So here is our second discussion, where we delve a bit into diuretic physiology, the issue of organ congestion, the myth of the “low-flow” acute renal failure associated with CHF (see earlier post), and a couple other things including a great way to determine if a patient isn’t respecting the low salt diet prescription!
I meant to, but forgot to discuss with Jon what I think is an important end-point in CHF management: the IVC. Yes, it is useful not just to make the diagnosis of congestion, but also target normalization of IVC physiology prior to discharge. It just makes common sense. If you decongest a patient just enough to get them off O2 and send them home, they bounce back a lot quicker than if you make sure you’re given them some intravascular leeway. How do you determine this? Simple enough, make sure your IVC is down at least to below 20mm, and has recovered the classic acxvy and respiratory variation. I personally try to get into the 8-12 mm range, but that’s arbitrary. Here is some good data for 20mm:
Without further due, here is the NYS Track 2:
Please share your thoughts!
Here are the references:
-DOSE Trial [http://www.nejm.org/doi/full/10.1056/NEJMoa1005419#t=abstract]
-Assessing Natriuretic Effect [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721236/]
-Here’s a #FOAM piece on morphine badness [http://rebelem.com/morphine-kills-in-acute-decompensated-heart-failure/] – i can understand its bad press, but i think it’s a little more nuanced than just saying “morphine is dangerous, stop using it.” a bit like using beta-blockers in an acute MI – may be friend, may be foe, operator dependent.