Must know Christ Medical Center CHF Protocol.
Mnemonic: LMNOPQ. Q=Quinton Catheter (ie. in the dialysis pt with CHF they need dialysis)
Lasix 1mg/kg. 1-2 x home daily dose (usually 60mg or 80mg IV)
If urine output <200ml after 1hour, repeat same dose
Morphine 2mg IV (debatable efficacy; not on CHF standing orders)
NTG
-IV NTG 20mcg/min and TTE by increasing gtt 10-20mcg q5min or doubling rate q5min
-Titrate to MAP decrease of 20% as per CHF protocol
-Recall SL tab is 400mcg/5min or 80mcg/min (20mcg IV is low dose)
Nesiritide (Natrecor)
2 mcg/kg bolus IVP, then start drip at 0.01mcg/kg/min. Hold if SBP < 90.
Usually ordered after consultation with a cardiologist
Much more expensive and not necessarily better than NTG (studies drug reps refer to pushing Natrecor criticized for using suboptimal doses of NTG)
Oxygen (titrate to O2 sat > 92% by nasal cannula, ventimask or nonrebreather)
Position pt upright
Positive pressure ventilations prn (either BiPAP, or intubation with PEEP. Start BIPAP I 10/ E 4 to maintain sat >92%)
Pressors/Drips if needed
-NTG IV if SBP >90 (preload reducer, will also mildly reduce afterload)
-Nipride IV if SBP > 100 (more afterload reduction than NTG, coronary stealàischemia)
-Dopamine IV 2-20mcg/kg/min if SBP <100
-Dobutamine IV 2-20mcg/kg/min if SBP >100
-May drop BP due to beta-receptor mediated vasodilation
Ace Inhibitor:
-Note that hospital is graded on ACE-I administration so document reason for withholding ACE or ARB (renal insufficiency; allergy; hx of severe cough with ACE; potassium elevated; hypotension; pregnant, severe aortic stenosis)
Lisinopril (Prinvil/Zestril) 10 mg PO
Enalapril (Vasotec) 1.25mg IV
-First dose okay without creatinine, subsequent doses require creatinine
-Contraindications: hypotension, dehydration, poor perfusion, allergy, angioedema, pregnancy, renal insufficiency (cr >3), renal artery stenosis, hyperkalemia
- Hold if patient already took ACE in dosing cycle
Angiotensin Receptor Blocker (ARB)
Losartan (Cozaar) 25mg PO
-Use in Ace allergy
-First dose okay without creatinine, subsequent doses require creatinine
-Same contraindications as ACE Inhibitor.
-Hold if already taken in dosing cycle