Med Surge 2 Heart Failure, ECMO, LVAD, Infections, Aneurysms, Tamponade, Contusion, Hemodynamic Monitoring 5/28/2025
Heart Failure
Review left-sided and right-sided heart failure.
Left-sided Heart Failure:
Causes:
Conditions that weaken the heart muscle:
Coronary artery disease (CAD): Reduced blood flow to the heart muscle due to plaque buildup in the arteries.
Hypertension: Chronic high blood pressure that strains the heart.
Cardiomyopathy: Diseases of the heart muscle, such as dilated, hypertrophic, or restrictive cardiomyopathy.
Conditions that damage the heart:
Myocardial infarction (Heart Attack): Damage to the heart muscle due to blocked coronary arteries.
Valvular heart disease: Conditions affecting the heart valves, such as stenosis or regurgitation.
Myocarditis: Inflammation of the heart muscle, often due to viral infections.
Mechanism:
Systolic Failure: The left ventricle loses its ability to contract normally, reducing the amount of blood it can pump out with each beat (reduced ejection fraction).
Diastolic Failure: The left ventricle loses its ability to relax and fill properly, reducing the amount of blood it can hold (preserved ejection fraction but impaired filling).
Symptoms: Primarily lung-related due to fluid backing up into the pulmonary circulation.
Shortness of breath (dyspnea):
Especially during exertion (exertional dyspnea).
When lying down (orthopnea): Often relieved by sitting up or using extra pillows.
Paroxysmal nocturnal dyspnea (PND): Sudden, severe shortness of breath that wakes the patient up at night.
Crackles (rales) in the lungs: Indicates fluid accumulation in the air sacs (pulmonary edema).
Cough: May be worse at night and can be frothy or blood-tinged if pulmonary edema is severe.
Fatigue and Weakness: Due to reduced cardiac output and oxygen delivery to the body.
Other Symptoms:
S3 heart sound: An abnormal heart sound indicating rapid ventricular filling.
Mitral regurgitation: Backup of blood into the left atrium due to a malfunctioning mitral valve.
Dizziness and confusion: Due to decreased blood flow to the brain.
Cool, pale extremities: Due to decreased peripheral perfusion.
Right-sided Heart Failure:
Causes:
Left-sided heart failure: Most common cause, as increased fluid pressure in the lungs damages the right side of the heart.
Pulmonary hypertension: High blood pressure in the arteries of the lungs, increasing the workload of the right ventricle.
Lung diseases: Such as chronic obstructive pulmonary disease (COPD), pulmonary embolism, and pulmonary fibrosis.
Right ventricular infarction: Damage to the right ventricle due to a blocked coronary artery.
Congenital heart defects: Such as atrial septal defect (ASD) or pulmonic stenosis.
Mechanism: The right ventricle has difficulty pumping blood to the lungs, leading to a backup of blood in the systemic circulation.
Symptoms:
Peripheral edema: Swelling in the lower extremities (BLE - bilateral lower extremities), often pitting edema.
Jugular vein distention (JVD): Enlarged jugular veins due to increased pressure in the superior vena cava.
Ascites: Fluid accumulation in the abdomen, causing abdominal swelling and discomfort.
Weight gain: Due to fluid retention.
Hepatomegaly: Enlarged liver, which can be tender to palpation.
Splenomegaly: Enlarged spleen.
Other Symptoms:
Anorexia and nausea: Due to abdominal congestion.
Nocturia: Increased urination at night.
Cyanosis: Bluish discoloration of the skin and mucous membranes due to poor oxygenation.
Right upper quadrant pain: Due to liver congestion.
Medications:
Diuretics: Reduce fluid overload by increasing urine output.
Furosemide (Lasix): A loop diuretic that works in the loop of Henle in the kidneys.
Bumetanide (Bumex): Another loop diuretic, often more potent than furosemide.
Torsemide (Demadex): A loop diuretic with a longer duration of action.
Hydrochlorothiazide (HCTZ): A thiazide diuretic that works in the distal convoluted tubule of the kidneys; less potent than loop diuretics and usually used for mild to moderate fluid retention.
Spironolactone (Aldactone): A potassium-sparing diuretic that also acts as an aldosterone antagonist, reducing sodium and water retention while preserving potassium.
ACE Inhibitors: Lower blood pressure and reduce strain on the heart by blocking the production of angiotensin II.
