SlideShare ist ein Scribd-Unternehmen logo
1 von 38
Downloaden Sie, um offline zu lesen
By Dr. Ahmad Y. Alansi
Althawra Modern General Hospital
Cardiac surgery department
Anesthesia & ICU unite
 Definitions
 Which heart failure patient should be
admitted in ICU?
 Monitoring
 Classification and plan
 Medical treatment
 Mechanical support
 The future
 Summary
Definition of Advanced HF
A subset of patients with chronic HF will
continue to progress and develop persistently
severe symptoms despite maximum therapy
.Various terminologies have been used to
describe this group of patients who are
classified with ACCF/AHA stage D
HF, including “advanced HF,” “end-stage
HF,” and “refractory HF.
Heart Failure management in ICU
Heart Failure management in ICU
Heart Failure management in ICU
Heart Failure management in ICU
Decompensated
chronic heart failure
(advanced heart
failure)
Acute heart failure
ACS
Sepsis
Post CPR
Toxic
VO2 Oxygen uptake from tissues
MRO2 Metabolic requirement for
oxygen
● Nonadherence with medication regimen, sodium and/or fluid restriction
● Acute myocardial ischemia
● Uncorrected high blood pressure
● AF and other arrhythmias
● Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem,
beta blockers)
● Pulmonary embolus
● Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones,
NSAIDs)
● Excessive alcohol or illicit drug use
● Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)
● Concurrent infections (e.g., pneumonia, viral illnesses)
● Additional acute cardiovascular disorders (e.g., valve disease endocarditis,
myopericarditis, aortic dissection
Hypotension systolic BP < 90 mmHg
SpO2 < 90 %
PH < 7.35
Lactate > 2.0
Oliguria, BUN > 30
Worsening renal function
VsO2 < 50 %
So the following patients should be admitted to
ICU :
 All pateints with NYHA class III-IV.
 Suspected or diagnoseed ACS .
 Potential life threatening arrhythmia (VF, VT, high
grade a- v block, persistent symptomatic tachy or
brady).
 Requiring or at risk of requiring invasive ventilatory
support .
 Cardiogenic shock or otherwise requiring chemical
or mechanical circulatory support (dopmamine
, dobutamine,….IABP,LVAD….etc)
 Multisystem Failure .
monitoringinvasiveNon
i.e. temperature, respiratory rate,
arterial pressure, continuous
ECG, pulse oximetry, daily I/O
chart and body weight are
required in all patients
Invasive monitoring:
1- Arterial pressure monitoring :
continues BP monitoring
repetitive blood gas analysis
.
2- Central venous catheter :
Monitoring right-sided filling pressure
Delivering vasoactive medication
Rapid volume replacement
3- Pulmonary artery catheterization
(PAC)
Indicated in patients with left ventricular
dysfunction
. In patients requiring inotropic or
vasoconstrictor drugs.
For monitoring
Cardiac output
Estimation of systemic vascular resistance
Mixed venous oxygen saturation
Lost popularity because of Invasiveness and no different in
mortality rate
4- Transoesophageal Echocardiography
Recently gained popularity as a haemodynamic
monitoring tool for ventilated intensive care patients.
It provides valuable information about morphology
and haemodynamic state,
but interpretation of data requires considerable
training and experience.
So Transthoracic Echo
Is more performed and remain the main tool .
 Low Output Failure in which there is decreased
contractility of heart leading to decreased
cardiac output
 High Output Failure in which demands of body
are high, which are not met even with increased
cardiac output like in case of severe Anemia ,
Thyrotoxicosis and Thiamine deficiency
Heart Failure management in ICU
 Which side of heart is affected
– Left (more common)
– Right (right-sided MI, pulmonary HTN)
 Which heart function is affected
– Systolic (↓ contraction and EF, dilated LV)
– Diastolic (↓ relaxation,)
 Failure of LV filling
