Congestive heart failure - Treatment strategies

CONGESTIVE HEART FAILURE:
TREATMENT STRATEGIES

Treatment

  • Inform the client of the diagnosis, prognosis, and cost of the treatment.
  • Intravenous fluid therapy with cardiac disease
    • The indications for intravenous fluid therapy include
      • Cardiogentic shock.
      • Dehydration.
      • Drug-induced hypotension.
      • Renal failure.
      • Moderate to severe hypokalemia.
      • Anorexia.
      • Vomitting.
      • Concurrent metabolic or infectious diseases.
      • Need of a vehicle for constant rate drug infusions.
    • Although Dextrose Saline or 2.5% dextrose in 0.45% Nacl are usually recommended due to their lower sodium content, these fluids are controversial. They supply free water and may actually increase cellular edema. 0.9% NaCl, in small volumes, 30-45 ml/kg/day, may be a more appropriate fluid with which to re-establish normal circulating plasma volume in hypovolemic patients.
    • Once the circulating plasma administer D5W or 2.5% dextrose in 0.45% NaCl at the rate of 20-40 ml/kg/day.
    • If the patient is receiving diuretics prior to admission and requires maintenance intravenous fluid therapy, continue diuretic therapy.
    • If the patient presents in cardiogentic shock, administer intravenous fluids and intropic support until renal perfusion and the circulating plasma volume are restored, then begin diretic therapy.
    • Discontinue fluid therapy and administer diuretics if fluid overload occurs.
    • Monitor the patient’s body weight, mucous membrane color, pulse rate and quality, respiratory rate and effort, and thoracic auscultation several times a day to monitor fluid therapy.
    • Also evaluate urine output, blood gas analysis, indirect blood pressure measurements, central venous pressure, PCWP, serum urea nitrogen, serum creatinine, ECG and thoracic radiographs.
  • If the patient is dyspneic but not cyanotic
    • Place an intravenous catheter.
    • Hospitalize the patient for observation.
    • Administer furosemide ,2-6mg/kg IV,q6-8th or bumetanide, 0.05-0.05 mg/kg IV or Po as needed for severe pulmonary edema (Caution: Must monitor serum potassium levels and maintain with IV fluids to prevent excessive fluid and potassium depletion).
    • Evaluate the need for intravenous fluid therapy.
  • If the patient is cyanotic
    • Place the patient in an oxygen cage, administer oxygen via nebulizer, consider nebulization of 20-35% ethyl alcohol if the patient has severe pulmonary edema.
    • Place an intravenous catheter.
    • Administer furosemide, 2-6mg/kg IV in dogs, q1-2h, 1-4 mg/kg in cats, q1-2h, until effective diutresis is established and respiratory rate decreases. Then decrease the dose of furosemide to 4 mg/kg in dogs and 2mg/kg in cats q2-8h . An alternative loop diuretic is bumetanide, 0.05-0.2 mg/kg IV or PO as needed, if furosemide appears to be ineffective.
    • Furosemide can also be administered as a constant rate infusion in refractory patients, 3-8µg/kg/min CRI IV.
    • If furosemide is ineffective, administer a thiazide diuretic, such as chlorthiazide, 20-40 mg/kg PO q12h.
    • Evaluate the need for intravenous fluid therapy.
    • If the patient is in immediate need of oxygen , has pulmonary venous engorgement or wheezes are auculted, administer aminophylline, 5-10 mg/kg IV, IM or PO q 8h, or terbutaline, 0.01 mg/kg SC q4th or 1.25-5.0 mg PO q8-12h.
    • Place a nasal oxygen catheter, administer nebulized nasal oxygen
    • Administer morphine sulfate , 0.2mg/kg SC or IM, if needed for anxiety and arteriolar dilatation.
  • Cardiogenic shock
    • The signs are dyspnea, tachycardia, decreased capillary refill time, decreased pulse strength, possibly hypothermia.