Enalapril (Vasotec).
Lisinopril (Prinivil, Zestril).
Captopril (Capoten): Has a shorter half-life and may require more frequent dosing.
Angiotensin Receptor Blockers (ARBs): Alternative to ACE inhibitors, work by blocking the action of angiotensin II at the receptor level.
Valsartan (Diovan).
Losartan (Cozaar).
Irbesartan (Avapro).
Beta Blockers: Slow heart rate and lower blood pressure by blocking the effects of adrenaline.
Metoprolol (Lopressor, Toprol XL): Selective beta-1 blocker.
Carvedilol (Coreg): Non-selective beta-blocker with alpha-blocking activity, which can further lower blood pressure.
Bisoprolol (Zebeta): Selective beta-1 blocker.
Inotropes: Increase the force of heart muscle contraction.
Digoxin (Lanoxin): A positive inotrope that also slows down the heart rate; used cautiously due to its narrow therapeutic index.
Dobutamine: A synthetic catecholamine that stimulates beta-1 adrenergic receptors, increasing heart rate and contractility; usually administered intravenously in acute heart failure.
Milrinone: A phosphodiesterase-3 inhibitor that increases contractility and causes vasodilation; administered intravenously.
Vasodilators: Dilate blood vessels, reducing the workload on the heart.
Nitroglycerin: Relaxes blood vessels and reduces preload; often used to treat acute heart failure.
Isosorbide dinitrate (Isordil): A long-acting nitrate that dilates blood vessels.
Hydralazine: Dilates arteries and reduces afterload.
Other Medications:
Entresto (sacubitril/valsartan): An angiotensin receptor-neprilysin inhibitor (ARNI) that enhances the effects of natriuretic peptides, promoting vasodilation and reducing sodium retention.
Ivabradine (Corlanor): A selective sinoatrial (SA) node inhibitor that reduces heart rate without affecting contractility; used in patients with stable heart failure and elevated heart rate.
Important Terms:
Inotropes: Medications that affect the force of heart muscle contraction.
Positive inotropes (e.g., digoxin, dobutamine): Increase contraction force, improving cardiac output.
Negative inotropes (e.g., beta-blockers): Decrease contraction force, reducing the workload on the heart.
Chronotropes: Medications that affect heart rate.
Positive chronotropes (e.g., atropine): Increase heart rate.
Negative chronotropes (e.g., beta-blockers, digoxin): Decrease heart rate.
Preload: The volume of blood in the ventricles at the end of diastole (filling).
High preload increases the stretch on the heart muscle, potentially leading to increased cardiac output (to a point).
Excessive preload can lead to congestion and heart failure symptoms.
Afterload: The resistance against which the heart must pump blood.
High afterload increases the workload on the heart, reducing cardiac output.
Medications that reduce afterload, such as ACE inhibitors and vasodilators, can improve cardiac function.
Ejection Fraction (EF): The percentage of blood that the left ventricle pumps out with each contraction. A normal EF is typically between 55% and 70%.
Heart failure with reduced ejection fraction (HFrEF): EF is less than 40%.
Heart failure with preserved ejection fraction (HFpEF): EF is greater than 50%.
Monitoring:
Daily weights: Monitor fluid retention; rapid weight gain (e.g., 2-3 pounds in a day or 5 pounds in a week) indicates fluid overload.
Intake and Output (I&Os): Assess fluid balance; monitor urine output in relation to fluid intake.
BNP Level:
Brain Natriuretic Peptide (BNP): A hormone released by the heart in response to ventricular stretching; used to assess the severity of heart failure.
Positive BNP: Greater than 100 pg/mL (the threshold may vary slightly between laboratories, but levels greater than 100 pg/mL typically indicates heart failure).
Higher BNP levels indicate more severe heart failure. Levels above 400 pg/mL often indicate moderate heart failure, and levels above 900 pg/mL indicate severe heart failure.
NT-proBNP (N-terminal pro-BNP): Another marker used to assess heart failure; NT-proBNP levels are typically higher than BNP levels.
Electrolytes: Monitor potassium, sodium, and magnesium levels, as diuretics can cause electrolyte imbalances.
Renal Function: Monitor BUN (blood urea nitrogen) and creatinine levels, as heart failure and its treatments can affect kidney function.
