Accelerated Diagnostic Pathway - CHF

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Jeremy R., M.D. -

What is the usual starting dose for nicardipine? I have always started with an ACE inhibitor if the nitro drip doesn't work.

Rob O -

Hey Jeremy,
Here is the dosing as per Scott Weingart start at 5 rapidly titrate up to 15 by 2.5 increments when goal is reached, drop down to 3 and work your way back up as needed

Henry A., -

I was always taught that the initial effect of IV loop diuretics was an increase in afterload,followed later by the diuretic effect. This increase in afterload could cause a clinical deterioration, before diuresis begins. Therefore,unless the Pt is hypotensive, my usual initial treatment is nitrates (to prevent or attenuate the initial effect of the vasoconstriction) and then follow closely w/ the Lasix. Look forward to any comments

Brooks W. -

Rob, these are great segments, very illuminating about the admin perspective on this issues.

One part made me chuckle, however. When Cameron describes giving "a few" NTG tabs, you immediately ask him to clarify that he didn't mean simultaneously.

The usual antianginal dose of SL is pretty weak sauce when your patient's BP is soaring past 180. Keep in mind that Levy et al. showed that giving IV boluses of 2 mg of NTG was safe - this should give us some perspective!

The EMS protocol in our region is that paramedics may give 2, 3, or even 4 tabs of NTG for CHF, depending on the BP. I'm not aware of any problems to date with this. A recent study out of Buffalo, entitled "Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension" found that only 3/95 patient who got ≥ 2 tabs at once developed hypotension.

This wasn't really the main point of the piece, I understand! But the dosing of "1 q 5, max 3" doesn't really apply to CHF.

Thanks!

Alex K. -

Where does the 1.5x home dose diuretic dosing come from? And does it refer to the numeric dose or the dose-equivalent? In other words, if my patient takes 40mg of furosemide daily, do I administer 60mg IV (1.5x the numerical dose) or 30mg IV (1.5 the effective dose [assuming a doubly-effective IV dose])?

Thanks,
Alex

brendanC -

The main problem is foresee with this treatment pathway is the lack of differentiation for patients of different ages, Ejection Fractions, CAD etc.... I wish we could bucket this nicely but a 45 yo with a systolic of 110 and chf if a world different than an 85 yo, with a-fib, and recent CABG. I wish we were provided a more detailed visualization of the pathway in the show notes....yes so I could steal and modify for my own hospital. Had to ask!!!!

Thx

Brendan C

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