Acute CHF

[winterallsummer]

There is a unique subset of patients presenting to the hospital with acute CHF exacerbation that I wanted to seek everyone's opinion on. I am not talking about the relatively healthy patients whom will do well with diuresis, BP control and go home in a couple days. Nor am I talking about the crashing patients who need NG drip and NIV or intubation and are ICU bound.

 

What are you all doing for these in between patients who aren't going to the ICU and thus can't get NIV or NG drips? And who happen to have a Cr somewhere between 1.3 and 2.0? Aggressive or conservative diuresis? Continuing ACEi? Anyone using NG tabs or NG paste or isordil? Hydralazine? Early PT? And when/if the Cr up trends are you backing off on diuresis or holding course?

 

Any articles cited as well as anecdotal practice appreciated.

[EMEDPA]

gentle diuresis, ntg paste, obs admit. follow labs. they seem to do fine when you get them away from their fast food lifestyle...

[FfIghter23]

gentle diuresis, ntg paste, obs admit. follow labs. they seem to do fine when you get them away from their fast food lifestyle...

Agree. And never underestimate the power of bipap if used appropriately and tolerated by patient. Now ER perspective will be different from cardiology and IM and so forth.

[EMEDPA]

if they are on bipap they are a full admit, not obs.

[winterallsummer]

I am talking about patients who are not sick enough to go to ICU so NIV not an option. But whose Cr is going up and not necessarily doing "well" yet healthy enough to stay on floor. Eg your EF 25-30% BNP in 1000s+ with baseline Cr 1.6 who come in congested hypertensive and Cr up next day.

 

Any literature to support continuing ace, NG paste or other VD options (again no drips not in ICU)?

[andersenpa]

The answer depends on the capability and units in your hospital. There are various places that have higher acuity floor unit with better RN ratios and specialty capability- CPAP, certain gtts (lasix, ntg, nontitrating/low dose inotropes).

Your hospital should have specific ICU criteria. If they don't meet it then (in my experience) you make the case to the ICU charge about why you want an ICU bed. If someone just doesn't feel right for the floor, their labs/numbers are trending in the wrong direction, you're just plain worried, you can make a case for ICU if not step-down or intermediate care unit.

 

I assume you're talking compensated HF but on the precipice.

 

For the renal question, I prefer to use non-ACEI/ARB rx and stick with other dilators- hydralazine, oral nitrates, amlodipine etc. Wait the creatinine out on that. Guide the need for diuresis on resp impact of fluid overload or severity of preload on heart by echo.

[bike mike]

 

I assume you're talking compensated HF but on the precipice.

 

For the renal question, I prefer to use non-ACEI/ARB rx and stick with other dilators- hydralazine, oral nitrates, amlodipine etc. Wait the creatinine out on that. Guide the need for diuresis on resp impact of fluid overload or severity of preload on heart by echo.

Agree with d/c of ACEi and starting hydralazine/isordil if you have the pressure to do so. Would also d/c BB if I'm worried that they are in low-output failure or creeping towards it. If they are volume overloaded you will need to give diuretics. Dose will depend. What is them home regimen? Are they taking 40 mg qd? Hit them with 80 mg IV once and see how they respond. If they are already on a high dose loop at home and they are Loop resistant give some Metolazone 1/2 hr before the Loop

[andersenpa]

Agree with d/c of ACEi and starting hydralazine/isordil if you have the pressure to do so. Would also d/c BB if I'm worried that they are in low-output failure or creeping towards it. If they are volume overloaded you will need to give diuretics. Dose will depend. What is them home regimen? Are they taking 40 mg qd? Hit them with 80 mg IV once and see how they respond. If they are already on a high dose loop at home and they are Loop resistant give some Metolazone 1/2 hr before the Loop

The half hour before practice with thiazide+loop is a bit if an old wives tale. The pharmacology behind it is accurate but I've been using lasix or bumex + metolazone for years and giving them simultaneously still gives a very potent diuresis.