Acute HF

Question 1

Warm/Wet/Cold/Dry

Answer 1

-Warm = normal perfusion
-Cold = poor perfusion, CI < 2.2, SBP < 90, lactate > 2
-Wet = excess fluid
-Dry = no excess fluid

Question 2

Warm + Wet Tx

Answer 2

All: Nitrates if SBP > 90

1. IV loop diuretics
2. Thiazide diuretics
3. Acetazolamide
4. Tolvaptan

Question 3

Loop Diuretics Dosing

Answer 3

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

Question 4

Max IV Boluses for Loops

Answer 4

Furosemide: 80 mg per dose

Bumetanide: 4 mg per dose

Question 5

Loop Conversions

Answer 5

40 mg Furosemide =

20 mg Torsemide
=
1 mg Bumetanide
=
50 mg EA

Question 6

Loops: Give as continuous infusion if high total daily dose

Answer 6

-Furosemide >= 161 mg
-Bumetanide >= 9 mg
=
-Furosemide 80 mg IVB then 10-20 mg/hr
-Bumetanide 2 mg IVB then 0.5 mg/hr

Question 7

Dose adj on CI: Loops

Answer 7

Question 8

Loops: AE/CI

Answer 8

AE:
-Low electrolytes (K/Na/Mg/Cl/Ca)
-Dehydration
-AKI
-Met alkalosis
-Ototoxicity

CI:
-Sulfa allergy (EA OK)

Question 9

Thiazides: When to Give + Dosing

Answer 9

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

Question 10

Thiazides: AE

Answer 10

-Low electrolytes (K/Na/Mg/Cl)
-Dehydration
-AKI

*but high Calcium

Question 11

Acetazolamide

Answer 11

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

Question 12

Acetazolamide: AE/CI

Answer 12

AE:
-Low K/Na
-Dehydration
-Metabolic acidosis
-AKI

CI:
-Sulfa
-SJS

Question 13

Tolvaptan

Answer 13

Hypervolemic or euvolemic hypoNa < 125

Dosing: 15 mg, can double dose every 24 hours, max 60 mg

Question 14

Tolvaptan: AE/DDI

Answer 14

-BBW for osmotic demyelination (rapid sodium rise 12+)
-Hyperkalemia
-Hyperglycemia
-Dehydration
-Liver toxicity
= DOLKG

-CYP3A4

Question 15

Nitrates Dosing

Answer 15

Nitroglycerin
-Max 200 mcg/min, start at 10-20

Nitroprusside
-Max 3 mcg/min, start at 0.25-0.5

Question 16

Nitrates Monitoring

Answer 16

AE:
-PRUSS: cyanide and thiocyanate toxicity
-Both: tachyphylaxis, hypotension, HA, rebound tachycardia

CI:
-PRUSS: caution in liver/kidney failure, avoid in pregnancy

Question 17

Cold + Dry Tx

Answer 17

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)

Question 18

Inotropes: Dosing

Answer 18

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

Question 19

Inotropes: Monitoring

Answer 19

AE:
-Dop: after load increase
-Dobut/Mil: hypotension
-All: tachy, arrhythmia

CI:
-Milrinone: renal

Question 20

Cold + Wet Tx

Answer 20

Use of diuretics, vasodilators, and inotropes (use is the same as other states)