Liver Function: Monitor liver enzymes (AST, ALT) to assess liver congestion due to right-sided heart failure.
Blood Pressure and Heart Rate: Monitor for hypotension (low blood pressure) and tachycardia (rapid heart rate).
Oxygen Saturation: Monitor oxygen levels to assess for hypoxemia (low blood oxygen).
Treatment:
Lasix (Furosemide): Decreases fluid, which decreases cardiac output and preload. It is a loop diuretic that helps the kidneys eliminate excess fluid and sodium.
Administer intravenously for rapid diuresis in acute heart failure.
Monitor potassium levels, as furosemide can cause hypokalemia (low potassium).
Nitrates: Improve blood flow to the heart by dilating vessels. Common side effect: Headache. Nitrates reduce chest pain (angina) by increasing blood supply to the heart and reducing its workload.
Administer sublingually or intravenously for rapid relief of chest pain.
Monitor blood pressure, as nitrates can cause hypotension.
Other Treatments:
Oxygen Therapy: Administer oxygen to maintain adequate oxygen saturation levels.
Fluid Restriction: Limit fluid intake to reduce fluid overload.
Sodium Restriction: Limit sodium intake to reduce fluid retention.
Cardiac Rehabilitation: Exercise and education programs to improve cardiovascular health.
Implantable Cardioverter-Defibrillator (ICD): Device implanted to prevent sudden cardiac death in high-risk patients.
Cardiac Resynchronization Therapy (CRT
Intra-Aortic Balloon Pump (IABP)
Used for CHF patients to help with preload and afterload. The IABP reduces the heart’s workload and improves coronary artery perfusion.
Preload: The volume of blood in the ventricles at the end of diastole.
Afterload: The resistance against which the heart must pump blood.
Inflatable balloon surgically implanted in the aorta. The balloon is typically inserted through the femoral artery and positioned in the descending aorta, just distal to the left subclavian artery.
Function:
When the heart is at rest (diastole), the balloon inflates, helping blood flow through the coronary arteries, improving myocardial oxygen supply.
When the heart contracts (systole), the balloon deflates rapidly, causing blood to flow more forcefully into the aorta, reducing afterload and improving cardiac output.
Used for patients post-heart attack or awaiting a heart transplant. It is a temporary measure to stabilize patients and improve cardiac function.
Patient Scenario: Heart Failure and Orthopnea
A heart failure patient reports orthopnea and has a 2 kg weight gain in 3 days. This indicates fluid overload and worsening heart failure.
Priority nursing action: Assess lung sounds and oxygen saturation. Also, elevate the head of the bed to ease breathing, administer prescribed diuretics, and monitor vital signs and I&Os.
Extracorporeal Membrane Oxygenation (ECMO)
Temporary bypass of the heart and lungs (heart-lung machine). ECMO provides respiratory and circulatory support to patients whose lungs or heart are severely damaged.
Allows the heart to rest. By bypassing the heart and lungs, ECMO allows these organs to recover.
History:
First used in 1971 on a motorcycle accident victim. Although the patient did not survive, this marked the beginning of ECMO technology.
Later used successfully on a baby with meconium aspiration. This success led to increased use of ECMO in neonatal care.
More commonly used in the pediatric population due to the relatively smaller size and simpler physiology of children.
During ECMO:
The body is resting, allowing the heart and lungs to recover.
No heartbeat (blood is circulated by the ECMO machine in V-A ECMO). In V-V ECMO, the heart continues to beat, but the lungs are bypassed.
No blood pressure (blood pressure is maintained by the ECMO machine). Medications and adjustments to the ECMO pump control blood pressure.
Requires multiple arterial lines and central venous pressure (CVP) monitoring. These lines are essential for monitoring the patient's condition and managing the ECMO circuit.
Blood is diverted through the ECMO machine via large tubes (garden hose size). Cannulas are surgically inserted into large blood vessels to divert blood to the ECMO machine.
Indications: severe pneumonia, ARDS, cardiogenic shock, and heart surgeries. ECMO is used when conventional treatments are insufficient.
Requires a 1:1 or 2:1 nurse-to-patient ratio due to the complexity and intensity of care required.
Left Ventricular Assist Device (LVAD)
Takes over the function of the left ventricle. It is used in patients with advanced heart failure.
Patients do not have a palpable pulse; regular non-invasive blood pressure readings are not possible. Blood pressure is typically assessed using a Doppler ultrasound to measure mean arterial pressure (MAP).
