June EMRAP Rob ORman

[Bjs04f]

Looking at this months EMRAP the CHF notes with Rob Orman. What do you guys think of this approach?

For hypotensive I have always been fond of dobutamine, I dont believe the peripheral vasodilation is significant enough to offset the positive ionotropy, and have had success avoiding levophed with the near cardiogenic shock patients.

For normotensive patients with worsening CHF, I get mixed messages, Ive tried to use bipap and be more agressive, but my understanding is lasix is of little utility, and a lot of attendings wont use bipap until the patient is death bed ill, they hesitate to use such a non invasive therapy with proven results, instead using this large lasix dose and home.

FOr hypertensive or sympathetic surge as the man calls it weve got that those are the bipap nitro go hard pt easy to manage.

The hypotensive are tricky due to all the things in play, the normotensive are tricky because dispo I find hard whether they really need to stay, or if they can go. Hypertensive are straightforward. Anyone else have some thoughts?

[kemple]

So I had a medicine resident tell me crit care is going towards levophed now as it has inotropic effects. Yoon has been using it over dopamine, dobutamine, etc.

[Bjs04f]

The issue with levophed is all the side affects, the tachyarrhytmias, the peripheral clamp down and ischemia. I f the pt is in florid shock yeah do it theres not much choice, but IM talking about the chatting with you short of breath map ~70 pt where you can try the dobutamine, or even the normotensive pt whos not responding well to bipap and still working way towards worsening failure. It just make sens in my mind, the heart isnt contracting well so give it a hand. Lasix doesnt seem to be beneficial in the ER as its effects are forever away, so other than bipap why not use an inotrope

[Bjs04f]

perhaps trying to get to cute with it just go levophed for low BP, lasix for normal, and nitro bpap for high

[kemple]

haha possibly

[slevittMD]

Depends on how low the BP is. If the MAP is <65, I'd go with levophed first, which is supposed to be the first line pressor for cardiogenic shock. Dobutamine doesn't reliably raise BP and can potentially lower it, won't help coronary perfusion much if MAP is low. After levophed, or if the MAP is ok already, then I'd go to dobutamine. The vasodilatory effects are enough to outweigh the inotropic effects of dobutamine about ⅓ of the time.

I generally agree with the rest. Lasix isn't that helpful in the ED, but I still think it should be given in the ED at some point. The sooner you get it in, the sooner it works. Low threshold for BiPAP. If they're having respiratory distress, I think you should make their work of breathing easier, and why not decrease preload and afterload while you're at it? You can always take them off. I've also seen attendings who like to give lots of lasix and avoid bipap, but I don't have to worry about that starting next week and you won't have to worry about it for much longer either.

[tyson]

where does milrinone fit in your equation?

good contractility and decreases afterload in CHF.

i can't say i've used it that much, maybe just a couple of times during ICU month. im certainly not comfortable with it and don't use it as a go-to, but wondered where it fit w/ everyone else?

[Bjs04f]

my understanding is milrinone has worse hypotension than dobutamine, so its not even on my radar, i knows cards likes t but not sure why