acute decompensated heart failure

acute decompensated heart failure

• 1.
  Dr. Saitejreddy
• 2.
   ADHF isa common and potential fatal cause of acute respiratory distress  Characterized by SOB, associated with rapid accumulation of within lung interstitial and alveolar spaces.  Most commonly due to left ventricular systolic and diastolic dysfunction +/_ cardiac pathology(CAD/valve abnormality)  Other causes includes primary fluid overload(blood transfusion), severe HTN, severe renal disease.
• 3.
   INITIAL STABILIZATION-  Airway assessment for adequate oxygenation and ventilation.  Vital signs assessment.  Continuous cardiac monitoring.  Seated posture  Diuretic therapy  Vasodilator therapy  Urine output monitoring.
• 4.
   Pt withpul edema due to HTN->vasodilator therapy  Pt with normotension & volume overload->diuretic + vasodilator therapy  Pt with hypotension & intravascular overload->diuretic +/_ ionotropes.  SUPPLEMENTAL O2 SUGGESTED AS FOLLOWS  1. Non rebreath facemask delivering highflow O2  2. If respiratory distress, acidosis, hypoxia-> NPPV(noninvasive positive pressure ventilation)  3. pt with resp failure who fail NPPV should be intubated for mechanical ventilation
• 5.
   DIURETICS Pts with ADHF and volume overload regardless of etiology, should be treated with IV diuretics.  Rare exceptions are severe hypotension, cardiogenic shock.  IV preferred over oral diuretics because of greater drug bioavailability  Drug dosage-  1.furosemide – 40mg IV  2.bumetanide – 1mg IV  3.torsemide – 10 to 20mg IV  Monitoring- volume status, evidence of congestion, oxygenation, daily weights, intake output assessment.  Diuretics can also precipitate attacks of gout.  Serum K+ and Mg levels monitored at least daily  Blood urea nitrogen(BUN) & S.creatinine often monitored
• 6.
  Summerized briefly Sodiumintake restricted <2g daily  Doubling diuretic dose till diuresis ensues  Add second diuretic in whom diuretic response is inadequate, IV chlorthiazide(500 to 1000mg/day) or oral metalazone or spironolactone are choices  Aldosterone antagonist recommended in pts with systolic HF.
• 7.
   IV vasodilatorsand diuretics are recommended in pts with acute pulmonary edema or severe HTN.  Frequent BP monitoring recommended.  IV nitroprusside, nitroglycerin or nesiritide are considered in pts with ADHF and advanced HF  IV Nitroglycerin initial dose 5 to 10mcg/min. dose increased @ 5 to 10mcg/min every 3 to 5 min(dose range 10- 200mcg/min)  IV Nitroprusside initial dose 5 to 10 mcg/min, dose range 5- 400mcg/min  Dose titrated to maintain SBP>90mmHg DBP>65 mmHg
• 8.
  1. ACE inhibitorsand ARBs- discontinued in hypotension, acute renal failure, hyperkalemia. 2. Inotropic agents- helpful in pts with LV systolic dysfunction and low output syndrome  Frequent BP monitoring and monitoring of cardiac rhythm  Symptomatic hypotension or tachyarrhythmias are contraindications  Milrinone-loading dose of 50mcg/kg over 10min, maintenance dose of 0.375 to 0.750mcg/kg/min  Dobutamine- started at 2.5mcg/kg/min increased to 20mcg/kg/min  Dopamine- titrated upto 10mcg/kg/min
• 9.
  3. Vasopressor therapy-indicatedin pts with ADHF and hypotension. Drugs used are norepinephrine, high dose dopamine(>5mcg/kg/min), vasopressin. 4. Beta blockers- indicated in pts with ADHF and systolic dysfunction. 5. Venous thromboembolism prophylaxis- LMW heparin or fondaparinux. 6. Morphine sulfate- reduces pt anxiety and decrease work of breathing->arteriolar ad venous dilatation->fall in cardiac filling pressures.
• 10.
  1. Mechanical cardiacassistance- indicated in pts with cardiogenic pul edema and cardiogenic shock  Modalities used are intraaortic balloon counterpulsation and implanted left ventricular assist device. 2. Ultrafiltration- method of fluid removal with no effect on S.electrolytes and decreased neurohormonal activity. 3. Vasopressin receptor antagoists
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  THANK YOU