What are the initial admitting orders for acute decompensated heart failure?

Initial Admitting Orders for Acute Decompensated Heart Failure

Immediate IV loop diuretics (furosemide 40-80 mg IV bolus if diuretic-naïve, or dose equal to/exceeding chronic oral daily dose if already on diuretics) should be administered within 60 minutes of presentation, as early treatment directly impacts outcomes. 1

Immediate Monitoring (Within Minutes of Arrival)

• Continuous monitoring including pulse oximetry, blood pressure, respiratory rate, and continuous ECG 2, 1
• Oxygen saturation monitoring with oxygen therapy if SpO₂ <90% (otherwise use clinical judgment) 2, 1
• Mental status assessment using AVPU mnemonic (Alert, Visual, Pain, Unresponsive) as indicator of hypoperfusion 2
• Strict intake and output measurement initiated immediately 1

Diagnostic Workup (Concurrent with Treatment)

• 12-lead ECG immediately to exclude ST-elevation MI and identify arrhythmias 2, 1
• Cardiac troponin to identify acute coronary syndrome as precipitant 2, 1
• BNP or NT-proBNP if diagnosis uncertain 2
• Chest X-ray to assess pulmonary congestion and exclude alternative diagnoses 2, 1
• Basic metabolic panel including electrolytes, BUN, creatinine 2
• Complete blood count 2
• Liver function tests 2

Respiratory Support Orders

• Oxygen therapy to maintain SpO₂ >90%, but avoid routine use in non-hypoxemic patients as it causes vasoconstriction 2
• Non-invasive positive pressure ventilation (CPAP or BiPAP) for patients with respiratory distress (respiratory rate >25/min, SpO₂ <90%) to reduce intubation rates 2
• Position patient upright to reduce work of breathing 3

Pharmacologic Orders (Based on Blood Pressure)

For SBP >110 mmHg (Hypertensive/Normotensive):

• IV loop diuretics as first-line: furosemide 40 mg IV if diuretic-naïve, or IV dose equal to/exceeding oral daily dose 2, 1
• IV vasodilators (nitroglycerin) should be considered for symptomatic relief, especially in hypertensive AHF 2
• Administer as intermittent boluses or continuous infusion based on response 2

For SBP <110 mmHg (Hypotensive):

• Lower initial diuretic doses with close monitoring for hypotension 1
• Inotropic support (dobutamine, levosimendan, or PDE III inhibitors) may be considered if signs of hypoperfusion despite adequate filling pressures 2
• Vasopressor therapy (norepinephrine preferably) if cardiogenic shock present 2

Daily Monitoring Orders

• Daily weights at same time each day 2, 1
• Daily basic metabolic panel (electrolytes, BUN, creatinine) during active diuresis or medication titration 2, 1
• Fluid balance charts with strict intake/output 3
• Vital signs monitoring including supine and standing blood pressure 2
• Clinical assessment of congestion (jugular venous distension, peripheral edema, lung examination) and perfusion 2

Medication Reconciliation

• Continue existing GDMT (ACE inhibitors/ARBs, beta-blockers, MRAs, SGLT2 inhibitors) in patients with reduced ejection fraction unless contraindicated by hemodynamic instability 2, 1
• Do not discontinue beta-blockers for mild renal function decrease or asymptomatic blood pressure reduction 1
• Reconcile all medications on admission and adjust as appropriate 2

Triage/Admission Location

ICU/CCU Criteria (Any of the following):

• Need for intubation or already intubated 2
• Cardiogenic shock or persistent hypotension (SBP <90 mmHg) 2
• Respiratory distress requiring non-invasive ventilation 2
• Hemodynamic instability requiring invasive monitoring 2
• Acute coronary syndrome with hemodynamic compromise 2

Telemetry Ward:

• Stable patients without above criteria but requiring continuous cardiac monitoring 2

Critical Pitfalls to Avoid

• Do not delay diuretic therapy beyond 60 minutes of presentation—time-to-treatment is critical for outcomes 1
• Do not routinely discontinue GDMT unless true contraindications exist (not for mild creatinine elevation or asymptomatic hypotension) 1
• Do not start beta-blockers in acutely decompensated patients requiring oxygen or IV therapies 1
• Do not use oxygen routinely in non-hypoxemic patients as it reduces cardiac output 2
• Monitor blood pressure frequently when using non-invasive ventilation as it can cause hypotension 2

Diuretic Intensification Strategy (If Inadequate Response)

If congestion persists despite initial diuretic therapy 2:

• Higher doses of loop diuretics, or
• Addition of second diuretic (metolazone, spironolactone, or IV chlorothiazide), or
• Continuous infusion of loop diuretic

Echocardiography Timing

• Immediate echocardiography mandatory only in cardiogenic shock or hemodynamic instability 2
• After stabilization for all other patients, especially de novo heart failure 2