 Contractile function and EF usually normal
Heart Failure management in ICU
Heart Failure management in ICU
The management of heart failure described here
is meant for patients with advanced or
decompensated heart failure. The approach
here is specifically designed for ICU patients: it
is based on invasive hemodynamic
measurements rather than symptoms and uses
only drugs that are given by continuous
intravenous infusion
Left-Sided (Systolic) Heart Failure :
1- High Blood Pressure
2- Normal Blood Pressure
3- Low Blood Pressure
Left-Sided (Systolic) Heart Failure :
1- High Blood Pressure (e.g. early period
after cardiopulmonary bypass surgery )
Profile: High PCWP/Low CO/High BP
Treatment: Vasodilator therapy with
nitroprusside or nitroglycerin. If the PCWP remains
above 20 mm Hg, add diuretic therapy with
furosemide.
Left-Sided (Systolic) Heart Failure :
2- Normal Blood Pressure: e.g. ischemic
heart disease, acute myocarditis, and the advanced
stages of chronic cardiomyopathy.
Profile: High PCWP/Low CO/Normal BP
Treatment: Inodilator therapy with dobutamine or
milrinone, or vasodilator therapy with nitroglycerin. If
the PCWP does not decrease to <20 mm Hg, add diuretic
therapy with furosemide.
Left-Sided (Systolic) Heart Failure :
3- Low Blood Pressure is the sine qua
non of cardiogenic shock. e.g. associated
with cardiopulmonary bypass surgery, acute myocardial
infarction, viral myocarditis, and pulmonary embolus.
Profile: High PCWP/Low CO/Low BP
Treatment: Dopamine in vasoconstrictor doses or
combination with Dubtamin.
Mechanical assist devices can be used as a temporary
measure in selected cases.
Diastolic Heart Failure :
Incidence of purely diastolic HF in nature is not
known.
no general agreement about the optimal treatment but
two recommendations seems to be valid :
1- positive inotropic agents have no role in the
treatment of diastolic heart failure.
2- diuretic therapy can be counterproductive,
vasodilator agents, such as nitroglycerin and milrinone,
Calcium channel blockers like verapamil are effective.
Right Heart Failure
The strategies below pertain only to primary right
heart failure (e.g., following acute myocardial
infarction) and not to right heart failure secondary
to chronic obstructive lung disease:
1- If PCWP is below 15 mm Hg, infuse volume until the PCWP
or CVP increases by 5 mm Hg or either one reaches 20 mm Hg .
2- If the RVEDV is less than 140 mL/m2, infuse volume until
the RVEDV reaches 140 mL/m2 .
3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 or
higher, infuse dobutamine, beginning at a rate of 5
mg/kg/minute .
In the presence of AV dissociation or complete heart block,
institute sequential A-V pacing and avoid ventricular pacing .
Diuretics in Hospitalized Patients: Recommendations
Class I
1. Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to reduce
morbidity (Level of Evidence: B)
2. If patients are already receiving loop diuretic therapy, the initial
intravenous dose should equal or exceed their chronic oral daily dose and
should be given as either intermittent boluses or continuous infusion.
Urine output and signs and symptoms of congestion should be serially
assessed, and the diuretic dose should be adjusted accordingly to relieve
symptoms, reduce volume excess, and avoid hypotension (Level of
Evidence: B)
3. The effect of HF treatment should be monitored with careful
measurement of fluid intake and output, vital signs, body weight that is
determined at the same time each day, and clinical signs and symptoms
of systemic perfusion and congestion. Daily serum electrolytes, urea
nitrogen, and creatinine concentrations should be measured during the
use of intravenous diuretics or active titration of HF medications. (Level of
Evidence: C)
Diuretics in Hospitalized Patients: Recommendations
Class IIa
