Drug’s of the Heart Failure
Diuretics For achieving optimal volume status eliminate or minimize congestion • High doses of i.v diuretics 2-3 times daily • More effective with continous i.v. • Combination diuretics • Resistent diuretics” is a common problem
Diuretics For achieving optimal volume status eliminate or minimize congestion •
High doses of i.v diuretics 2-3 times daily
•
More effective with continous i.v.
•
Combination diuretics
•
Resistent diuretics” is a common problem
Indication and dosing of diuretics in AHF
FUROSEMID
Pengenceran :
syringe pump : 100 mg (5 amp) /50 cc NaCl 0,9%
1 cc = 2 mg
Infus 90 cc NaCl 0,9% + 100 mg (5 amp) 100 cc= 100 mg
1cc = 1 mg
Misal dosis furosemid yang diinginkan 5 mg /jam mikrodrip (5 cc/jam) = 300/60 menit = 5 tts/menit
Morphine and its analogues In patient present with restlessness and dyspnoea
Morphine induces • Venodilatation • Mild arterial dilatation • Reduce heart rate Dose : 3 mg IV bolus, rate 1 mg/min. Repeated if required
ESC guidelines Acute Heart Failure, 2012
Cara pengenceran
Morphine 1 ampul @1cc = 10 mg
Encerkan dengan aqua 10 cc
1 cc = 1 mg
Vasodilators
Nitroprusside, Nitroglycerin, Nitrate family Work by cGMP mediated smooth muscle relaxation -> vasodilation Decrease myocardial work by afterload and preload reduction May cause hypotension May cause headache
Nitrate Not evaluated by large scale studies Many studies shown their favorable effect Limitation Side effect Nitrate Resistance Nitrate Tolerance
Prevention Intermittent dosing : 12 hour nitrate free interval Escalating dose Concomitant use of hydralazine
Elkayam, The American Journal of Cardiology
Intravenous Vasodilator used to treat AHF
pengenceran
ISDN Sediaan ISDN ampul 10 cc = 10 mg Syringe pump tanpa diencerkan 1 cc = 1 mg Infus 1 amp (10 mg) dalam 100 cc NaCl 0,9% 100 cc = 10 mg 1 cc = 0,1 mg Misal : dosis yang diinginkan 2 mg/jam 20 cc/jam Makrodrip 20 tts x 20 = 400 tts/jam = 7 tts/menit
Role of Inotropic Therapy in Acute Heart Failure The use of inotropes as a treatment of : • cardiogenic shock
• diuretic/ACE inhibitor– refractory heart failure decompensations • a short-term bridge to definitive treatment, such as revascularization or cardiac transplantation, is potentially appropriate
Felker GM. Am Heart J. 2001;142:393–401.
Inotropic Agent Indication : Peripheral hypoperfusion (hypotension, decrease renal function) with or without congestion Patients with CHF :
Clinical course, symptom and prognosis may depend on haemodynamics parameter Improvement of haemodynamics may become a goal of treatment Beneficial effect of improvement haemodynamics potentially counteract by the rise of arrythmia (increase oxygen demand, Ca++ loading, excessive increase in energy) may potentially harmful ESC, Acute Heart Failure, 2012
Inotropes: Dopamine, Dobutamine, Milrinone • Improve cardiac output - by directly increasing cardiac contractility
• Significant proarrhythmic effects • May precipitate ischemia • Not recommended for routine use in AHF, but clearly have a role in specific patients
Inotropic Agents Dopamine
Is dose dependent and they involve in three different receptors.
In low dose (< 2 g/kgBW/min),
At doses > 5 g/kgBW/min dopamine
vasodilatation occurs predominantly in renal, coronary, and cerebral vascular beds.
will increase peripheral vascular resistance via adrenergic receptors
However if no response is seen in diuresis the therapy should be terminated (Level of evidence C, class IIb)
ESC, Acute Heart Failure, 2005
Drugs used to treat AHF that are positive inotropes or vasopressor or both
pengenceran
Sediaan 200/5 ml
Syringe pump 200 mg/50 cc NaCL 0,9% Dosis sesuai tabel Infus
200 cc +200 mg dopamin 1 cc = 1 mg = 1000 mikrogram Misal : pasien dengan BB 50 kg memerlukan drip dopamin 5 mikro/KgBB/menit
Kebutuhan 5 x 50 kg = 250 mikrogram/menit 0,25 cc/menit
Mikrodrip : 0,25 x 60 = 15 tts/menit
Inotropic Agents Dobutamine
Clinical action is dose dependent positive inotropic and chronotropic effects.
In low dose induce arterial vasodilatation and in higher induce arterial vasoconstriction
ESC, Acute Heart Failure, 2005
dobutamin
Sediaan 5 cc= 250 mg syringe pump 50 cc = 250 mg 1 cc = 5 mg dosis sesuai tabel
Infus
250 cc NaCl 0,9% + 250 mg dobutamin 1 cc = 1 mg
Misal : pasien dengan BB 50 kg memerlukan drip dobutamin 5 mikro/KgBB/menit
Kebutuhan 5 x 50 kg = 250 mikrogram/menit 0,25 cc/menit
Mikrodrip : 0,25 x 60 = 15 tts/menit
Nor ephinefrine
Sediaan 4 ml = 4 mg
Syringe pump 50 cc = 4 mg 1 cc = 0,08 mg = 80 mikro
Infus 1 ampul dilarutkan dalam 200 cc NaCl 0,9%
200 cc = 4 mg 1cc = 0,02 mg = 20 mikro
Misal pasien dengan BB 50 kg membutuhkan Norephinefrin 0.1 mikro/kgBB/menit
50 x 0.1 = 5 mikro/menit
= 0,25 cc Tetesan = 60 x 0,25 = 15 tts mikro
Inotropic Agents Phosphodiesterase inhibitors
Block the breakdown of cyclic AMP into AMP (milrinone, enoximone)
In advance HF, associated with inotropic, lusitropic, vasodilating effects
Intermediate between vasodilator and predominant inotrope
ESC, Acute Heart Failure, 2012
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