Hairudi Sugijo, dr, Sp.

JP-FIHA
EDUCATION
1980-1987 Medical, Airlangga University, Surabaya (M.D.)
1995-2001 Residency (Cardiology), Airlangga University, Surabaya
2012-present Post-graduate Programme, Brawijaya University, Malang
MEDICAL SOCIETIES
2001-present Member, IHA
2009-present Member, HFA-ESC
2014-present Fellow, ASEAN College Of Cardiology
HOSPITAL APPOINTMENTS
2001-present Cardiologist, Sidoarjo General Hospital, Sidoarjo

1
 ACUTE PULMONARY EDEMA /
HYPOTENSION / SHOCK ALGORITHM

Hairudi Sugijo SpJP-FIHA

SMF Kardiologi RSUD Sidoarjo
26 October 2017
Differential Diagnosis
Shock
Hypotension / Shock
Hypotension / Shock
Norepinephrine (Noradrenaline)
Potent alpha-agonist

Vasoconstriction Inotropic + Vasodilatation

• Should be diluted in D5W or D5W/0.9% NaCl.

• Administration in saline solution alone is not
recommended.
Dopamine
 Dopamine

Dopamine hydrochloride can be diluted with Sodium

Chloride (0.9%) Intravenous Infusion Dextrose (5%), sodium
chloride (0.45%) solution or Sodium Lactate Intravenous
Infusion.
Hypotension / Shock
 Dobutamine

• can be diluted with 5% glucose solution, 0.9% sodium

chloride or 0.45% sodium chloride in 5% glucose solution.
• If administered continuously for more than 72 hours,
tolerance may occur, requiring an increase in the dose.
Hypotension / Shock
 Nitroglycerine

• Venodilator at low doses, reduces CVP / PCWP (< 40mcg/min)

• Arteriolar dilation at high doses (> 200 mcg/min).

• Decrease coronary vasoconstriction by relaxing coronary arteries

• Diluted in D5 or NS solution

• initial infusion rate 10 mcg/min. May increase by 10 mcg/min

every 5 minutes until response.
 Acute Pulmonary Edema manifestations

• Persistent cought with

pink, frothy sputum
• Dyspnea, orthopne, SOB
• Hypoxemia, restlessness,
confusion
• Skin is cool, clammy and
diaphoretic
• Tachycardia, tachypnea
• crackles
 Causes of Heart Failure
• Coronary artery disease
• Hypertension
• Valves disease
• Cardiomyopathy
• Myocarditis
• congenital heart disease
• Arrhythmias
• Other diseases : diabetes, pregnancy, HIV,
thyroid, amyloidosis)
Acute Pulmonary Edema
• Oxygen / intubation as
needed
• Nitroglycerine SL then 10-
20mcg/min iv if SBP ≥
100mmHg
• Furosemide 0.5-1 mg/kg
IV over 1-2 minutes
• Morphine iv 2-4mg
• Captopril
 Furosemide

• inhibit reabsorption of NaCl and KCl by

inhibiting the Na+-K+-2Cl- symport in
the luminal membrane of the thick
ascending limb (TAL) of loop of Henle.
Resulting in increased urine production
 Furosemide
• Furosemide 0.5-1 mg/kg IV over 1-2
minutes
• a continuous furosemide infusion is
generally to be preferred to repeated
bolus injections.
• The recommended maximum daily
dose of furosemide administration is
1,500 mg.
 Morphine
• Advantage :
• Venodilator → venous return ↓ → ventricular
preload ↓
• Arteriodilator → afterload ↓
• Sedative effect
• Side effect :
• Respiratory depression
• severe hypotension
• should not be used routinely in the treatment
of acute pulmonary oedema
• Dose : IV 1–4 mg, repeated doses (up to every
5 minutes if necessary). Maximal dose 10 mg
• Must be diluted in 5% dextrose
 2nd Line of Action
Management of acute pulmonary edema
 3rd Line of Action
Management of APE / Shock

• Diagnostic :
• Pulmonary artey catheter
• Echocardiography
• Angiography for MI / ischemia
• Therapeutic
• IABP
• Reperfusion
 Take Home Message
• Acute pulmonary edema and Cardiogenic
shock are medical emergencies commonly
found in ER
• Immediate recognition and treatment need
TERIMA KASIH

Grube E. et al, Am Journal Cardiol 2006; “in press”