1. When diuresis is inadequate to relieve symptoms, it is reasonable
to intensify the diuretic regimen using either:
a. higher doses of intravenous loop diuretics (Level of Evidence: B);
b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B).
Class IIb
Low-dose dopamine infusion may be considered in addition
to loop diuretic 1 therapy to improve diuresis and better
preserve renal function and renal blood flow (Level of
Evidence: B)
Short term therapeutic options
( Nondurable)Bridge to recovery
Long term therapeutic options
Bridge to transplantation ( durable)
Destination therapy (permanent)
Percutaneous devices
IABP
Impella
ECMO and centrifugeal pump devices
Implantable devices (cardiotomy)
LVAD, RVAD, BiVAD, total artificial heart (different models, different
indications)
Class IIa
MCS is beneficial in carefully selected* patients with stage
D HFrEF in whom definitive management (e.g., cardiac
transplantation) or cardiac recovery is anticipated or planned
. (Level of Evidence: B)
Nondurable MCS, including the use of percutaneous and
extracorporeal ventricular assist devices (VADs), is
reasonable as a “bridge to recovery” or “bridge to decision”
for carefully selected* patients with HFrEF with acute,
profound hemodynamic compromise . (Level of Evidence: B)
Durable MCS is reasonable to prolong survival for carefully
selected* patients with stage D HFrEF (672-675). (Level of
Evidence: B)
selected* patients are those with
LVEF <25% and NYHA class III-IV functional
status despite GDMT, when CRT indicated , with
either high predicted 1- to 2-y mortality or
dependence on continuous parenteral inotropic
support.
Intra-Aortic Balloon Counterpulsation
Intra-aortic balloon counterpulsation was introduced
in 1968 as a method of promoting coronary blood
flow .
It is available in various lengths to match body height.
Hemodynamic Effects
Inflation begins at the onset of diastole, just after the aortic
valve closes that cause Increase in diastolic pressure
which should also augment coronary blood
flow, because the bulk of coronary flow occurs during
diastole.
Deflation at the onset of ventricular systole, just before the
aortic valve opens so Deflation of the balloon reduces
the end-diastolic pressure, This decreases ventricular
afterload and promotes ventricular stroke output.
IABP Indication:
when cardiac pump failure is life-threatening and
either pump function is expected to improve
spontaneously, or a corrective procedure is planned.
Cardiogenic shock following CPB
Acute MI .
Unstable angina,
Acute mitral insufficiency,
Planned cardiac transplantation.
Support PCI & reduce size of Infarction
??!!! controversy
Heart Failure management in ICU
Yemeni future
Get to international standards of treatment (new drugs,
assist devices programs)
Transplantation
International future
Genetics
Stem cell cultures and implantation
Truly viable total artificial heart
 The approach to advanced or decompensated heart failure in the ICU
is best guided by invasive hemodynamic measurements and by the
type of heart failure involved (systolic, diastolic, left-sided, or right-
sided failure).
 The management of acute, decompensated heart failure should
augment cardiac output and reduce ventricular filling pressures
while producing little or no increase in myocardial O2 consumption.
 Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to
reduce morbidity .
 Diuretic therapy should not play a major role in the management of
acute heart failure, particularly if the failure is due to diastolic
dysfunction.
 Low-dose dopamine infusion may be considered in addition to loop
diuretic 1 therapy to improve diuresis and better preserve renal
function and renal blood flow .
 If cardiogenic shock is identified, mechanical cardiac support should
be initiated as soon as possible, if indicated.
Heart Failure management in ICU

