life

Question 29

Monitoring for Nitroglycerin

Answer 29

BP Urine output May need Swan-Ganz

Question 30

Monitoring for Na Nitroprusside

Answer 30

BP Urine Output Need Swan-Ganz Thiocyanate levels

Question 31

Monitoring for Nesiritide

Answer 31

BP Urine Output No Swan-Ganz****

Question 32

Nitroglycerin AE

Answer 32

Hypotension Reflex tachycardia Tachyphylaxis Headache

Question 33

Nitroprusside AE

Answer 33

Hypotension Reflex tachycardia Tachyphylaxis Cyanide toxicity

Question 34

Nesiritide AE

Answer 34

Hypotension tachycardia (continuous EKG) Acute RF Expensive

Question 35

Manage Hypotension for Vasodilators

Answer 35

Reduce the dose but do not stop (must taper) | May d/c nesiritide

Question 36

What do you treat Cold and Dry ADHP or Cold and Wet ADHP with?

Answer 36

Inotropes

Question 37

Cold and dry ADHP requires

Answer 37

Patient has optimal PAOP, preload, volume status

Question 38

Cold and wet ADHP inotrope therapy when

Answer 38

vasodilators are not an option due to hypotension or they failed

Question 39

Dobutamine Hemodynamic effects

Answer 39

+ inotrope + Chronotrope (tachycardia) Slight vasodilation

Question 40

Milirinone Hemodynamic effects

Answer 40

+ Inotropic Few chronotropic changes + Vasodilation (possible hypOTN)

Question 41

Milrinone is preferred if

Answer 41

on a beta blocker | BUT NOT HYPOTENSIVE

Question 42

Dobutamine is preferred in

Answer 42

frank hypotension

Question 43

Titration targets to the intropes is:

Answer 43

CI > 2.2

Question 44

Intropes Monitoring

Answer 44

Continuous EKG for arrhythmias, BP, urine output, new onset chest pain

Question 45

Dobutamine AE

Answer 45

``` Arrhythmias Tachycardia Hypotension Myocardial Ischemia Tachyphylaxis ```

Question 46

Milirinone AE

Answer 46

``` Arrhythmias Tachycardia Hypotension Myocardial Ischemia Thrombocytopenia ```

Question 47

Long term use of inotropes is associated with

Answer 47

Increased mortality