Wut r the 6 hemodynamic values for ADHF? Which 3 are decreased and which 3 are increased in ADHF?
What are the normal and ADHF values for:
MAP: Nl - 80-100; ADHF - 60-80
CO: Nl - 4-7; ADHF - 2-4
CI: Nl - 2.8-3.6; ADHF - 1.3-2
What are the normal and ADHF values for:
PCWP: Nl - 8-12; ADHF - 18-30
SVR: Nl - 800-1200; ADHF - 1500-3000
CVP: Nl - 2-6; ADHF - 6-15
Wut r the 9 s/sx for congestion (Elevated PCWP)?
- 1. Dyspnea on exertion or at rest
- 2. Orthopnea (paroxysmal nocturnal dyspnea)
- 3. Peripheral edema
- 4. Rales
- 5. Early satiety, N/V
- 6. Ascites
- 7. Hepatomegaly, splenomegaly
- 8. Jugular venous distention (JVD)
- 9. Hepatojugular reflux
Wut r the 7 s/sx of hypoperfusion (decreased CO)?
- 1. Fatigue
- 2. AMS or sleepiness
- 3. Cold extremities
- 4. Worsening renal f(x)
- 5. Narrow pulse pressure
- 6. Hypotension
- 7. HypoNa
Describe the 4 Forester subsets for ADHF (numbers dec/inc)
I. Warm and dry (CI>2.2; PCWP<18)
II. Warm and wet (CI>2.2; PCWP>18)
III. Cold and dry (CI<2.2; PCWP<18)
IV. Cold and wet (CI<2.2; PCWP>18)
What are the general interventions suggested for patients with ADHF in subsets I and II?
I. Warm and dry: Optimize oral meds
II. Warm and wet: IV diuretics +/- IV venous vesodilators [venous dec PCWP]
Wut r the general interventions suggested for the following situations in ADHF pt in subset III:
In all of these, CI<2.2 AND -
2. PCWP>=15 and MAP<=50
3. PCWP>=15 and MAP>=50
- In all of these, CI<2.2 AND -
- 1. PCWP<15: IVF until PCWP 15-18
2. PCWP>=15 and MAP<=50: IV DA (1-15mcg/kg/min)
- 3. PCWP>=15 and MAP>=50:
- If no compelling reason for inotrope, use IV arterial vasodilator
- If compelling reason for inotrope (SBP<90, sx'atc hypotension, worsening renal f(x)), use IV inotrope
Wut r the general interventions suggested for the following situations in ADHF pt in subset IV:
1. MAP<=50: IV diuretics + IV DA
- 2. MAP>=50
- If no compelling reason for inotrope, use IV venous and/or arterial vasodilator
- If compelling reason for inotrope (SBP<90, sx'atc hypotension, worsening renal f(x)) use IV inotrope
Describe the general effects of DA at low, high, and intermediate doses.
Low 1-5mcg/kg/min: Renal efx (inc renal blood flow and UOP)
Int 5-15mcg/kg/min: Renal and heart efx (inc renal blood flow, HR, heart contractility, CO)
High >15mcg/kg/min: Alpha-adrenergic efx (Inc BP, vasodilation)
FYI if must use DA>20mcg/kg/min, better to use E/NE... also FYI no renal d-adj needed for DA
Of these 3 drug classes - ACE/ARB, BB, digoxin - which one should be held if hemodynamically unstable? Which should not be uptitrated or initiated until euvolemic?
Both questions - BB
Whats the goal serum digoxin level in HF?
Avoid d/c digoxin during ADHF unless compelling reason b/c of what? Wuts the recommended renal d-adjustment for digoxin?
B/c digoxin w/drawal has been asso'd w/worsening HF symptoms
- CrCL 10-50: Admin q36hrs
- CrCL <10: Admin q48hrs
Wuts the recommended IV diuretic for fluid overload? What 4 options should be considered if response to diuretics is minimal?
IV loops recommended
- Minimal response:
- 1. Fluid and Na restriction
- 2. Initiate inc'd doses or CIV of loops
- 3. Add 2nd diuretic w/diff MOA (metolazone, HCTZ, CTZ)
- 4. Ultrafiltration
Inotropes for ADHF may relieve s(x)s and improved end-organ f(x) in pt w/reduced LVEF and diminished peripheral perfusion. What 4 compelling reasons should warrant inotrope consideration?
- 1. SBP<90
- 2. Symptomatic hypotension despite adequate filling P
- 3. Worsening renal f(x)
- 4. No response or intolerance to IV vasodilators
When adjunctive therapy is required in add'n to loop diuretics for acute pulm edema or severe HTN, which types of drugs should be considered?
Wut r the equivalents of IV and PO loop diuretics (4)?
Bumetanide: 1/1 (IV/PO in mg)
Torsemide: 20/20 (IV/PO in mg)
Furosemide: 20/40 (IV/PO in mg)
Ethacrynic acid: 50 (PO in mg)
Wuts the ceiling dose of IV furosemide?
160-200mg IV furosemide
Wut r 3 ways to reduce/avoid diuretic resistance?
1. Inc dose b4 inc'ing frequency of loops
2. Add 2nd diuretic w/diff MOA (HCTZ 12.5-25 daily or metolazone 2.5-5 daily 30 mins b4 loop admin)
3. CIV of loop (furosemide 0.1mg/kg/hr IV double q4-8hrs to max 0.4mg/kg/hr)
Wut r the 2 available inotropes for ADHF? Which 1 is not recommended for BB users and why?
- Dobutamine (Dobutrex) - inc inotrope and chronotrope
- Milrinone (Primacor) - no chronotrope activity
Dobutamine not rec'd in BB users b/c its a B1-agonist and counteracts with it
Wut r the differences in dobutamine and milrinone in the following:
2. Renal dose adjustments
3. Tachyphylaxis risk >72hrs
4. Concomitant use of BB
5. Requirement of IV bolus
1. Dobutamine t1/2 is shorter (2min vs 1hr in milrinone)
2. Dobutamine req's no renal d-adj (milrinone req when CrCL<50)
3. Only dobutamine causes tachyphylaxis risk >72hrs
4. Dobutamine cannot be used with BB d/t counteracted MOA (dobutamine can be used in inc'd BP pts)
5. Milrinone requires 50mcg/kg IV bolus (dobutamine doesnt need bolus dose)
In ADHF, wut r the starting and max titrated dose of the 2 inotropes?
Dobutamine: 2.5-5mcg/kg/min IV to max 20mcg/kg/min IV
Milrinone: 50mcg/kg IVB then 0.375mcg/kg/min to max 0.75mcg/kg/min
Which IV vasodilators have MORE arterial vasodilation and which have MORE venous? What r the diff efx of arterial vs venous?
- Arterial: Reduces SVR and Inc CI
- Sodium nitroprusside (Nipride)
- Nesiritide (Natrecor)
All 3 vasodilators for ADHF must be used w/caution in hypotensive pts. Which one has CN toxicity? Which one has contraindication in SBP<100?
CN toxicity: Na nitroprusside
CI in SBP<100: Nesiritide (Natrecor)
Which 1 of the vasodilators require IV bolus (and wuts the dose)? Wut r the dosings and max dose of the other 2 vasodilators?
Nesiritide: 2mcg/kg IV bolus, then 0.01mcg/kg/min IV
Na Nitroprusside: 0.1-0.2mcg/kg/min IV, increase by 0.2-2mcg/kg/min
IV NTG: 5mcg/min IV, inc by 5mcg/min up to 200mcg/min