Weitere ähnliche Inhalte

Was ist angesagt?

Heart Failure(HFrEF) management- an Overview
Heart Failure(HFrEF) management- an Overview Heart Failure(HFrEF) management- an Overview
Heart Failure(HFrEF) management- an Overview Ashok Dutta
 
POCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh IranPOCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh Iranmansoor masjedi
 
Acute complications of haemodialysis
Acute complications of haemodialysisAcute complications of haemodialysis
Acute complications of haemodialysisDr Narinder Sharma
 
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPYLEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPYDr Siva subramaniyan
 
Hypertensive emergencies treatment
Hypertensive  emergencies treatmentHypertensive  emergencies treatment
Hypertensive emergencies treatmentabhishek144
 
Hyertension in patients on regular hemodialysis
Hyertension in patients on regular hemodialysisHyertension in patients on regular hemodialysis
Hyertension in patients on regular hemodialysisEhab Ashoor
 
cardiopulmonary bypass
cardiopulmonary bypasscardiopulmonary bypass
cardiopulmonary bypassAkash Kanojia
 
Complications of hemodialysis
Complications of hemodialysisComplications of hemodialysis
Complications of hemodialysisReynel Dan
 
Heart Failure
Heart FailureHeart Failure
Heart Failuredrucsamal
 
Blood cell Trauma
Blood cell TraumaBlood cell Trauma
Blood cell TraumaManu Jacob
 
Intra operative blood_conservation
Intra operative blood_conservationIntra operative blood_conservation
Intra operative blood_conservationManu Jacob
 
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Ade Wijaya
 
Renal impairment and anaesthesia
Renal impairment and anaesthesiaRenal impairment and anaesthesia
Renal impairment and anaesthesiaErrol Williamson
 
Deep hypothermic circulatory arrest in pediatric cardiac sur
Deep hypothermic circulatory arrest in pediatric cardiac surDeep hypothermic circulatory arrest in pediatric cardiac sur
Deep hypothermic circulatory arrest in pediatric cardiac surManu Jacob
 

Was ist angesagt? (20)

Arrhythmias In The ICU
Arrhythmias In The ICU Arrhythmias In The ICU
Arrhythmias In The ICU
 
Acute liver failure in icu
Acute liver failure in icuAcute liver failure in icu
Acute liver failure in icu
 
Heart Failure(HFrEF) management- an Overview
Heart Failure(HFrEF) management- an Overview Heart Failure(HFrEF) management- an Overview
Heart Failure(HFrEF) management- an Overview
 
POCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh IranPOCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh Iran
 
Acute complications of haemodialysis
Acute complications of haemodialysisAcute complications of haemodialysis
Acute complications of haemodialysis
 
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPYLEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
 
Priming and Hemodilution
Priming and HemodilutionPriming and Hemodilution
Priming and Hemodilution
 
Hypertensive emergencies treatment
Hypertensive  emergencies treatmentHypertensive  emergencies treatment
Hypertensive emergencies treatment
 
Hyertension in patients on regular hemodialysis
Hyertension in patients on regular hemodialysisHyertension in patients on regular hemodialysis
Hyertension in patients on regular hemodialysis
 
DHCA
DHCA DHCA
DHCA
 
cardiopulmonary bypass
cardiopulmonary bypasscardiopulmonary bypass
cardiopulmonary bypass
 
NT-ProBNP
NT-ProBNPNT-ProBNP
NT-ProBNP
 
Complications of hemodialysis
Complications of hemodialysisComplications of hemodialysis
Complications of hemodialysis
 
Heart Failure
Heart FailureHeart Failure
Heart Failure
 
Blood cell Trauma
Blood cell TraumaBlood cell Trauma
Blood cell Trauma
 
Sodium bicarbonate in acidosis
Sodium bicarbonate in acidosisSodium bicarbonate in acidosis
Sodium bicarbonate in acidosis
 
Intra operative blood_conservation
Intra operative blood_conservationIntra operative blood_conservation
Intra operative blood_conservation
 
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
 
Renal impairment and anaesthesia
Renal impairment and anaesthesiaRenal impairment and anaesthesia
Renal impairment and anaesthesia
 
Deep hypothermic circulatory arrest in pediatric cardiac sur
Deep hypothermic circulatory arrest in pediatric cardiac surDeep hypothermic circulatory arrest in pediatric cardiac sur
Deep hypothermic circulatory arrest in pediatric cardiac sur
 

Andere mochten auch

Hospital Readmissions Reduction Program: Keys to Success
Hospital Readmissions Reduction Program: Keys to SuccessHospital Readmissions Reduction Program: Keys to Success
Hospital Readmissions Reduction Program: Keys to SuccessHealth Catalyst
 
Diagnosis and Management of Shock
Diagnosis and Management of Shock		Diagnosis and Management of Shock
Diagnosis and Management of Shock Khalid
 
Shock - Pathophysiology / Types & Management
Shock - Pathophysiology / Types & ManagementShock - Pathophysiology / Types & Management
Shock - Pathophysiology / Types & ManagementUthamalingam Murali
 

Andere mochten auch (7)

Guidelines heart failure 2016
Guidelines heart failure 2016Guidelines heart failure 2016
Guidelines heart failure 2016
 
Ivc guided fluid management in the icu
Ivc guided fluid management in the icuIvc guided fluid management in the icu
Ivc guided fluid management in the icu
 
