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Chris Jones Acute Heart Failure

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Chris Jones lecture for students studying anaesthesia and recovery care modules at Edge Hill university

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Chris Jones Acute Heart Failure

  1. 1. Acute Heart Failure
  2. 2. Acute Heart Failure <ul><li>Remember </li></ul><ul><li>Heart Failure is a symptom of something else gone wrong. It is rarely the thing itself. </li></ul><ul><li>So what else might have gone wrong? </li></ul><ul><li>Prompt assessment is essential. The problem might be correctable </li></ul>
  3. 3. Acute Heart Failure <ul><li>Presenting features: </li></ul><ul><li>Anxiety </li></ul><ul><li>Tachycardia </li></ul><ul><li>Dyspnoea </li></ul><ul><li>And in serious cases </li></ul><ul><li>Pallor </li></ul><ul><li>Hypotension </li></ul><ul><li>In cardiogenic shock there is the triad of: </li></ul><ul><li>Hypotension< 90mm Hg </li></ul><ul><li>Oliguria </li></ul><ul><li>Low cardiac output </li></ul>
  4. 4. Causes of acute heart failure <ul><li>Extensive myocardial infarction </li></ul><ul><li>Sustained arrhythmias (like AF or VT) </li></ul><ul><li>Mechanical problems (like papillary muscle rupture or post infarction ventricular septal defect </li></ul>
  5. 5. Acute heart failure: a medical emergency <ul><li>Aims Of medical treatment: </li></ul><ul><li>Assessment of underlying cause </li></ul><ul><li>Improvement of haemodynamics </li></ul><ul><li>Relief of pulmonary congestion </li></ul><ul><li>Improvement of tissue oxygenation </li></ul>
  6. 6. Nursing the patient in acute heart failure <ul><li>Position </li></ul><ul><li>Mental status </li></ul><ul><li>Breathing </li></ul><ul><li>Catheter </li></ul><ul><li>Observations </li></ul><ul><li>Fluids </li></ul><ul><li>Nutrition </li></ul><ul><li>Comfort </li></ul><ul><li>Spiritual needs </li></ul><ul><li>Family considerations </li></ul><ul><li>Skin </li></ul>
  7. 7. What tubes do these patients need putting in? <ul><li>Urinary catheter – What for? </li></ul><ul><li>Arterial line – What for? </li></ul><ul><li>Central line – What for? </li></ul><ul><li>Swan Ganz catheter – What for? </li></ul>
  8. 8. One by one ….. <ul><li>Central lines </li></ul><ul><li>Will give some guide to the hearts performance. </li></ul><ul><li>Can act as a conduit for the infusion of potent medications which will damage other tissues </li></ul>
  9. 9. One by one …… <ul><li>Arterial lines </li></ul><ul><li>Useful for the (painless) sampling of arterial blood for blood gas estimations – Oxygen and carbon dioxide tension, blood Ph, and base excess </li></ul><ul><li>Useful for continuous readouts of blood pressure </li></ul>
  10. 10. Investigating acute heart failure <ul><li>Chest x ray </li></ul><ul><li>Echocardiography </li></ul><ul><li>ECG </li></ul><ul><li>Blood tests </li></ul>
  11. 11. Drug treatment of acute heart failure <ul><li>Loop diuretics – and the problems associated thereof …..? Will reduce preload and afterload </li></ul><ul><li>Opiates – perchance to dream …..? Will reduce anxiety, restlessness and pain and also preload. </li></ul><ul><li>Nitrates reduce preload, afterload increase myocardial oxygen supply </li></ul>
  12. 12. Drug treatment of acute heart failure <ul><li>Inotropic support. Dobutamine, dopamine, dopexamine, adrenaline (rarely) </li></ul><ul><li>Require central line for infusion </li></ul><ul><li>Require monitoring due to arrhythmogenesis. </li></ul><ul><li>Have a very short half life </li></ul><ul><li>Require volumetric devices </li></ul>
  13. 13. Drug treatment of acute heart failure <ul><li>Phosphodiasterase inhibitors (e.g. enoximone) </li></ul><ul><li>Rarely seen </li></ul><ul><li>Longer half life </li></ul><ul><li>Have inotropic and vasodilatory properties </li></ul>
  14. 14. Problems with drug therapy <ul><li>Inotropic support might cause non infarcted areas to work harder. </li></ul><ul><li>If their oxygen supply is compromised the area of infarct can be extended and the problem worsened </li></ul><ul><li>Also higher doses of inotropes cause alpha effects and increase after load </li></ul>
  15. 15. And beyond drugs? <ul><li>In cases where there is a clear strategy to resolve problems there is the option of mechanical support: </li></ul><ul><li>The intra aortic balloon pump </li></ul><ul><li>Inflatable trousers </li></ul><ul><li>Both these are fraught with ethical problems </li></ul>
  16. 16. And beyond drugs? <ul><li>Aids to respiration such as: </li></ul><ul><li>Non invasive ventilation </li></ul><ul><li>IPPV </li></ul><ul><li>These too require a viable ‘exit strategy’ before commencement. </li></ul>

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