Diapositiva 1

(1)

HF Critical Pathway

Michael Gavin, MD Monique Nestor, NP

Karen Cajiao, MD Shweta Motiwala, MD

Robb Kociol, MD

(2)

Suspicion for CHF

1) Symptoms: Dyspnea, orthopnea, edema, chest pain

2) Exam: Vital Signs, Weight with comparison to dry weight, Jugular Venous Pressure, Presence of rales, Temperature of extremities, presence of S3 gallop

1) Labs:

a. Chem 7, LFTs, Coags, CBC b. NT-BNP, lactate if “cold”

c. If suspicious for acute coronary syndrome or new presentation of CHF – TnT, CPK, CK-MB 2) Chest X-ray

3) EKG Using guidance from the

Most Helpful Features in Making a Diagnosis o f CHF in The ER

, Is CHF the most likely diagnosis?

Consider alternate diagnosis

Initiate HF management:

1) Loop Diuretics (see aside) 2) Supplemental oxygen if O2<93%

3) Serial ECGs if suspicion for ACS

4) Vasodilators for hypertensive patients (see aside)

Loop Diuretic Dosing Guidelines:

1) If mild volume overload consider single bolus dose IV lasix protocol

2) If mild to moderate volume overload consider bolus and short infusion or overnight infusion

3) If moderate overload keep overnight for lasix infusion and assess response next day to decide on admission

4) If severe volume overload or consider overnight infusion for partial volume removal and serial outpatient visits for bolus dosing

Imminent respiratory failure anticipated or hemodynamic instability

- NIPPV

- ET intubation

- If hypertensive administer IV vasodilator e.g. nitroglycerine or nitroprusside

- If hypotensive, administer IV inotrope e.g. dopamine or levophed

- Call HF attending and plan for ICU admission

Perform history and physical exam and order laboratory and basic studies

No

Yes

What is your assessment of hemodynamic status using

the hemodynamic model?

Impaired Perfusion or “Cold”:

- Signs: Narrow pulse presure, elevated lactate, cool

extremities, altered mentation, AKI, elevated transaminases

- Discuss with HF attending on service regarding triage to cath lab, Farr 3 HF, or CCU and establish initial

management strategy while awaiting bed (including initiation of IV inotrope if indicated)

“Cold”

“Warm”

Vasodilator guidelines:

1) If BP > 160/90mmHg administer PO, SL, or topical vasodilator (e.g. ACE inhibitor, labetalol, SL NTG, Topical NTG) 2) If BP remains elevated or SBP

>180/100mmHg on arrival favor IV therapy (e.g. IV NTG (bridge to floor), IV NTP (CCU), IV labetalol (CCU)) 3) If patient has evidence of pulmonary

edema, favor use of primary venodilator (e.g. SL NTG, Topical NTG, or IV NTG).

4) Avoid Morphine Sulfate

(3)

Reassess after 1-2 hours

General Criteria for CDAc Management:

I. Stable hemodynamics (SBP>= 90mmHg on presentation) and respiratory status (RR<32 breaths/min, O2 sat > 90% on room air)

II. Creatinine < 3.0mg/dL and no change greater than 33% from baseline (this is guide, but with many HF patients having advanced CKD can be adjusted to individual patients)

III. Absence of new ST depressions on ECG or Troponin-T <0.10

IV. No significant co-morbidities requiring acute intervention

V. No signs of poor perfusion VI. Response to initial therapy No

CDAc Observation Management Protocol

Yes

1. Initial plan single bolus: Give double the previous dose of diuretic and start infusion with plan to keep overnight

2. Initial plan bolus and infusion:

Give double the previous bolus dose and increase infusion 50%

3. Add IV nitroglycerine

4. Consider alternative diagnosis

Reassess after 1-2 hours

Is This Patient Appropriate for CDAc management?

Admit to HF (see protocol for handoff to

Heart Failure Team)

Yes No

1. IMPROVING SYMPTOMS with urine output > 500-750cc?

2. SBP normalized (120-140mmHg)?

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Administer dose of oral diuretics

Guidance on oral diuretic dose:

1. If lasix naïve give an equivalent dose to the IV dose needed to achieve adequate urine output (generally 20-40mg PO)

2. If on lasix at home and dietary or medication non-compliance to blame for decompensation give home dose

3. If it seems home lasix dose was insufficient or renal function has worsened double home dose

4. Same principles apply to torsemide except PO torsemide ≅ IV lasix so if patient is getting 40mg IV lasix then would transition to 20mg PO torsemide

What is the patient’s EF?

Check Chem 7 every 12 hours

Replete K to > 4.0 with PO KCL. If repletion is needed, patient should be discharged

on supplemental potassium chloride

Symptoms stabilized and

congestion improved after

IV diuretics?

Order TTE

Not Known

Algorithm for patients with dep ressed EF (see additional notes below)

Notes on the above algorithm:

1. If patient on ACE-I or ARB at home and SBP >

140/90 despite treatment, uptitrate dose 2. If patient not on either ACE or BB and SBP

<140/90mmHg then start with ACE-I only, if patient is hypertensive then both can be started

3. Contraindications to ACE initiation should be documented

4. Metoprolol succinate is favored over metoprolol tartrate because of once daily dosing

Algorithm for patients with pre served EF (see additional notes below)

Notes on the above algorithm:

1. Metoprolol succinate is favored over metoprolol tartrate because of once daily dosing

Admit

Cr increase >

15%?