Cardiopulmonary bypass
Cardiopulmonary bypassCardiopulmonary bypass
Cardiopulmonary bypass
 
Hospital Readmissions Reduction Program: Keys to Success
Hospital Readmissions Reduction Program: Keys to SuccessHospital Readmissions Reduction Program: Keys to Success
Hospital Readmissions Reduction Program: Keys to Success
 
Diagnosis and Management of Shock
Diagnosis and Management of Shock		Diagnosis and Management of Shock
Diagnosis and Management of Shock
 
Heart failure 2013 Therapy
Heart failure 2013 TherapyHeart failure 2013 Therapy
Heart failure 2013 Therapy
 
Shock - Pathophysiology / Types & Management
Shock - Pathophysiology / Types & ManagementShock - Pathophysiology / Types & Management
Shock - Pathophysiology / Types & Management
 

Ähnlich wie Heart Failure management in ICU

Device therapy in advanced HF.
Device therapy in advanced HF.Device therapy in advanced HF.
Device therapy in advanced HF.asadsoomro1960
 
management of acute Heart failure
management of acute Heart failure management of acute Heart failure
management of acute Heart failure Basem Enany
 
Post operative management
Post operative management Post operative management
Post operative management Tapish Sahu
 
refractory heart failure
refractory heart failurerefractory heart failure
refractory heart failureHarsha Ganta
 
Current management of Spontaneous intracerebral haemorrhage 2016
Current management of Spontaneous intracerebral haemorrhage 2016Current management of Spontaneous intracerebral haemorrhage 2016
Current management of Spontaneous intracerebral haemorrhage 2016Woralux Phusoongern
 
Pharmacotherapy of Heart Failure
Pharmacotherapy of Heart FailurePharmacotherapy of Heart Failure
Pharmacotherapy of Heart FailureDr. Ashutosh Tiwari
 
Heart Failure Grand Rounds July 2023.pptx
Heart Failure Grand Rounds July 2023.pptxHeart Failure Grand Rounds July 2023.pptx
Heart Failure Grand Rounds July 2023.pptxValmiki Seecheran
 
The Problem Of Heart Failure
The Problem Of Heart FailureThe Problem Of Heart Failure
The Problem Of Heart Failurefmaklady
 
slide-set-heart-failure-management.pptx
slide-set-heart-failure-management.pptxslide-set-heart-failure-management.pptx
slide-set-heart-failure-management.pptxAhmadNoor61
 
Acute Decompensated Heart Failure : What is New ?
Acute Decompensated Heart Failure : What is New ?Acute Decompensated Heart Failure : What is New ?
Acute Decompensated Heart Failure : What is New ?drucsamal
 
Djjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjd
DjjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjdDjjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjd
Djjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjdssuserdb48e4
 
Heart Failure and Cardiomyopathy copy.pptx
Heart Failure and Cardiomyopathy copy.pptxHeart Failure and Cardiomyopathy copy.pptx
Heart Failure and Cardiomyopathy copy.pptxSarahYambao1
 
Heart failure review
Heart failure reviewHeart failure review
Heart failure reviewVikas Gupta
 
intracerebral haemorrhage:
intracerebral haemorrhage: intracerebral haemorrhage:
intracerebral haemorrhage: Sohail Sachdeva
 
hypertension anesthesia, general management. antihypertensive pharmacology
hypertension anesthesia, general management. antihypertensive pharmacologyhypertension anesthesia, general management. antihypertensive pharmacology
hypertension anesthesia, general management. antihypertensive pharmacologyAbayneh Belihun
 
Heart failure imrose
Heart failure imroseHeart failure imrose
Heart failure imroseNizam Uddin
 
Diagnosis and treatment of Acute and Chronic Heart failure
Diagnosis and treatment of Acute and Chronic Heart failureDiagnosis and treatment of Acute and Chronic Heart failure
Diagnosis and treatment of Acute and Chronic Heart failureM A Hasnat
 

Ähnlich wie Heart Failure management in ICU (20)

Device therapy in advanced HF.
Device therapy in advanced HF.Device therapy in advanced HF.
Device therapy in advanced HF.
 
