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Initial Management :- the patient with AHF on the ICU
- 1. THE PATIENT WITH ACUTE HEART FAILURE ON THE ICU – INITIAL MANAGEMENT Alain Rudiger, MD University Hospital Zurich, Switzerland Heart Failure Meeting of the ESC Sevilla, May 23rd 2015
- 2. Conflict of interests Honoraria were received from: •AOP Orphan (esmolol, vernakalant) for lectures •BAXTER (esmolol) for expert meetings and lectures •NOVARTIS (human relaxin-2) for advisory board meetings •ORION (levosimendan) for expert meetings
- 3. Case report • 36-year old man • History: Fatigue, dyspnoea, orthopnoea, abdominal pain • Clinical examination: Cool periphery, T 36.6 °C, HR 110 /min, BP 110/80 mmHg, normal chest examination, tender and enlarged liver • Elevated liver enzymes • Ultrasound: Ascites, pleural effusions
- 4. Case report
- 5. Case report
- 6. Case report
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- 11. Case report Echocardiography • Dilated LV with globally impaired function (EF 14 %), moderate MR • Dilated RV with impaired function (FAC 21 %) Pulmonary artery catheter • Cardiac index 1.9 l/min/m2 (with milrinone 20 g/min) • PAP 50/40/34 mmHg • SmvO2 41 % (SaO2 98 %)
- 12. Case report Treatment • Inotropes (dobutamine, milrinone) • Vasodilators (nitroglycerin) • IABP • Mechanical assist device (Excor® from Berlin Heart)
- 14. Case report
- 15. Case report Histology • Inflammation (granulomas with giant cells) cardiac sarcoidosis
- 16. Case report Treatment • Heart transplantation one month later Follow up • Immunosuppression with prednison, mycofenolat mofetil, ciclosporin • Good quality of life • Working capacity 80%
- 17. AHF on the ICU – Initial management □ History, clinical investigation, examinations: ØRecognition of AHF-syndrome ØDiagnosis of underlying heart disease ØIdentification of trigger for decompensation ØUnderstanding the pathophysiology □ Monitoring □ Management
- 18. History AHF-symptoms: Dyspnoea, fatigue, appetite loss, weight gain/loss Causes for dyspnoea: •Pulmonary congestion •Pleural effusions •Bronchial obstructions (asthma cardiale) •Cerebral hypoxia (hypoxemia, shock) •Metabolic acidosis •Anxiety, pain
- 19. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 20. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 21. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 22. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 23. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 24. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 25. Clinical signs • Pulse rate • Blood pressure • Cardiac auscultation • RR, lung auscultation • Skin evaluation • Neck veins, ascites • Peripheral oedema • GCS, somnolence • Body temperature
- 26. Laboratory parameters • Chemistry • Hematology • Coagulation parameters • Serologic testing • Sampling for microbiology
- 27. Arterial blood gas analysis
- 28. Mikkelsen ME. Crit Care Med 2009; 37; 1670-7 Lactate
- 29. Rudiger A. Crit Care Med 2006: 34: 2140-4 At ICU admission (grey) and maximal value during ICU stay (black) NT-proBNP
- 30. Shock Nikolau M. Eur Heart J 2013; 34: 742-9 Liver transaminases and alkaline phosphatase
- 31. Additional examinations • Electrocardiogram • Chest X-ray • Echocardiography • Coronary angiogram
- 32. Underlying cardiac diseases • Ischemic heart disease • Valvular heart disease • Hypertensive cardiopathy • Infectious myocarditis • Dilatated / hypertrophic cardiomyopathy (genetic) • Peripartum cardiomypathy • Drugs (alcohol, cocain) • Scleroderma, rheumatoid arthritis; Anti-TNF therapy • Chemotherapy, radiation therapy; Neoplasia • Amyoloidosis, haemochromatosis, sarkoidosis Felker GM. N Engl J Med 2000: 342: 1077-84
- 33. Triggers for decompensation • Myocardial ischemia • Arrhythmia • High blood pressure • Infections / inflammations • Malcompliance • Disease progression • Iatrogenic causes Felker GM. N Engl J Med 2000: 342: 1077-84