A small machine (worn as a fanny pack) pumps for the heart. The device is battery-powered, and patients must always have backup batteries.
Assessment:
Use a stethoscope to listen for the device's hum. The presence of the hum indicates that the device is functioning correctly.
Assess perfusion: capillary refill (less than 2 seconds), skin signs (pink, warm, and dry), and mentation. These are indicators of adequate blood flow to the tissues.
Mental status is the most important indicator; ask if they are OK. Changes in mental status can indicate decreased perfusion or other complications.
Patients carry extra batteries and chargers and must be educated on how to change the batteries and troubleshoot alarms.
NEVER turn the device off. Turning off the LVAD will result in immediate loss of cardiac function.
Right Ventricular Assist Device (RVAD)
Same concept as LVAD but assists the right ventricle. It supports patients with right ventricular failure.
Often temporary, transitioning to LVAD if the patient's condition warrants long-term support.
Used while waiting for a heart transplant to support the right ventricle until a suitable donor heart is available.
Ensure adequate perfusion to vital organs. Monitor for signs of right ventricular failure such as edema, ascites, and JVD.
Hospital LVAD Book
Many hospitals maintain a book with information on local LVAD patients. This book is a valuable resource for healthcare providers.
Includes: name, birthday, contact information, type of device, and affiliated medical center (e.g., UCLA, UCI, USC). This information helps ensure coordinated care and facilitates communication between healthcare teams.
Infections of the Heart
Pericarditis
Infection or swelling of the pericardium (lining around the heart). It can be acute or chronic.
Usually caused by a viral or staph infection; can also result from trauma, autoimmune disorders, or post-MI (Dressler's syndrome).
Increased fluid between the layers of the pericardium, which can lead to cardiac tamponade.
Signs/Symptoms:
Pleural friction rub (scratchy, leathery sound best heard at the end of expiration) using the diaphragm of the stethoscope with the patient leaning forward.
Pain radiating to the back, often relieved by sitting or leaning forward.
Low-grade fever.
EKG: ST elevations in all leads, along with PR depression.
Patients often present with chest pain, leaning forward in a tripod position to relieve pressure on the heart.
Treatment: Relieve pain and address the underlying cause.
Pericardiocentesis: Drain fluid from around the heart if cardiac tamponade occurs.
Endocarditis
Infection of the inner surface of the heart, especially the valves. It can lead to severe valve damage and systemic complications.
Often caused by staph (Staphylococcus aureus), strep (Streptococcus viridans), or enterococci.
Risk Factors: Recent cardiac history, dental procedures, IV drug use, presence of prosthetic heart valves, congenital heart defects.
Signs/Symptoms:
Fever and chills.
Petechiae (small, purple spots) on hands and feet, as well as splinter hemorrhages under the fingernails.
General feeling of illness (malaise), fatigue, and night sweats.
Diagnosis: Echocardiogram (reveals vegetation on the valves) and blood cultures (to identify the causative organism).
Vascular Alterations
Aneurysms
Bulge or swelling in the aorta. It results from weakening of the vessel wall.
Locations:
Ascending Thoracic Aortic Aneurysm: Located in the ascending portion of the thoracic aorta.
Thoracic Aortic Aneurysm: Located in the thoracic aorta.
Abdominal Aortic Aneurysm (most common): Located in the abdominal aorta, often near the level of the renal arteries.
Symptoms: Back pain, abdominal pain, or chest pain; pulsating sensation in the abdomen (especially in slender individuals). Many aneurysms are asymptomatic and discovered incidentally during imaging for other conditions.
Complications: Rupture or dissection, which are life-threatening emergencies.
Management:
Ultrasound or CT scan to diagnose and monitor the size of the aneurysm.
Monitoring (for small aneurysms) with regular imaging to assess growth.
Surgery (for larger aneurysms) or those that are rapidly expanding or causing symptoms. Surgical options include open repair or endovascular repair (EVAR).
Aortic Dissection
Tear in the inner wall of the aorta. It allows blood to flow between the layers of the aortic wall, creating a false lumen.
Variable blood pressures between right and left sides (except in the arch). This occurs due to the dissection affecting blood flow to different arteries.
Differences in pulses in upper and lower extremities. This is due to the dissection compromising blood flow to various parts of the body.