management of acute Heart failure
management of acute Heart failure management of acute Heart failure
management of acute Heart failure
 
Post operative management
Post operative management Post operative management
Post operative management
 
refractory heart failure
refractory heart failurerefractory heart failure
refractory heart failure
 
Current management of Spontaneous intracerebral haemorrhage 2016
Current management of Spontaneous intracerebral haemorrhage 2016Current management of Spontaneous intracerebral haemorrhage 2016
Current management of Spontaneous intracerebral haemorrhage 2016
 
Pharmacotherapy of Heart Failure
Pharmacotherapy of Heart FailurePharmacotherapy of Heart Failure
Pharmacotherapy of Heart Failure
 
Emergency HF service
Emergency HF serviceEmergency HF service
Emergency HF service
 
Heart Failure Grand Rounds July 2023.pptx
Heart Failure Grand Rounds July 2023.pptxHeart Failure Grand Rounds July 2023.pptx
Heart Failure Grand Rounds July 2023.pptx
 
The Problem Of Heart Failure
The Problem Of Heart FailureThe Problem Of Heart Failure
The Problem Of Heart Failure
 
slide-set-heart-failure-management.pptx
slide-set-heart-failure-management.pptxslide-set-heart-failure-management.pptx
slide-set-heart-failure-management.pptx
 
Cardiogenic Shock.pdf
Cardiogenic Shock.pdfCardiogenic Shock.pdf
Cardiogenic Shock.pdf
 
Acute Decompensated Heart Failure : What is New ?
Acute Decompensated Heart Failure : What is New ?Acute Decompensated Heart Failure : What is New ?
Acute Decompensated Heart Failure : What is New ?
 
Djjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjd
DjjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjdDjjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjd
Djjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjdjjddjdjd
 
Heart Failure and Cardiomyopathy copy.pptx
Heart Failure and Cardiomyopathy copy.pptxHeart Failure and Cardiomyopathy copy.pptx
Heart Failure and Cardiomyopathy copy.pptx
 
Heart failure review
Heart failure reviewHeart failure review
Heart failure review
 
intracerebral haemorrhage:
intracerebral haemorrhage: intracerebral haemorrhage:
intracerebral haemorrhage:
 
hypertension anesthesia, general management. antihypertensive pharmacology
hypertension anesthesia, general management. antihypertensive pharmacologyhypertension anesthesia, general management. antihypertensive pharmacology
hypertension anesthesia, general management. antihypertensive pharmacology
 
hear failure.ppt
hear failure.ppthear failure.ppt
hear failure.ppt
 
Heart failure imrose
Heart failure imroseHeart failure imrose
Heart failure imrose
 
Diagnosis and treatment of Acute and Chronic Heart failure
Diagnosis and treatment of Acute and Chronic Heart failureDiagnosis and treatment of Acute and Chronic Heart failure
Diagnosis and treatment of Acute and Chronic Heart failure
 

Kürzlich hochgeladen

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 

Kürzlich hochgeladen (20)

