Pressors with low EF and CHF

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by Caitlyn22 Caitlyn22 (New) New Nurse

Specializes in Critical Care. Has 1 years experience.

I always learned that you should initiate fluid resuscitation prior to starting a vasopressor for it to work most effectively. What do you do in the case of a patient who is fluid volume overloaded with a low EF that is hypotensive? 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 8,058 Posts

Pressors are tricky in a patient with low cardiac output since pressors increase afterload, potentially worsening cardiac output.  Often these patients may require the addition of an inotrope before a pressor.

It's important to differentiate their volume status, are they fluid overloaded but all of that overload is extravascular, but yet are intravascularly dry? 

It's also important to remember that in these patients mild hypotension (systolic the 80's) might be better in terms of perfusion than getting aggressive with pressors.

Wedgepressure

Wedgepressure, ADN, EMT-B

Specializes in CCL RCIS. Has 4 years experience. 27 Posts

My thoughts:  I want to check an LVEDP to determine fluid volume status.  If EDP is greater than 15-20 no fluids necessary go straight to pressors, once on levo or dopamine or epinephrine etc. to maintain MAP >60mmHg consider adding dopamine or milranone to increase contractility, they can have increased ectopy with dobutamine so sometimes this can make things worse if not watched closely.   At this point they are in cardiogenic shock so you need to start tending cardiac power outputs (CPO) and consider a Mechanical circulatory support (MCS) if less than 0.6.   So consider impella,  tandem heart,  or ECMO as an adjunct to what ever fix is needed IE intervention,  revascularization,  TAVR,  or transplant or what ever.  With cardiogenic shock and low CO states pressors are not the end point that is just an adjunct to MCS and ultimately intervention to fix the problem.  

Tegridy

Tegridy

Specializes in Former NP now Internal medicine PGY-3. 418 Posts

Usually we use something like dopamine or levophed (guidelines vary). I would lean more toward dopamine if I believe its pure cariogenic shock. When once you get an adequate blood pressure with dopamine try to diuresis with the usual meds (loops). Some also use milrinone. If they are end stage then honestly palliative is the most beneficial option unless you believe they can actually get a transplant (some do LVADs as a bridge to destination therapy though in patients who are intent on living). 

But if you try to give fluid when already FVO then you just make their frank starling curve physio worse. Sometimes once you get them euvolemic you can actually have the heart recover some EF since its not over distended and allows better contractility. 

 

Edited by Tegridy
fix word

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 8,058 Posts

On 1/8/2022 at 7:07 PM, Wedgepressure said:

My thoughts:  I want to check an LVEDP to determine fluid volume status.  If EDP is greater than 15-20 no fluids necessary go straight to pressors, once on levo or dopamine or epinephrine etc. to maintain MAP >60mmHg consider adding dopamine or milranone to increase contractility, they can have increased ectopy with dobutamine so sometimes this can make things worse if not watched closely.   At this point they are in cardiogenic shock so you need to start tending cardiac power outputs (CPO) and consider a Mechanical circulatory support (MCS) if less than 0.6.   So consider impella,  tandem heart,  or ECMO as an adjunct to what ever fix is needed IE intervention,  revascularization,  TAVR,  or transplant or what ever.  With cardiogenic shock and low CO states pressors are not the end point that is just an adjunct to MCS and ultimately intervention to fix the problem.  

If a patient happens to be getting a heart cath then an LVEDP is useful, although still not as useful as any of the various direct measurements of fluid responsiveness.  Otherwise, sending a patient for a heart cath for the sole purpose of obtaining an LVEDP isn't appropriate.

Various methods of determining fluid responsiveness are far less invasive and far more relevant, as are other methods of evaluating fluid volume status.

If there's a question of the need for MCS then an echo is by far the best assessment, this will offer a better assessment of both volume status and myocardial contractility than a LVEDP will.

Wedgepressure

Wedgepressure, ADN, EMT-B

Specializes in CCL RCIS. Has 4 years experience. 27 Posts

On 1/19/2022 at 9:52 PM, MunoRN said:

If a patient happens to be getting a heart cath then an LVEDP is useful, although still not as useful as any of the various direct measurements of fluid responsiveness.  Otherwise, sending a patient for a heart cath for the sole purpose of obtaining an LVEDP isn't appropriate.

Various methods of determining fluid responsiveness are far less invasive and far more relevant, as are other methods of evaluating fluid volume status.

If there's a question of the need for MCS then an echo is by far the best assessment, this will offer a better assessment of both volume status and myocardial contractility than a LVEDP will.

Yeah my option is for specific circumstances, I work in the cath lab.  This is what I use in the lab when in making moment by moment clinical decision for someone in cardiogenic shock.  In not necessarily calling echo while they are coding or we are stenting. Echo is definitely a more non invasive option bit that's just not the reality on my area generally.  

Edited by Wedgepressure

0.9%NormalSarah, ADN, RN

Specializes in ICU. Has 3 years experience. 242 Posts

Enjoying this discussion on the hemodynamic evaluation and management of heart failure patients!

offlabel

offlabel

1,403 Posts

On 1/22/2022 at 9:35 PM, Wedgepressure said:

Yeah my option is for specific circumstances, I work in the cath lab.  This is what I use in the lab when in making moment by moment clinical decision for someone in cardiogenic shock.  In not necessarily calling echo while they are coding or we are stenting. Echo is definitely a more non invasive option bit that's just not the reality on my area generally.  

In a healthy heart, LVEDP correlates to to LVED volume (which is what you're really interested in). But not in a 'stiff heart' or one with one degree or the other of diastolic failure. Looking at the LV ejection fraction is a better guide to volume responsiveness and you do that in the CCL every day. 

ghillbert, MSN, NP

Specializes in CTICU. Has 26 years experience. 3,792 Posts

On 1/6/2022 at 12:50 PM, Caitlyn22 said:

I always learned that you should initiate fluid resuscitation prior to starting a vasopressor for it to work most effectively. What do you do in the case of a patient who is fluid volume overloaded with a low EF that is hypotensive? 

You definitely fill the tank before squeezing the tank.

In the case of low EF, hypervolemia and hypotension, you need inotropy for increasing contractility - epi, dobutamine (if tolerated by BP), or milrinone (if tolerated by BP), or maybe dopamine. You also need diuresis, one of the pillars of HFrEF treatment. Thereafter, consider mechanical unloading with an IABP.