K < 4.0

> 40%

< 40%

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Transition of care

PATIENT HAS NO

CARDIOLOGIST PATIENT HAS

NO

CARDIOLOGIST

Email Jacqueline Chasse, NP for follow-up in “post-discharge” HF

clinic within one week

PATIENT HAS OUTSIDE CARDIOLOGIST

Contact office and to relay discharge weight and ask for labs to

be done within 72 hours and at least a phone check in on weight

within one week

PATIENT HAS BIDMC

CARDIOLOGIST PATIENT HAS

BIDMC

CARDIOLOGIST

Email “Cardiology clinic nurses” and CC:

primary provider asking for labs and phone check-in on weight within 72 hours and office follow-up (ideally within

2 weeks, but at primary provider’s

discretion)

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Single Bolus Dose Protocols

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According to patient’s usual oral dose Furosemide According to patient’s usual oral dose Furosemide

Low dose 20 mg

Low dose 20 mg Standard dose 40 mg Standard dose 40 mg High dose 60 mgHigh dose 60 mg Mega dose 80-100 mgMega dose 80-100 mg Assess volume overload in ambulatory

patients with stable CHF Assess volume overload in ambulatory

patients with stable CHF

Order Labs to assess electrolytes and renal function

Potassium and Magnesium repletion protocol

Increased oral dose Increased oral dose

40 mg

40 mg 80 mg80 mg 120 mg 120 mg 160-200 mg 160-200 mg

Receive IV dose (IVP) Receive IV dose (IVP)

20-40 mg

20-40 mg 40-80 mg40-80 mg 60-100 mg 60-100 mg 120 mg 120 mg

Can add Metolazone 2.5-5 mg as needed Oral or IV therapy

NESTOR IV BOLUS OUTPATIENT PROTOCOL

(FUROSEMIDE)

DOSE EQUIVALENTS:

furosemide 80 mg PO = furosemide 40 mg IV = torsemide 20 mg IV/PO = bumetanide 1 mg IV/PO

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Assess volume overload in ambulatory patients with stable CHF Assess volume overload in ambulatory

According to patient’s usual oral dose Torsemide (Demadex) (Furosemide equivalence)*

10 mg

10 mg 20 mg 20 mg 30 mg30 mg 40 mg40 mg 60 mg60 mg 80-100 mg 80-100 mg

20 mg

20 mg 40 mg 40 mg 60 mg60 mg 80 mg80 mg 100-120mg100-120mg 160-200 mg 160-200 mg

Can add Metolazone 2.5-5 mg as needed

NESTOR IV BOLUS OUTPATIENT PROTOCOL

(TORSEMIDE)

*DOSE EQUIVALENTS:

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According to patient’s usual oral dose Bumetanide (Bumex) (Furosemide equivalence)*

0.5 mg

0.5 mg 1 mg 1 mg 1.5 mg1.5 mg 2 mg2 mg 3 mg3 mg 4 mg 4 mg

1 mg

1 mg 2 mg 2 mg 3 mg3 mg 4 mg4 mg 4-6 mg4-6 mg 8-10 mg 8-10 mg

Can add Metolazone 2.5-5 mg as needed

NESTOR IV BOLUS OUTPATIENT PROTOCOL

(BUMETANIDE)

*DOSE EQUIVALENTS:

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Bolus followed by 3-hour

infusion protocol

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Receive IV furosemide bolus Receive IV furosemide bolus

20 mg

20 mg Numeric equivalent of

maintenance diuretic dose Numeric equivalent of

maintenance diuretic dose 200 mg *200 mg * 200 mg *Ŧ200 mg *Ŧ According to patient’s home oral diuretic daily dose (Furosemide equivalence)*

According to patient’s home oral diuretic daily dose (Furosemide equivalence)*

Low dose <= 40 mg

Low dose <= 40 mg Standard dose 41-160 mg Standard dose 41-160 mg High dose 161-300 mgHigh dose 161-300 mg Mega dose >=301 mgMega dose >=301 mg

Followed by 3-h continuous infusion rate 20mg/h

* If inadequate urine output after 90 min of continuous infusion: Second bolus of furosemide 200 mg

Ŧ Optional premedication with a thiazide diuretic:

Metolazone 1.25 to 10mg; hydrochlorothiazide 12.5 to 50 mg; chlorothiazide 1,000 mg orally or 500mg IV

Ŧ Optional premedication with a thiazide diuretic:

Metolazone 1.25 to 10mg; hydrochlorothiazide 12.5 to 50 mg; chlorothiazide 1,000 mg orally or 500mg IV

BWH OUTPATIENT BOLUS/3H INFUSION

PROTOCOL

*DOSE EQUIVALENTS:

Buckley et al. JACC

Heart Fail, 2016;4:1-8.

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Bolus followed by continuous

overnight infusion

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Receive IV furosemide bolus Receive IV furosemide bolus

40 mg

40 mg 80 mg80 mg 120 mg 120 mg 160 mg 160 mg 200 mg200 mg

According to patient’s home oral diuretic daily dose (Furosemide equivalence)*

Dose 20-40 mg

Dose 20-40 mg Dose 40-80 mg Dose 40-80 mg Dose 80-120 mgDose 80-120 mg Dose 120-200 mgDose 120-200 mg >200>200

Followed by continuous infusion rate Followed by continuous infusion rate

5 mg/h

5 mg/h 7,5 mg/h7,5 mg/h 10 mg/h 10 mg/h 15 mg/h 15 mg/h 20 mg/h20 mg/h

OVERNIGHT OBSERVATION IV DIURESIS INFUSION

PROTOCOL