American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 

Heart Failure management in ICU

  • 1. By Dr. Ahmad Y. Alansi Althawra Modern General Hospital Cardiac surgery department Anesthesia & ICU unite
  • 2.  Definitions  Which heart failure patient should be admitted in ICU?  Monitoring  Classification and plan  Medical treatment  Mechanical support  The future  Summary
  • 3. Definition of Advanced HF A subset of patients with chronic HF will continue to progress and develop persistently severe symptoms despite maximum therapy .Various terminologies have been used to describe this group of patients who are classified with ACCF/AHA stage D HF, including “advanced HF,” “end-stage HF,” and “refractory HF.
  • 8. Decompensated chronic heart failure (advanced heart failure) Acute heart failure ACS Sepsis Post CPR Toxic VO2 Oxygen uptake from tissues MRO2 Metabolic requirement for oxygen
  • 9. ● Nonadherence with medication regimen, sodium and/or fluid restriction ● Acute myocardial ischemia ● Uncorrected high blood pressure ● AF and other arrhythmias ● Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers) ● Pulmonary embolus ● Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs) ● Excessive alcohol or illicit drug use ● Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) ● Concurrent infections (e.g., pneumonia, viral illnesses) ● Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection
  • 10. Hypotension systolic BP < 90 mmHg SpO2 < 90 % PH < 7.35 Lactate > 2.0 Oliguria, BUN > 30 Worsening renal function VsO2 < 50 %
  • 11. So the following patients should be admitted to ICU :  All pateints with NYHA class III-IV.  Suspected or diagnoseed ACS .  Potential life threatening arrhythmia (VF, VT, high grade a- v block, persistent symptomatic tachy or brady).  Requiring or at risk of requiring invasive ventilatory support .  Cardiogenic shock or otherwise requiring chemical or mechanical circulatory support (dopmamine , dobutamine,….IABP,LVAD….etc)  Multisystem Failure .
  • 12. monitoringinvasiveNon i.e. temperature, respiratory rate, arterial pressure, continuous ECG, pulse oximetry, daily I/O chart and body weight are required in all patients
  • 13. Invasive monitoring: 1- Arterial pressure monitoring : continues BP monitoring repetitive blood gas analysis . 2- Central venous catheter : Monitoring right-sided filling pressure Delivering vasoactive medication Rapid volume replacement
  • 14. 3- Pulmonary artery catheterization (PAC) Indicated in patients with left ventricular dysfunction . In patients requiring inotropic or vasoconstrictor drugs. For monitoring Cardiac output Estimation of systemic vascular resistance Mixed venous oxygen saturation Lost popularity because of Invasiveness and no different in mortality rate
  • 15. 4- Transoesophageal Echocardiography Recently gained popularity as a haemodynamic monitoring tool for ventilated intensive care patients. It provides valuable information about morphology and haemodynamic state, but interpretation of data requires considerable training and experience. So Transthoracic Echo Is more performed and remain the main tool .
  • 16.  Low Output Failure in which there is decreased contractility of heart leading to decreased cardiac output  High Output Failure in which demands of body are high, which are not met even with increased cardiac output like in case of severe Anemia , Thyrotoxicosis and Thiamine deficiency
  • 18.  Which side of heart is affected – Left (more common) – Right (right-sided MI, pulmonary HTN)  Which heart function is affected – Systolic (↓ contraction and EF, dilated LV) – Diastolic (↓ relaxation,)  Failure of LV filling  Contractile function and EF usually normal
  • 21. The management of heart failure described here is meant for patients with advanced or decompensated heart failure. The approach here is specifically designed for ICU patients: it is based on invasive hemodynamic measurements rather than symptoms and uses only drugs that are given by continuous intravenous infusion
  • 22. Left-Sided (Systolic) Heart Failure : 1- High Blood Pressure 2- Normal Blood Pressure 3- Low Blood Pressure
  • 23. Left-Sided (Systolic) Heart Failure : 1- High Blood Pressure (e.g. early period after cardiopulmonary bypass surgery ) Profile: High PCWP/Low CO/High BP Treatment: Vasodilator therapy with nitroprusside or nitroglycerin. If the PCWP remains above 20 mm Hg, add diuretic therapy with furosemide.
  • 24. Left-Sided (Systolic) Heart Failure : 2- Normal Blood Pressure: e.g. ischemic heart disease, acute myocarditis, and the advanced stages of chronic cardiomyopathy. Profile: High PCWP/Low CO/Normal BP Treatment: Inodilator therapy with dobutamine or milrinone, or vasodilator therapy with nitroglycerin. If the PCWP does not decrease to <20 mm Hg, add diuretic therapy with furosemide.
  • 25. Left-Sided (Systolic) Heart Failure : 3- Low Blood Pressure is the sine qua non of cardiogenic shock. e.g. associated with cardiopulmonary bypass surgery, acute myocardial infarction, viral myocarditis, and pulmonary embolus. Profile: High PCWP/Low CO/Low BP Treatment: Dopamine in vasoconstrictor doses or combination with Dubtamin. Mechanical assist devices can be used as a temporary measure in selected cases.