- 34. The AHF syndromes Cardiogenic shock Pulmonary edema Decompensated CHF Typical scenario Large myocardial infarction; Fulminant myocarditis Hypertensive emergency in diastolic HF Malcompliance in dilated cardiomyopathy Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l); Organ dysfunction (ecephalopathy, renal failure, liver dysfunction) Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%) Dyspnoea at exercise; Weight gain, ascites, peripheral oedema Pump failure Systolic; Left and/or right Diastolic; Left Systolic and diastolic; Left and/or right Diagnostic test ABGA (lactate) Chest x-ray NT-proBNP
- 35. AHF on the ICU – Initial management □ History, clinical investigation, examinations: ØRecognition of AHF-syndrome ØDiagnosis of underlying heart disease ØIdentification of trigger for decompensation ØUnderstanding the pathophysiology □ Monitoring □ Management x
- 36. Basic monitoring • Continuous SpO2 • Continuous ECG • Non-invasive blood pressure • Urinary catheter • Arterial line • Central venous catheter
- 37. AHF on the ICU – Initial management □ History, clinical investigation, examinations: ØRecognition of AHF-syndrome ØDiagnosis of underlying heart disease ØIdentification of trigger for decompensation ØUnderstanding the pathophysiology □ Monitoring □ Management x x
- 38. Managment • Treat underlying cardiac disease and triggering factors ! • Rhythm control • Optimisation of preload (fluid vs diuretics) • Improvement of contractility (inotropes, ECLS) • Optimization of afterload (vasopressors vs vasodilators)
- 39. Hochman JS. N Engl J Med 1999; 341: 625-34 Interventions and cardiac surgery
- 40. Frank Starling mechanism Fluid management
- 41. • Excessive use of i.v. diuretics • Increased perspiratio insensibilis • Reduced fluid intake Fluid management
- 42. Cardiogenic shock Pulmonary edema Decompensated CHF Volemia Intravascular hypovolemia (low fluid intake, fluid losses, diuretics) Fluid redistribution Hypervolemia (weight gain, ascites, peripheral oedema) Diuretic use Contraindicated Careful (furosemide 10 mg i.v. push) Indicated (furosemide infusion 1-10mg/h) Fluids Fluid challenge recommended If shock develops Fluid restriction Fluid balance target Urine output 0.3-0.5 ml/kg/h Depending on intravascular volemia Negative fluid balance Fluid management
- 43. Cardiogenic shock Pulmonary edema Decompensated CHF Blood pressure Low (or normal) High Normal Vasoactive drugs Vasopressors (noradrenaline, adrenaline, vasopressin) Vasodilators (nitroprusside) Vasodilators (nitrates) Inotropes Indicated (dobutamine, adrenaline, levosimendan) In selected cases In selected cases Hemodynamic targets MAP 60-75 mmHg, Lactate < 2.2 mmol/l SvO2 > 60% CI >2.2 l/min/m2 MAP 65-85 mmHg Individual targets Vasoactive drugs and inotropes
- 44. Cardiogenic shock Pulmonary edema Decompensated CHF Respiratory support Intubation and invasive ventilation Non-invasive ventilation Oxygen via face mask SpO2 target 92-98 % 92-98 % 92-98 % Potassium levels 4.5-5.5 mmol/l 4.5-5.5 mmol/l 4.5-5.5 mmol/l Magnesium levels >1.0 mmol/l >1.0 mmol/l >1.0 mmol/l Enteral feeding No No Yes Blood glucose 4.5-8.5 mmol/l 4.5-8.5 mmol/l 4.5-8.5 mmol/l Thromboprophylaxis Yes Yes Yes Additional treatments
- 45. Singer M. PLoS Med 2005; 2: e167
- 46. Jeger RV. Ann Intern Med 2008; 149 618-26 Avoid iatrogenic harm
- 47. Summary The correct diagnosis of the … • Underlying heart disease • Trigger for the acute decompensation • Pathophysiology • Organ dysfunctions • Co-morbidities … is the basis for the correct management of the patient.
- 48. Summary Cardiogenic shock Pulmonary edema Decompensated CHF Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l); Organ dysfunction (ecephalopathy, renal failure, liver dysfunction) Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%) Dyspnoea at exercise; Weight gain, ascites, periperal edema Treatment Inotropes, vasopressors, fluids Intubation, mechanical ventilation Vasodilators Non-invasive ventilation Vasodilators, diuretics Oxygen via face mask Avoid iatrogenic harm