Morning Report: 2/12/2015

Thanks to Dr. Lewis for today’s Morning Report!

Congestive Heart Failure: Acute Pulmonary Edema

Goal: (1) Preload Reduction (2) Afterload Reduction (3) Inotropic Support

Nitroglycerin

• short-acting, rapid onset systemic venous and arterial dilator – decreases MAP by reducing afterload and preload
• repeated SL nitro (0.4 mg) q3-5 mins = IV 60-100 mcg/min
• titrate IV nitro rapidly starting 100 mcg/min upward to 200 – 400 mcg/min or higher (650 mcg/min) until BP controlled
  • High dose nitrates:
    • 2007 Ann Emerg Med – hypertensive severely decompensated HF, started nitro drip at 0.3 -0.5 µg/kg/min, titrating at 20 µg/min q1-3mins, max dose of 400 µg/min (SBP <90 was absolute contraindication), all pts received initial 2 mg bolus q3-5 mins for period of 30 mins to max potential dose of 20 mg. Conclusion: pts who received high-dose nitro required intubation, BiPAP or ICU admissions less frequently
    • <250 µg/min: predominantly venodilatory → preload reduction
    • ≥250 µg/min: induce both venous and arterial dilation → preload & afterload reduction

NIPPV: BIPAP

• Decreases Preload & Afterload
• IPAP – EPAP = PEEP, reduces the need to intubate but not mortality or new MI
• opens alveoli, increases FRC, decreases dead space, increase TV and decreases intrapulmonary shunt
  • Start at IPAP/EPAP = 10/5 →20/15, if pt not blowing off enough CO2→increase IPAP = increases tidal volume and alveolar ventilation, if pt not oxygenating effectively→ increase EPAP, pts with APE often require high EPAP
  • Initial FIO2 setting from 21-50% (usually 40%) to maintain Sao2 88% for known PCO2 retainers, 90% if refractory hypoxemia an issue, 92% for all other patients

Lasix

• Decrease Preload → diuresis and direct venodilation
• CAUTION: pts may be volume deplete due to increase work of breathing, total body euvolemic or HYPOvolemic but shifted fluid in lungs → electrolyte abnormalities, worsened renal function, hypotension, goal is to redistribute fluid not remove
• When do they start working??
• Decrease afterload then give lasix if needed
• Dose?

Morphine

• morphine or related opiods increase need for intubation and ICU LOS= no longer recommended, can result in respiratory depression

ACEI

• reduces pre and afterload (15-30 mins to work) but little data to support use in acute situation

The following two tabs change content below.

• Bio
• Latest Posts

Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

• Morning Report: 7/30/2015 - July 30, 2015
• Morning Report: 7/28/2015 - July 28, 2015
• IN THE STRETCHER INSTEAD OF BESIDE IT - July 22, 2015
• Morning Report: 7/14/2015 - July 14, 2015
• Morning Report: 7/10/2015 - July 10, 2015