What are the recommended medications and ICU management plans for this patient?

Medication Management and ICU Plan for Acute Heart Failure

For patients with acute heart failure, intravenous furosemide should be administered immediately, with dosing based on prior diuretic exposure: 40mg IV for new-onset heart failure or a bolus at least equivalent to the oral dose for established heart failure patients. 1, 2

Initial Assessment and Monitoring

• Implement continuous cardiac monitoring with:

  • Pulse oximetry
  • Blood pressure monitoring (every 15-30 minutes initially)
  • Continuous ECG telemetry
  • Frequent respiratory rate assessment
  • Strict input/output monitoring

• Obtain baseline laboratory studies:

  • Complete blood count
  • Comprehensive metabolic panel
  • Cardiac biomarkers
  • Arterial or venous blood gas
  • Natriuretic peptide levels

• Perform chest X-ray and consider echocardiography if hemodynamically unstable

Respiratory Management

• For SpO₂ <90% or PaO₂ <60 mmHg:

  • Start supplemental oxygen, targeting SpO₂ 88-92%
  • Avoid hyperoxia which can cause vasoconstriction and reduced cardiac output

• For respiratory distress:

  • Initiate non-invasive ventilation (NIV) promptly
  • Use continuous positive airway pressure (CPAP) if available in pre-hospital setting
  • Consider pressure-support positive end-expiratory pressure (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history 1
  • Proceed to intubation for patients progressing to grade III/IV encephalopathy or respiratory failure not responding to NIV 1

Pharmacological Management

Diuretic Therapy

• Administer IV furosemide:
  • New-onset HF: 40mg IV bolus
  • Established HF: IV bolus at least equivalent to oral dose 1
  • Consider continuous infusion if inadequate response to bolus doses (although evidence shows similar efficacy between bolus and continuous administration) 3

Vasodilator Therapy

• For patients with SBP >110 mmHg:
  • Consider IV nitroglycerin to reduce preload and afterload
  • Avoid vasodilators if SBP <110 mmHg 1, 2

Rate Control for Atrial Fibrillation

• Use beta-blockers as first-line treatment for rate control
• Consider IV cardiac glycoside for rapid ventricular rate control 1

ACE Inhibitors

• Consider lisinopril within 24 hours of stabilization for patients with:
  • Hemodynamic stability (SBP >100 mmHg)
  • No severe renal dysfunction (serum creatinine <2 mg/dL) 4

Medications to Use with Caution

• Avoid routine use of opioids - associated with higher rates of mechanical ventilation, ICU admission, and death 1
• Avoid vasopressors or sympathomimetics unless signs of hypoperfusion persist despite adequate filling status 1
• Avoid dobutamine when pulmonary edema is associated with normal or high systolic blood pressure 1

ICU Management Plan

Criteria for ICU Admission

• Respiratory rate >25/min
• SpO₂ <90% despite supplemental oxygen
• Need for NIV or mechanical ventilation
• Hemodynamic instability or shock
• Heart rate >150 bpm or <40 bpm
• Need for IV antihypertensive medication after first-line drugs have failed 1

ICU Management Priorities

1. Hemodynamic stabilization:

   • Continuous hemodynamic monitoring
   • Consider pulmonary artery catheterization for refractory cases
   • Volume replacement if needed
   • Pressor support only if persistent signs of hypoperfusion despite adequate filling status

2. Electrolyte management:

   • Monitor potassium, magnesium, phosphate levels
   • Adjust oral medications based on blood pressure, heart rate, potassium levels, and renal function according to the guideline table 1

3. Renal function monitoring:

   • Avoid nephrotoxic agents
   • Consider continuous modes of hemodialysis if needed for renal failure 1

Discharge Planning from ICU

• Transfer from ICU when:

  • Hemodynamically stable for >24 hours
  • No longer requiring NIV or mechanical ventilation
  • Improved symptoms of heart failure
  • Stable renal function for at least 24 hours
  • Established on appropriate oral medications

• Arrange early follow-up (within 72 hours) after hospital discharge 2

Pitfalls to Avoid

• Overuse of fluid resuscitation - can worsen pulmonary edema
• Delayed initiation of NIV - early use reduces intubation rates
• Routine use of morphine - associated with worse outcomes
• Inappropriate use of vasopressors - not indicated if SBP >110 mmHg
• Neglecting rate control in atrial fibrillation - can worsen heart failure

By following this structured approach to medication management and ICU care, you can optimize outcomes for patients with acute heart failure while minimizing complications.