Acute HF Flashcards
Warm/Wet/Cold/Dry
-Warm = normal perfusion
-Cold = poor perfusion, CI < 2.2, SBP < 90, lactate > 2
-Wet = excess fluid
-Dry = no excess fluid
Warm + Wet Tx
All: Nitrates if SBP > 90
- IV loop diuretics
- Thiazide diuretics
- Acetazolamide
- Tolvaptan
Loop Diuretics Dosing
IV Bolus
-Multiply home oral dose by 1-2.5 = give that as an IV bolus BID
Wt loss/sx
-Urine output of 2-3 L per dose or 3-5 L per day
Not at goal?
-Double the dose until goal is met, THEN can increase frequency if still not at goal
Max IV Boluses for Loops
Furosemide: 80 mg per dose
Bumetanide: 4 mg per dose
Loop Conversions
40 mg Furosemide =
20 mg Torsemide
=
1 mg Bumetanide
=
50 mg EA
Loops: Give as continuous infusion if high total daily dose
-Furosemide >= 161 mg
-Bumetanide >= 9 mg
=
-Furosemide 80 mg IVB then 10-20 mg/hr
-Bumetanide 2 mg IVB then 0.5 mg/hr
Dose adj on CI: Loops
Loops: AE/CI
AE:
-Low electrolytes (K/Na/Mg/Cl/Ca)
-Dehydration
-AKI
-Met alkalosis
-Ototoxicity
CI:
-Sulfa allergy (EA OK)
Thiazides: When to Give + Dosing
Consider giving if on 4 mg B IV BID or 80 mg F IV BID or continuous infusion of diuretic
Dosing: 30 min B4 loop
-Metolazone 2.5-10 mg PO daily or divided doses
-Chlorothiazide 250-1000 mg IV daily or bid
Thiazides: AE
-Low electrolytes (K/Na/Mg/Cl)
-Dehydration
-AKI
*but high Calcium
Acetazolamide
Consider if on at least 2x home oral loop dose given as IV or if bicarb is high (30+)
Dosing: 500 mg IV daily or bid
Acetazolamide: AE/CI
AE:
-Low K/Na
-Dehydration
-Metabolic acidosis
-AKI
CI:
-Sulfa
-SJS
Tolvaptan
Hypervolemic or euvolemic hypoNa < 125
Dosing: 15 mg, can double dose every 24 hours, max 60 mg
Tolvaptan: AE/DDI
-BBW for osmotic demyelination (rapid sodium rise 12+)
-Hyperkalemia
-Hyperglycemia
-Dehydration
-Liver toxicity
= DOLKG
-CYP3A4
Nitrates Dosing
Nitroglycerin
-Max 200 mcg/min, start at 10-20
Nitroprusside
-Max 3 mcg/min, start at 0.25-0.5
Nitrates Monitoring
AE:
-PRUSS: cyanide and thiocyanate toxicity
-Both: tachyphylaxis, hypotension, HA, rebound tachycardia
CI:
-PRUSS: caution in liver/kidney failure, avoid in pregnancy
Cold + Dry Tx
If PCWP < 15, dry skin, diarrhea, weight loss, orthostasis:
-Give 250-500 ml IV fluids
If PCWP > 15, no sx of dehydration:
-SBP < 90: Inotropes
-SBP > 90: Nitrates (refractory > Inotropes)
Inotropes: Dosing
Dopamine
-Max 20 mcg/kg/min, start at 3-5
Dobutamine
-Max 20 mcg/kg/min, start at 3-5
Milrinone
-Max 0.75 mcg/kg/min, start at 0.125-0.25
Inotropes: Monitoring
AE:
-Dop: after load increase
-Dobut/Mil: hypotension
-All: tachy, arrhythmia
CI:
-Milrinone: renal
Cold + Wet Tx
Use of diuretics, vasodilators, and inotropes (use is the same as other states)