  • 26. Diastolic Heart Failure : Incidence of purely diastolic HF in nature is not known. no general agreement about the optimal treatment but two recommendations seems to be valid : 1- positive inotropic agents have no role in the treatment of diastolic heart failure. 2- diuretic therapy can be counterproductive, vasodilator agents, such as nitroglycerin and milrinone, Calcium channel blockers like verapamil are effective.
  • 27. Right Heart Failure The strategies below pertain only to primary right heart failure (e.g., following acute myocardial infarction) and not to right heart failure secondary to chronic obstructive lung disease: 1- If PCWP is below 15 mm Hg, infuse volume until the PCWP or CVP increases by 5 mm Hg or either one reaches 20 mm Hg . 2- If the RVEDV is less than 140 mL/m2, infuse volume until the RVEDV reaches 140 mL/m2 . 3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 or higher, infuse dobutamine, beginning at a rate of 5 mg/kg/minute . In the presence of AV dissociation or complete heart block, institute sequential A-V pacing and avoid ventricular pacing .
  • 28. Diuretics in Hospitalized Patients: Recommendations Class I 1. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity (Level of Evidence: B) 2. If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension (Level of Evidence: B) 3. The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. (Level of Evidence: C)
  • 29. Diuretics in Hospitalized Patients: Recommendations Class IIa 1. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics (Level of Evidence: B); b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B). Class IIb Low-dose dopamine infusion may be considered in addition to loop diuretic 1 therapy to improve diuresis and better preserve renal function and renal blood flow (Level of Evidence: B)
  • 30. Short term therapeutic options ( Nondurable)Bridge to recovery Long term therapeutic options Bridge to transplantation ( durable) Destination therapy (permanent) Percutaneous devices IABP Impella ECMO and centrifugeal pump devices Implantable devices (cardiotomy) LVAD, RVAD, BiVAD, total artificial heart (different models, different indications)
  • 31. Class IIa MCS is beneficial in carefully selected* patients with stage D HFrEF in whom definitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned . (Level of Evidence: B) Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices (VADs), is reasonable as a “bridge to recovery” or “bridge to decision” for carefully selected* patients with HFrEF with acute, profound hemodynamic compromise . (Level of Evidence: B) Durable MCS is reasonable to prolong survival for carefully selected* patients with stage D HFrEF (672-675). (Level of Evidence: B)
  • 32. selected* patients are those with LVEF <25% and NYHA class III-IV functional status despite GDMT, when CRT indicated , with either high predicted 1- to 2-y mortality or dependence on continuous parenteral inotropic support.
  • 33. Intra-Aortic Balloon Counterpulsation Intra-aortic balloon counterpulsation was introduced in 1968 as a method of promoting coronary blood flow . It is available in various lengths to match body height. Hemodynamic Effects Inflation begins at the onset of diastole, just after the aortic valve closes that cause Increase in diastolic pressure which should also augment coronary blood flow, because the bulk of coronary flow occurs during diastole. Deflation at the onset of ventricular systole, just before the aortic valve opens so Deflation of the balloon reduces the end-diastolic pressure, This decreases ventricular afterload and promotes ventricular stroke output.
  • 34. IABP Indication: when cardiac pump failure is life-threatening and either pump function is expected to improve spontaneously, or a corrective procedure is planned. Cardiogenic shock following CPB Acute MI . Unstable angina, Acute mitral insufficiency, Planned cardiac transplantation. Support PCI & reduce size of Infarction ??!!! controversy
  • 36. Yemeni future Get to international standards of treatment (new drugs, assist devices programs) Transplantation International future Genetics Stem cell cultures and implantation Truly viable total artificial heart
  • 37.  The approach to advanced or decompensated heart failure in the ICU is best guided by invasive hemodynamic measurements and by the type of heart failure involved (systolic, diastolic, left-sided, or right- sided failure).  The management of acute, decompensated heart failure should augment cardiac output and reduce ventricular filling pressures while producing little or no increase in myocardial O2 consumption.  Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity .  Diuretic therapy should not play a major role in the management of acute heart failure, particularly if the failure is due to diastolic dysfunction.  Low-dose dopamine infusion may be considered in addition to loop diuretic 1 therapy to improve diuresis and better preserve renal function and renal blood flow .  If cardiogenic shock is identified, mechanical cardiac support should be initiated as soon as possible, if indicated.