When your patient with acute pulmonary edema is brought into the resus bay, Swami and Haney say, “Put the lasix away until they are stabilized and you can sort out whether or not there is volume overload.”
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I have to disagree with a few things-number one ACE inhibitors cause efferent arteriole relaxation hence they decrease GFR, they don't really act on the afferent side. For this reason I worry about giving it as a lot of these pts will have renal insufficiency and are at risk for being pushed into cardiorenal syndrome, though one dose upfront is probably ok. Lasix is important even upfront, I don't think it causes much kidney damage unless you give a mega dose, initially lasix also has vasodilatory properties, and it assists with getting fluid off the pts. I don't trust weights, at all, unless you guarantee you're using the same method of measuring, same scale etc. These people need fluid to be taken off and it takes time to work so you might as well give it early--only reason I would hold it is if their IVC on US looks like it's small and collapsing. This whole anti-lasix thing ED docs are promulgating is not right, the studies Marik shows are models where they used huge doses of Iv lasix upfront which I agree is not appropriate.
In the Levy paper, I couldn't find anything about giving 1 gram boluses. All I could find was a max 400mcg/min plus 2mg boluses every 3 min. which would equal 1300 mcg/min. I am post shift so I'm sure I missing something.
Sunny - Just looked at article again. Looks like patients got 2 mg (2000 mcg) boluses concurrent with starting the drip (see page 146 under interventions)
Sunny and Anand....I think I know the problem....when we started the discussion on bolus dose NTG, I meant to say 1 mg (1,000mcg) but erroneously said 1 gram. Sorry about that....1 gram would be a very bad dose. Here's a post by Cliff Reid who discusses this bolus strategy in more detail; http://resus.me/nitrate-bolus-in-acute-heart-failure/
Milrinone is a good inotrope, however it can cause systemic vasodilation and hypotension in some patients. Milrinone also has a long half-life so if you drop the pressure this may last for awhile. If an inotrope is needed, I prefer using drugs with a shorter duration of action (e.g., Dobutamine or low-dose epinephrine) because of the potential for rapid hemodynamics changes when we first start managing such patients; especially with high-dose NTG.
Ali - not sure which article you mean but below are our references in full. Let me know if that helps. Thanks! 1. Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006; 73(2): 506-27.
2. Zile MR, Bennett TD, St John Sutton M, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous
3. Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM. Patterns of weight change preceding hospitalization for heart failure. Circulation 2007;116:1549 –54.
4. Fallick C, Sobotka PA, Dunlap ME. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation. Circ Heart Fail 2011; 4: 669-75.
5. Hoffman JR, Reynolds S. Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema. Chest 1987; 92: 586-93.
6. Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine B, Cohn JN. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Ann Int Med 1985; 103(1): 1-6
8. Marik PE, Flemmer M. Narrative review: the management of acute decompensated heart failure. J Intensive Care Med 2012; 27: 343-53.
9. Liesching T, Nelson DL, Cormier KL, Sucov A, Short K et al. Randomized trial of bilevel versus continuous positive pressure for acute pulmonary edema. J of EM 2014: 46(1): 130-40.
10. Bussmann W, Schupp D. Effect of sublingual nitroglycerin in emergency treatment of severe pulmonary edema. Am J Card 1978; 41: 931-936.
11. Cotter G, Metzkor E, Kaluski E, Faigenberg Z et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 1998: 351: 389-93.
12. Levy P, Compton S, Welch R, Delgado G, Jennett A et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann of EM 2007; 50: 144-52.
13. Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
14. Haude M, Steffen W, Erbel R, Meyer J. Sublingual administration of captopril versus nitroglycerin in patients with severe congestive heart failure. Intl J Card 1990; 27: 351-9.
Mohammed A. - February 5, 2016 12:58 PM
I have to disagree with a few things-number one ACE inhibitors cause efferent arteriole relaxation hence they decrease GFR, they don't really act on the afferent side. For this reason I worry about giving it as a lot of these pts will have renal insufficiency and are at risk for being pushed into cardiorenal syndrome, though one dose upfront is probably ok.
