A 58 y/o female with a history of CHF presents with acute dyspnea. She is hypertensive 190/120, and has rales up both lung fields. She is on 100% Non-rebreather, has a respiratory rate of 38, and her saturation is 94%. CXR confirms pulmonary edema. You initiate treatment with sublingual nitroglycerine (3 doses) and IV lasix. The patient responds very little, so you initiate a drip of nitroglycerin and Bipap.
1. How much nitroglycerine can you give?
Several studies suggest the doses of nitroglycerin commonly used to treat decompensated congestive heart failure are to low. A recent study at Detroit Receiving Hospital (Detroit, MI) in hypertensive severe decompensated heart failure revealed success at very high doses of Nitroglycerin. In this study, decompensated heart failure patients not improving after sublingual Nitroglycerin and IV lasix were give a bolus of 2 mg of nitroglycerin IV and then placed on a drip (rapid titration to max of 400 micrograms/min). Interestingly, in this study, the 2 mg bolus of nitroglycerin could be repeated every 3-5 minutes, to a maximum of 20 milligrams of nitroglycerin in 30 minutes. With this high dose, the authors found that need for intubation and ICU admission was less (than a comparison group not given high dose nigroglycerin). Although this is only one small study, this is not the first study to suggest our traditional doses of nitroglycerin may not maximize the benefit, and perhaps we may need to rethink our doses. Larger studies with better out come data are needed before we can definitively identify the ideal dose.
Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Treatmetn of severe decompensated heart failure with high-dose intravenous nitroglycerine: a feasibility and outcome analysis. Ann Emerg Med 2007. Aug;50(2):144-52.