Suspected Acute Heart Failure — Treatment for Initial Acute Heart Failure — Clinical Pathway: Emergency, ICU and Inpatient

Suspected Acute Heart Failure Clinical Pathway — Emergency Department, ICU and Inpatient

Treatment for Initial Acute Heart Failure

 Warm & WetCold & WetCold & Dry
Diuretics
  • Furosemide
    • PO   1-2   mg/kg DOSE 1-4 times/day
    • IV   0.5-2   mg/kg/DOSE 1-4 times/day
  • Consider continuous infusion of furosemide, other diuretic to avoid large fluid shifts
  • Consider bumetanide, chlorothiazide or metolazone if poor response to furosemide
  • Furosemide
    • PO   1-2   mg/kg DOSE 1-4 times/day
    • IV   0.5-2   mg/kg/DOSE 1-4 times/day
  • Consider continuous infusion of furosemide, other diuretic to avoid large fluid shifts
  • Consider bumetanide, chlorothiazide or metolazone if poor response to furosemide
No diuretics
Afterload Reduction
  • MILD symptoms
    • Captopril < 6 mo
    • Enalapril > 6 mo
  • MODERATE symptoms
    • Milrinone* infusion (no load):
      0.25-1.0 mcg/kg/min
  • If normotensive:
    • Milrinone* infusion (no load)
      0.25-1.0 mcg/kg/min
  • If normotensive:
    • Milrinone* infusion (no load)
      0.25-1.0 mcg/kg/min
Chronic HF Medications
  • Continue unless patient is hypotensive and/or creatinine is elevated
  • Continue unless patient hypotensive and/or creatinine elevated
  • If hypotensive, consider low-dose dopamine or epinephrine
    • Dopamine infusion (starting dose):
      2-5 mcg/kg/min
    • Epinephrine infusion (starting dose):
      0.01 mcg/kg/min
  • If symptomatic relief is not achieved with initial management, consider:
    • Escalating inotropes
    • Escalating respiratory support
    • Initiation of mechanical support
  • Continue unless patient hypotensive and/or creatinine elevated
  • If hypotensive, consider low-dose dopamine or epinephrine
    • Dopamine infusion (starting dose):
      2-5 mcg/kg/min
    • Epinephrine infusion (starting dose):
      0.01 mcg/kg/min
  • If symptomatic relief is not achieved with initial management, consider:
    • Escalating inotropes
    • Escalating respiratory support
    • Initiation of mechanical support
* Use milrinone with caution in patients w/renal impairment or receiving other afterload reducing agents

Stepwise introduction of medical therapy in heart failure borrowed from the Canadian Cardiovascular Society Pediatric Heart Failure Guidelines (2013)