Lasix is important even upfront, I don't think it causes much kidney damage unless you give a mega dose, initially lasix also has vasodilatory properties, and it assists with getting fluid off the pts. I don't trust weights, at all, unless you guarantee you're using the same method of measuring, same scale etc. These people need fluid to be taken off and it takes time to work so you might as well give it early--only reason I would hold it is if their IVC on US looks like it's small and collapsing. This whole anti-lasix thing ED docs are promulgating is not right, the studies Marik shows are models where they used huge doses of Iv lasix upfront which I agree is not appropriate.
Ibrahim M. - February 14, 2016 8:44 AM
Any role for Milrinone and Inamrinone in the ED?
Sunny H. - February 20, 2016 6:50 PM
In the Levy paper, I couldn't find anything about giving 1 gram boluses. All I could find was a max 400mcg/min plus 2mg boluses every 3 min. which would equal 1300 mcg/min. I am post shift so I'm sure I missing something.
Anand S. - February 21, 2016 4:40 AM
Sunny - Just looked at article again. Looks like patients got 2 mg (2000 mcg) boluses concurrent with starting the drip (see page 146 under interventions)
Haney M. - February 21, 2016 6:33 AM
Sunny and Anand....I think I know the problem....when we started the discussion on bolus dose NTG, I meant to say 1 mg (1,000mcg) but erroneously said 1 gram. Sorry about that....1 gram would be a very bad dose. Here's a post by Cliff Reid who discusses this bolus strategy in more detail; http://resus.me/nitrate-bolus-in-acute-heart-failure/
Haney M. - February 21, 2016 6:39 AM
Milrinone is a good inotrope, however it can cause systemic vasodilation and hypotension in some patients. Milrinone also has a long half-life so if you drop the pressure this may last for awhile. If an inotrope is needed, I prefer using drugs with a shorter duration of action (e.g., Dobutamine or low-dose epinephrine) because of the potential for rapid hemodynamics changes when we first start managing such patients; especially with high-dose NTG.
Hope that helps.
ali a. - March 8, 2016 1:22 AM
may I ask from where can I get access to the 1940 paper about treating acute pulmonary edema with high dose lasix only
thank you
Anand S. - March 8, 2016 6:26 AM
Ali - not sure which article you mean but below are our references in full. Let me know if that helps. Thanks!
1. Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006; 73(2): 506-27.
2. Zile MR, Bennett TD, St John Sutton M, et al. Transition from
chronic compensated to acute decompensated heart failure: pathophysiological
insights obtained from continuous
3. Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM. Patterns
of weight change preceding hospitalization for heart failure. Circulation
2007;116:1549 –54.
4. Fallick C, Sobotka PA, Dunlap ME. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation. Circ Heart Fail 2011; 4: 669-75.
5. Hoffman JR, Reynolds S. Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema. Chest 1987; 92: 586-93.
6. Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine B, Cohn JN. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Ann Int Med 1985; 103(1): 1-6
7. Kraus PA, Lipman J, Becker PJ. Acute preload effects of furosemide. Chest. 1990; 98: 124-8.
8. Marik PE, Flemmer M. Narrative review: the management of acute decompensated heart failure. J Intensive Care Med 2012; 27: 343-53.
9. Liesching T, Nelson DL, Cormier KL, Sucov A, Short K et al. Randomized trial of bilevel versus continuous positive pressure for acute pulmonary edema. J of EM 2014: 46(1): 130-40.
10. Bussmann W, Schupp D. Effect of sublingual nitroglycerin in emergency treatment of severe pulmonary edema. Am J Card 1978; 41: 931-936.
11. Cotter G, Metzkor E, Kaluski E, Faigenberg Z et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 1998: 351: 389-93.
12. Levy P, Compton S, Welch R, Delgado G, Jennett A et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann of EM 2007; 50: 144-52.
13. Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
14. Haude M, Steffen W, Erbel R, Meyer J. Sublingual administration of captopril versus nitroglycerin in patients with severe congestive heart failure. Intl J Card 1990; 27: 351-9.
J. B. L. - March 15, 2016 6:17 AM
I Give 1mg boluses of NTG all the time- faster than seting up a drip and safe