急性心衰和心源性休克.ppt

急性心衰和心源性休克.ppt

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AcuteHeartFailure/CardiogenicShockApril16,2004DarrenM.Triller,PharmDTheplanStickclosetothetextReviewpharmacologyandpathophysiologyonlytoenhanceunderstandingofthedrugtherapyKnowthefewdrugswellExpectationsforpharmacistsingeneralhospitalorhomecarepracticeTestquestionswilltargetthesegoalsWhyisthisimportant?

HFcommondiagnosisHospitalizationsarecommonAssociatedcostsareastronomicalPharmacistswillroutinelybeinvolvedinpreparinganddispensingtoICU/CCUUseofthedrugsisfrequentlyinurgent/emergentsituationsAcuteHF/CardiogenicshockDeathShockIIIHeartFailureIIIIVHTNDrugsMIValveDzMIRelationships/KeyTermsCardiacoutput=HRxStrokevolumeMAP=COxSVRPreloadContractilityAfterloadFrank-StarlingrelationshipTheBigPictureinFailurePreloadContractilityNeedvolumetoincreasestretch,FrankStarlingNeedcontractilityandratetomaintainoutputNeedconstrictiontomaintainpressureAfterloadVeinsHeartArteriesAutoregulationTheabilitytomaintainbloodflowoverwiderangeofperfusionpressuresCerebralandcoronaryarteriesAbilitydeclinesatMAP60mmHgMediatedbyvasoconstrictors:

epi,NE,AngII,TxA2,vasopressinvasodilators:

PGI2,NO,adenosine,natriureticpeptidesNormalreflexmechanismsIncreasepreload:

Na/H20retention,RAASIncreasedcontractility:

adrenergicoutflow（NE）Increasedafterload:

norepi,AngII,endothelin,vasopressinItisimportanttorelax!

RememberthatcoronaryarteriesfillduringdiastoleRememberthatfillingduringdiastolecontributestostrokevolume（Starling）Rememberthatincreasingheartratedecreasesventricularandcoronaryfilling,upsetscalciumprocessingbySR,O2demandincreaseChronicHFpatientshavetypicallymaxedoutpreload,anddonothavethereservethatyoudoContractilityIncreasedcontractilitywillprovideincreasedstrokevolume/COforagivenlevelofpreloadandafterloadChronicHFpatientshavehighcirculatinglevelsofcatecholaminesandarelessresponsivetoadrenergicstimulireceptordownregulationCatecholaminescardiotoxic?

Necrosis/apoptosis?

Arrhythmias?

AfterloadisdoubleedgedswordIncreasedSVRisimportantformaintainingMAPIncreasedafterloadwillreducestrokevolumeslamsthescreendoorbeforeallthekidsgetoutChronicHFpatientsareverysucceptabletoincreasesinafterloadApproachtopatientAssessstatus:

s/s,targetorgandamageAddressalterablecausesDrugsDiseases/conditionsAssessfluidstatus-overorunderhydrated?

AssessseverityandinitiatepharmacotherapyAdjustmomentbymomentPatientmonitoringVitalsignsAcid/baseOxygenationHydrationRenalfunctionSwanlinePCWPCardiacoutputApproachbyhemodynamicsubsetPCWPCISTDtreatment/monitoringMortalityincreasesfromsettoset!

Seefigure13-7intext.SubsetOnePatientsymptomaticWarrantfullwork-upAddressothercauseMaximizeoraltherapyforchronicHFACEIBBDiureticsDigMisc.:

vaccines,smokingcessation,diet,education,etc.ApproachbyhemodynamicsubsetPCWPCILowerpcwp（preload）withnitrates,diureticsMortalityincreasesfromsettoset!

Seefigure13-7intext.SubsetTwoPatientperfusingatexpenseofhigherpressureGraduallylowerPAOPwithoutcausingadverseeffectsAvoidover-shootingorelse!

AvoidpromptingreflexmechanismsTypicallyinvolvesdiuretics,nitratesand（morerecently）nesiritide.NitroglycerinePreferredpreloadreducerDecreasesPCWP,decreasespulmonarycongestionCheap,shortT50,easilytitratedUsedincombinationwithinotropesinpatientswithpulmonarycongestionandreducedLVfunctionCoronarydilationathighdoses:

usefulinpatientswithischemiaAvoidifelevatedintracranialpressureTolerancein12-72hoursTypicalDosage/AdministrationProtectfromlightStableinD5WorNSinGLASSorspecialcontainerSpecial“nitro”tubing,avoidfiltersCheckforinfusionincompatabilities5to10mcg/mininitiallyTitrateuptoabout200mcg/minascontinuousIVinfusionDiureticsVasodilation:

5-10min,prostaglandinmediatedDiuresis:

20+minutesReductioninpreloadinpatientswithvolumedepletionordecreaseddiastolicfunctionmaybeharmfulDoesnotimproveCI/COinmostpatients（curveflat）Role:

usecarefullytoreducesymptomsofcongestionwithoutcompromisingcardiacoutputLoopdiureticsFurosemide（Lasix）IV（40mg/5ml）,IM,POBioavailabilitypoor/variableStableinLR,D5WorLRTypically40mg80mgIVPover1-2minRepeatevery1-2hoursasneededMonitorhemodynamicsMonitorI/OformeasureofnetfluidlossAdministerpotassiumasneededinfluidsOtotoxicity,allergypossibleOtherDiureticsBumetanide（Bumex）:

1/40thdoseoflasixGoodbioavailabilityIV,IM,PO0.5-1mgIVPover1-2minutes,repeat1-2hrs0.25mg/mlsolution;0.5mg,1mg,2mgtabletLasixrefractoryorallergicpatientsCancausemusculoskeletals/sTorsemide（Demadex）IV/PODoseapproximatelyhalfoflasixdoseGoodbioavailabilityPotentialPKandelectrolyteadvantagesoverfurosemideDiureticresistanceAfterloadreduction“Renaldose”dopamineIncreasebolusdoseContinuousinfusionAddthiazideDiuril（chlorothiazide）ContinuousInfusionsBum