Background:
Loop diuretics are the mainstay of therapy for the relief of pulmonary edema and systemic venous congestion related to congestive heart failure. This protocol is intended to relieve congestion in patients for whom the goal of care is to achieve symptom relief and avoid hospitalization. These patients have an established history of advanced congestive heart failure on optimal medical therapy without further options for advanced treatments such as transplantation. There are no published guidelines on diuresis in this population, therefore a team of cardiologists and home-based palliative care physicians created this protocol based on current best practice.
It should be understood that the intensity of monitoring will not match that of an inpatient or emergency room encounter. Patients, their families and caregivers should have the understanding that with less monitoring, there is an increased risk of metabolic abnormalities and associated arrhythmias, however, the focus is on relief of symptoms and palliation.
Instructions:
The main parameters to evaluating the efficacy of treatment are: daily symptom burden, daily weights and presence of peripheral edema. Urine output does not need to be monitored. Counsel the patient and family regarding the need to urinate more frequently, considering mobility and the degree of dyspnea. Consider a commode chair, a urination bottle, or a condom catheter if mobility is an issue.Nursing will page you with patient’ weight, BP and symptoms. You only need to respond if low BP AND symptoms of hypotension.
If patients cannot be weighed, edema or dyspnea can be monitored alone.
The protocol includes an initial option for oral dose escalation. This may serve as a temporizing measure if there is a delay in arranging for intravenous administration. It is also possible that an escalation in oral dosing may be sufficient to relieve congestion. This protocol employs simple twice daily administration of diuretics either orally or intravenously. If this is insufficient, additional thiazide diuretics may be added.
Regular blood work is not mandatory and in the physician’s discretion to perform.
If symptom relief is not being achieved, the strategy should be reassessed. Refer to protocol for ‘Symptoms not improved’ instructions.
Non-pharmacologic treatment:
Effective treatment of congestion due to HF is enhanced by fluid and sodium intake restriction. You can remind caregivers to reinforce appropriate restrictions.
Potassium supplementation: As noted, biochemical monitoring is not essential. Potassium supplementation is given empirically depending on effective diuresis.