J81
DESCRIPTION
A life-threatening condition with abnormal accumulation of fluid in the lungs.
Common causes include acute decompensation of chronic underlying heart failure and acute renal failure (e.g. acute nephritis).
The acute decompensated heart failure patient appears extremely ill, restless, poorly perfused and sweaty, tachypnoeic, tachycardic, hypoxic, increased work of breathing, frothy sputum.
GENERAL MEASURES
Maintain open airway. Consider non-invasive positive pressure ventilation.
Position in Fowler’s position, unless hypotensive or comatose.
Correct electrolyte disturbances.
Determine and correct any dysrhythmias.
MEDICINE TREATMENT
- Administer oxygen using face mask to deliver 40% oxygen at a rate of 6–8 L per minute.
Fluid overload suspected/detected:
- Furosemide, slow IV, 40 mg.
- If response is adequate, follow with 40 mg in 2–4 hours.
- If no response within 20–30 minutes: furosemide, IV, 80 mg.
Followed by:
- Nitrates, e.g.:
- Isosorbide dinitrate, SL, 5 mg repeat every 5–10 minutes, if necessary.
- Monitor blood pressure. Do not administer if hypotensive.
OR
- Glyceryl trinitrate, IV, 5–200 mcg/minute, titrated to response.
- Start with 5 mcg/minute and increase by 5 mcg/minute every 5 minutes until response or until the rate is 20 mcg/minute.
- If no response after 20 mcg/minute increase by 20 mcg/minute until response.
- Flush the PVC tube before administering to patient.
- Monitor blood pressure carefully.
| Volume of diluent |
Glyceryl trinitrate 5 mg/mL |
Concentration of dilution |
|---|---|---|
| 250 mL | 5 mL (25 mg) | 100 mcg/mL |
| 250 mL | 10 mL (50 mg) | 200 mcg/mL |
| 250 mL | 20 mL (100 mg) | 400 mcg/mL |
| 500 mL | 10 mL (50 mg) | 100 mcg/mL |
| 500 mL | 20 mL (100 mg) | 200 mcg/mL |
| 500 mL | 40 mL (200 mg) | 400 mcg/mL |
|
Solution Concentration (mcg/mL) |
100 mcg/mL solution |
200 mcg/mL solution |
400 mcg/mL solution |
|---|---|---|---|
|
Dose (mcg/min) |
Flow rate (microdrops/min = mL/hr) |
||
| 5 | 3 | - | - |
| 10 | 6 | 3 | - |
| 15 | 9 | - | - |
| 20 | 12 | 6 | 3 |
| 30 | 18 | 9 | - |
| 40 | 24 | 12 | 6 |
| 60 | 36 | 18 | 9 |
| 80 | 48 | 24 | 12 |
| 100 | 60 | 30 | 15 |
| 120 | 72 | 36 | 18 |
| 160 | 96 | 48 | 24 |
| 200 | - | 60 | 30 |
No fluid overload present:
Initiate nitrates, followed by furosemide.
If distressed, consider adding morphine:
- Morphine, IV. (See Appendix II, for individual dosing and monitoring for response and toxicity).
If hypotensive consider inotropic support, e.g.:
- Dobutamine, IV infusion, 5–20 mcg/kg/minute.
- Dilute 1 vial (250 mg/20 mL) up to 50 mL with sodium chloride 0.9% or dextrose 5%. (Solution = 5 mg/mL or 5 000 mcg/mL)
- Administer under constant ECG monitoring.
- Rate of infusion in mL/hour: see weight-dose table in Cardiogenic shock.