What are the initial hospital orders for a patient presenting with congestive heart failure (CHF) exacerbation?

Initial Hospital Orders for CHF Exacerbation

Upon hospital arrival, immediately initiate IV loop diuretics at a dose equal to or exceeding the patient's chronic oral daily dose (or 40-80 mg IV furosemide if diuretic-naïve), start continuous monitoring, and obtain diagnostic testing—all within 60 minutes of presentation. 1

Immediate Monitoring and Stabilization (Within Minutes)

Establish continuous monitoring immediately upon arrival: 2

• Continuous pulse oximetry, blood pressure, respiratory rate, and ECG 2
• Oxygen therapy if SpO₂ <90% (otherwise use clinical judgment) 2
• Non-invasive ventilation (BiPAP/CPAP) for patients with respiratory distress 2

Assess cardiopulmonary stability as the critical first step: 2

• Respiratory rate, work of breathing, ability to lie flat, degree of hypoxia 2
• Signs of hypoperfusion: cool extremities, narrow pulse pressure, altered mental status, decreased urine output 2, 1
• Systolic and diastolic blood pressure, heart rate and rhythm 2

Diagnostic Testing (Concurrent with Treatment Initiation)

Order immediately upon arrival: 2, 1

• 12-lead ECG to exclude ST-elevation MI and assess for arrhythmias 2, 1
• Cardiac troponin to identify acute coronary syndrome 1
• Chest X-ray to assess pulmonary congestion (though may be normal in up to 20% of cases) 2, 1
• BNP or NT-proBNP if the contribution of heart failure to dyspnea is uncertain 1
• Complete metabolic panel, complete blood count, renal function (BUN/creatinine), electrolytes 2, 1

Echocardiography should be performed during hospitalization to assess ejection fraction, chamber size, wall thickness, and valve function, but is not needed immediately unless hemodynamic instability is present 2, 1

Bedside thoracic ultrasound for B-lines (lung rockets) indicating pulmonary edema and abdominal ultrasound for IVC diameter if expertise is available 2

Pharmacologic Management (Blood Pressure-Guided Algorithm)

For SBP >110 mmHg (Most Common Presentation):

Start IV loop diuretics within 60 minutes: 2, 1

• If already on loop diuretics: IV dose equal to or exceeding chronic oral daily dose 1
• If diuretic-naïve: furosemide 40-80 mg IV bolus 2

Consider IV vasodilators for severe fluid overload without hypotension: 1

• IV nitroglycerin starting at 5-10 mcg/min, titrate by 5-10 mcg/min every 3-5 minutes (using non-absorbing tubing) 3
• Target: symptom relief and blood pressure reduction while maintaining SBP >90-100 mmHg 3

For SBP <110 mmHg:

Diuretics remain first-line therapy 2

• Use lower initial doses and monitor closely for hypotension 2
• Avoid vasodilators 2
• Consider inotropic support (dobutamine 2-20 mcg/kg/min) if signs of hypoperfusion persist 4

Inadequate Diuretic Response:

Add a second diuretic such as a thiazide (metolazone) or increase aldosterone antagonist dose 1

Guideline-Directed Medical Therapy (GDMT) Management

Continue existing GDMT in patients with reduced ejection fraction unless contraindications or hemodynamic instability present 1

• ACE inhibitors/ARBs/ARNIs: continue if already on therapy 1
• Beta-blockers: continue if already on therapy and patient is stable 1

Do NOT start beta-blockers on day 1 if patient required oxygen and is acutely decompensated 1

Initiate GDMT during hospitalization once clinical stability achieved: 1

• Start SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) first (often day 1) as they have minimal blood pressure effects 1
• Delay ACE inhibitors/ARBs/ARNIs until volume optimized, no marked azotemia/hyperkalemia, and SBP >90-100 mmHg 1
• Start beta-blockers only after volume optimization, IV diuretics/vasodilators/inotropes discontinued, and clinical stability confirmed 1

Daily Monitoring Orders

Assess daily: 1

• Strict intake and output measurement 1
• Daily weights 1
• Vital signs including orthostatic blood pressures 1
• Clinical signs of perfusion (mental status, extremity temperature, urine output) and congestion (JVP, rales, edema) 1
• Electrolytes and renal function 1

Identify and Treat Precipitating Factors

Search for triggers: 1

• Acute coronary syndrome (troponin, ECG) 1
• Severe hypertension 1
• Arrhythmias (atrial fibrillation, ventricular tachycardia) 1
• Infections 1
• Pulmonary embolism 1
• Renal failure 1
• Medication/dietary noncompliance 1

Critical Pitfalls to Avoid

Do not delay diuretic therapy beyond 60 minutes of presentation—the "time-to-treatment" concept is critical in acute heart failure 2, 1

Do not discontinue GDMT for mild renal function decrease or asymptomatic blood pressure reduction unless truly contraindicated 1

Do not start beta-blockers in acutely decompensated patients requiring oxygen or IV therapies—wait until volume optimized and IV medications discontinued 1

Recognize that most CHF exacerbations present with normal or elevated blood pressure (63-77% have SBP >140 mmHg), not hypotension 2