    • Administer intravenous fluids. 2.5% dextrose in 0.45% NaCL at the rate of 30-45 ml/kg/day is usually appropriate. Consider the administration of Hetastarch, 5ml/kg IV boluses, re-evaluate CVP , repeat up to a dose of 20 ml/kg to increase the circulating plasma volume and control pulmonary edema.
    • Administer furosemide, 2-6 mg/kg IV in dogs, q1-2h, 1-4mg/kg in cats, q1-2h,until effective diuresis is established and respiratory rate decreases. Then decrease the dose of furosemide to 4mg/kg in dogs and 2 mg/kg in cats as needed. If furosemide appears to be effective.
    • Furosemide can also be administered as a constant rate infusion in refractory patients, 3-8 µg/kg/min CRI IV.
    • If furosemide is ineffective, adminster a thaiazide diuretic, such as chlorthiazide, 20-40 mg/kg PO q12h.
    • If the patient is in immediate need of oxygen , has pulmonary venous engorgement or wheezes are auscuted, administer aminophylline 5-10 mg/kg IV, IM or PO, q8th , or terbutaline, 0.01 mg/kg q4th or 1.25-5.0 mg POq8-12th.
    • Place a nasal oxygen catheter, administer nebulized nasal oxygen
    • Administer morphine sulfate, 0.2 mg/kg SC or IM, if needed for anxiety and arterior dilation.
  • Vasodilator therapy
    • Niytoglycerin cream: 0.25-2.0 inches, applied to a clipped area on the thorax or on the abdomen , q4-6h, especially for pulmonary edema (venous dilator). Wear gloves during application, use a tongue depressor to apply and cover the area with tape. Avoid contact with the applicator’s skin. The dose for cats is 0.25-0.5 inch cutaneously 86-8h, every other day.
    • Captopril: 0.25-2 mg/kg PO q8-24th, (Arteriolar and venous dilator)
    • Enalaprill: 0.25-2 mg/kg PO q8-12th. (dogs), 2-6 mg PO q12th (cats).
    • Hydralzaine: 0.5-3 mg/kg PO q12h (Arteriolar dilator). Use caution and monitor closely as hydralazine can induce marked vasodilation, decreased blood pressure, and increased heart rate. Clinical affect occurs within 1h. Start with the low dose and gradually increase as needed.
    • Sodium nitroprusside (arteriolar and venous dilator): if unresponsive to all the other treatment, administer sodium nitroprusside, up to 1-10µ/kg/min IV in the dog; 0.25-5 µg/kg/min IV in the cat.
  • If the patient has cardimyopathy or low cardiac output, use a positive inotropic agent
    • Dobutamine: 5-20 µg/kg/min IV infusion in dogs ,2.5-10µg/kg/min in cats. (High doses or prolonged use can cause seizures in cats). Avoid in cats with hypertrophic cardiomyopathy.
      • (wt.inkg)x(no.of µg/kg/min) = no. of mg to add to 250 ml D5W at drip rate of 15 ml/hr.
      • Must protect from light.
      • See affect within 3-5 min.
    • Sodium nitroprusside treatment; very potent arterial dilator
      • Must use only after using dobutamine.
      • Must put in separate line from dobutamine.
      • Start at 2µg/kg/mg/min. (Dose = 1-10µg/kg/min IV in the dog 0.25-5µg/kg/min IV in the cat.)
      • Usually see and hear effects within 15-20 min of the right dosage.
      • Administer at a rate of 15ml/h.
      • Very sensitive to light, must cover the entire IV line.
    • Monitor CVE, maintain between 5-12 cm H2O
      • Normal CVP is 0-5 cm H2O
      • A CVP of 8-11 cm H2O is considered to be the optimal right ventricular filing pressure in the presence of heart failure.
      • Values above 16 cm H2O usually associated with ascites.
      • Elevated CVP measurements may indicates catheter malfunction, right heart failure, or intravascular volume overload.
      • Left heart failure in the absence of right heart failure does not change the CVP
  • Monitor urine output, minimum is 1-2 ml/kg/h
Last modified: Tuesday, 5 June 2012, 12:38 PM