Symptoms: Ripping, shearing back pain, often described as the worst pain ever experienced.
Requires emergency surgery to repair the aorta and prevent rupture.
High mortality rate if ruptured (death within minutes). Rapid diagnosis and intervention are critical.
Cardiac Tamponade
Fluid accumulation within the pericardial sac. It compresses the heart and impairs its ability to pump blood effectively.
Severity depends on the rate of accumulation. Rapid accumulation is more dangerous than slow accumulation, as the pericardium has less time to stretch.
Beck's Triad:
Hypotension (low blood pressure) due to reduced cardiac output.
Increased JVD (jugular vein distention) due to impaired venous return to the heart.
Muffled heart sounds due to fluid surrounding the heart.
Other Symptoms: Increased heart rate (tachycardia), cool moist skin, decreased level of consciousness.
Treatment:
Pericardiocentesis (if stable) to drain the fluid from the pericardial sac.
Open thoracotomy (if unstable) to create a pericardial window and relieve pressure on the heart.
Myocardial Contusion
Bruising of the heart muscle. It often occurs in the setting of chest trauma.
Causes:
Blunt trauma to the chest (e.g., baseball hit, falls, traffic collisions, CPR). High-impact trauma is the primary cause.
Potential to cause dysrhythmias (e.g., Ventricular fibrillation, atrial fibrillation). The injured heart muscle can become electrically unstable.
Management:
Monitor EKG and heart rate (4-6 hours for minor cases) and cardiac enzymes (troponin levels) to assess the extent of myocardial damage.
Hemodynamic Monitoring
Non-Invasive Monitoring
Blood Pressure: Assesses fluid levels and cardiac function. Trends in blood pressure can indicate changes in the patient's condition.
Jugular Venous Pressure: Measurement of pressure in the jugular vein. It is not commonly used due to its subjective nature and variability.
Invasive Monitoring
Lactic Acid
Byproduct of anaerobic metabolism. It is produced when the body's cells do not receive enough oxygen.
Elevated levels indicate tissue hypoxemia (inadequate oxygen delivery to tissues). This can be due to poor perfusion, shock, or other causes.
Normal range: . This range can vary slightly between laboratories.
Causes of elevated levels: Sepsis, strenuous exercise, liver disease, diabetes, malignancy, alcohol intoxication, and any condition that impairs oxygen delivery or utilization.
Central Venous Pressure (CVP)
Measured via a central line inserted into a large vein (e.g., subclavian, internal jugular).
Reflects volume status and right heart function. It is an estimate of the pressure in the right atrium.
Normal range: 2 - 6 \frac{mmHg}. Optimal CVP values may vary depending on the patient's condition.
Elevated CVP indicates: Fluid overload, cardiac tamponade, right ventricular failure, mitral stenosis, pulmonary edema, COPD, and positive pressure ventilation.
Decreased CVP indicates: Dehydration, hemorrhage, shock, third spacing, and vasodilation.
Arterial Line (ART Line)
Catheter inserted into an artery (usually in the wrist - radial artery) to directly monitor blood pressure and obtain frequent blood samples.
Requires an Allen's test to ensure adequate collateral circulation via the ulnar artery before insertion. This test assesses whether the ulnar artery can provide sufficient blood flow to the hand if the radial artery is compromised.
Important Measurements: Systolic blood pressure, diastolic blood pressure, Mean Arterial Pressure (MAP), which is the average arterial pressure during a single cardiac cycle.
Pulmonary Artery Catheter (PAC) also Swan-Ganz
Inserted into a vein (usually subclavian) and advanced through the right atrium, right ventricle, and pulmonary artery to assess right-sided heart function and pulmonary artery pressures.
Used to manage heart failure, shock, and fluid overload, providing detailed information about the patient's hemodynamic status.
Provides real-time monitoring of pressures in the right side of the heart. However, it doesn't provide information for the left side of the heart directly; left-sided pressures are inferred.
CVP (Central Venous Pressure): 2-6 \frac{mmHg}
MAP (Mean Arterial Pressure): 70-105 \frac{mmHg} (required for adequate organ perfusion)
Cardiac Output: 4-8 L/min (amount of blood pumped by the heart per minute)
CI (Cardiac Index): (cardiac output adjusted for body surface area)
SVR (Systemic Vascular Resistance):
Lactic Acid: