Perioperative Care of the Patient with Diastolic Heart Failure ... - AORN

June 2011 Vol 93 No 6 NAABTABLE 1. Symptoms of Diastolic Heart Failure 1Right-sided diastolic heart failure Ascites (ie, excess peritoneal fluid) Congestion of the gastrointestinal tract that results inweight loss Hepatomegaly (ie, enlargement of the liver) Impaired liver function Increased jugular venous pressure Peripheral edema Presence of a parasternal heave, which indicatescompensatory increase in contraction strengthLeft-sided diastolic heart failure Cyanosis, which suggests hypoxemia Dullness in lung fields to finger percussion Increased work of breathing Pleural effusion detectable by reduced breath sounds at thebases of the lungs Pulmonary edema Rales or crackles initially heard in lung bases but, whensevere, are heard throughout the lung fields Tachypnea (ie, increased respiratory rate)1. Pierce JD, Dalton K, Duke K, Spaniol JR. Heart failure guidelines and implications for surgically treating heart failure. AORN J. 2009;90(6):874-892.increase abnormally during exercise, with reducedexercise tolerance. When left ventricularfilling pressures increase further, the left atrialpressure and size increase and exercise tolerancedecreases with clinical signs of CHF. Thefundamental problem in DHF is the inability ofthe left ventricle to accommodate blood volumeduring diastole at normal filling pressures. 14Abnormalities associated with DHF includeslow and delayed relaxation and increasedchamber stiffness, which impairs filling anddecreases the ability of the heart to eject bloodproperly. 15 Resting left ventricular stiffness isthe resistance to stretch that occurs to counterhigh systolic pressures. 16 Three conditions mustbe present to confirm DHF: first, CHF symptoms must be detected; second, there must be preserved systolic functionnoted within the first 72 hours after CHFsymptoms are detected; and third, there must be diastolic dysfunction. 17EtiologyThe most common causes of systolic dysfunctionare ischemic heart disease, idiopathic dilatedcardiomyopathy, hypertension, and valvularheart disease, whereas the most commoncauses of diastolic dysfunction are ischemicheart disease, hypertrophic and restrictive cardiomyopathies,and hypertension. 6 Risk factorsfor DHF include aging, being female, hypertension,increased left ventricular mass, diabetes,obesity, and ischemic heart disease. 18SymptomsThe symptoms of DHF are very similar to thoseof SHF, and it is almost impossible to clinicallydifferentiate between the two without echocardiography.12 The difference in symptoms,which depends on the side of the heart involvedin DHF, are shown in Table 1. 19 It is importantto note that DHF is seen more often in elderlywomen with a long-standing history of hypertension.The first symptom is usually exerciseintolerance, with shortness of breath, both ofwhich are also seen in SHF.SURGICAL CONSIDERATIONSResults of previous studies have found thatheart failure confers a significant risk of morbidityand mortality after noncardiac surgery.7,20,21 Heart failure is present in almost20% of cases of common surgical proceduresperformed in elderly patients, and these patientshave a 63% greater risk of surgical mortalityand a 51% greater risk of a 30-day, all-causereadmission among patients with heart failurecompared with patients who do not have heartfailure or coronary artery disease. 7 For morethan three decades, the presence of signs and784 AORN Journal

SPECIAL NEEDS POPULATIONSwww.aornjournal.orgThe nurse works with the surgeon and anesthesiaprofessional to correct any reversible predisposingfactors before surgery. 18Intraoperative Nursing CareThe key to managing a patient with DHF duringand after surgery is to maintain preoperativeparameters as closely as possible. 18 Awareness onthe nurse’s part of a patient’s increased risks forlow cardiac output and pulmonary venous congestionwill help to ensure that all precautions aretaken. Depending on the severity of the heart failure,many patients are unable to lie flat to sleep,and a patient with heart failure, therefore, maynot be able to tolerate being in the supine positionon the OR bed. The nurse works with the anesthesiaprofessional to enable the patient to remainin the lawn chair position during induction if atall possible. 19The nurse also must be aware that the adverseeffects of inadvertent perioperative hypothermiaon wound healing are even more significantfor patients with heart failure who alreadyhave a compromised cardiovascular system. 19Initiating thermoregulatory measures for patientsundergoing heart failure interventions,therefore, is extremely important. Patientsshould undergo preoperative warming (eg,forced-air warming, warmed IV solutions), andthese interventions should be continued in theOR and during recovery. 19Postoperative Nursing CareThe postanesthesia care unit nurse closely monitorsthe patient’s vital signs, respiratory status,heart rhythm, and intake and output for signsand symptoms of fluid overload. Patients with ahistory of DHF are at an increased risk of atrialfibrillation as a result of ventricular stiffnessand higher end-diastolic pressures. 9 The nurseshould monitor the patient’s heart rate andrhythm before, during, and after surgery, andshould instruct the patient to alert the nurse ifhe or she experiences chest pain, discomfort,tightness, or any difficulty breathing. The nurseshould continue to monitor the patient’s vitalsigns according to hospital policy in addition tomonitoring respiratory status, pain level, andsigns of fluid volume overload.Assessing for nausea and pain is very importantin the postoperative period, and the nursemust understand which pain medications shouldbe avoided in patients with a history of heart failure.Results of recent studies have shown thatpatients with a history of heart failure shouldavoid nonsteroidal anti-inflammatory drugs(NSAIDs) for analgesia. 23,24 Certain medications,such as NSAIDs, inhibit prostaglandin synthesis,which causes a decrease in renal blood flow andcompensatory water and sodium retention. Prostaglandindepletion directly increases vascular resistance,thus worsening the patient’s hemodynamicstatus. 23 The nurse should also instruct the patientnot to use NSAIDs at home for pain managementunless this is approved by the physician.CONCLUSIONHeart failure places a major economic burden onsociety, and those who have it lead a decreasedquality of life. As the population continues to ageand older adults undergo more surgical procedures,perioperative nurses must have an understandingof the different types of heart failure andthe differences in treatment and management ofeach type. Patients with a history of DHF have anincrease risk of surgical complications and adversesurgical outcomes. Applying sound nursinginterventions throughout the perioperative periodwill help to decrease postoperative complicationsand improve patient outcomes.References1. About heart failure. American Heart Association. http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/About-Heart-Failure_UCM_002044_Article.jsp. Accessed February 24, 2011.2. Heart failure. MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/000158.htm. Accessed February24, 2011.3. Allman E, Berry D, Nasir L. Depression and coping inheart failure patients: a review of the literature. J CardiovascNurs. 2009;24(2):106-117.AORN Journal 787

June 2011 Vol 93 No 6 NAAB4. Grossman S, Brown D. Congestive heart failure and pulmonaryedema. Emedicine. http://emedicine.medscape.com/article/757999-overview. Accessed February 24,2011.5. De Keulenaer G, Brutsaert D. Systolic and diastolicheat failure: different phenotypes of the same disease?Eur J Heart Fail. 2007;9(2):136-143.6. Figueroa MS, Peters JI. Congestive heart failure: diagnosis,pathophysiology, therapy, and implications forrespiratory care. Respir Care. 2006;51(4):403-412.7. Hammill BG, Curtis LH, Bennett-Guerrero E, et al.Impact of heart failure on patients undergoing majornoncardiac surgery. Anesthesiology. 2008;108(4):559-567.8. Satpathy C, Mishra T, Satpathy R, Satpathy H, BaroneE. Diagnosis and management of diastolic dysfunctionand heart failure. Am Fam Physician. 2006;73(5):841-846.9. Gutierrez C, Blanchard DG. Diastolic heart failure:challenges of diagnosis and treatment. Am Fam Physician.2004;69(11):2609-2616.10. Chatterjee K, Massie B. Systolic and diastolic heartfailure: differences and similarities. J Card Fail. 2007;13(7):569-576.11. White MM, Howie-Esquivel J, Caldwell MA. Improvingheart failure symptom recognition: a diary analysis.J Cardiovasc Nurs. 2010;25(1):7-12.12. Wu EB, Yu CM. Management of diastolic heartfailure—a practical review of pathophysiology andtreatment trial data. Int J Clin Pract. 2005;59(10):1239-1246.13. Groban L, Kitzman DW. Diastolic function: a barometerfor cardiovascular risk? Anesthesiology. 2010;112(6):1303-1306.14. Feld Y, Dubi S, Reisner Y, Schwammenthal E, ElamiA. Future strategies for the treatment of diastolic heartfailure. Acute Card Care. 2006;8(1):13-20.15. Redderson LA, Keen C, Nasir L, Berry D. Diastolicheart failure: state of the science on best treatmentpractices. J Am Acad Nurse Pract. 2008;20(10):506-514.16. Hamlin SK, Villars PS, Kanusky JT, Shaw AD. Role ofdiastole in left ventricular function, II: diagnosis andtreatment. Am J Crit Care. 2004;13(6):453-468.17. Sürücü H, Tatli E, Değirmenci A, Okudan S, Boz H.Subtle systolic dysfunction may be associated with thetendency to develop diastolic heart failure in patientswith preserved left ventricular ejection fraction. Echocardiography.2009;26(4):365-370.18. Alsaddique AA, Royse AG, Royse CF, Fouda MA.Management of diastolic heart failure following cardiacsurgery. Eur J Cardiothoracic Surg. 2009;35(2):241-249.19. Pierce JD, Dalton K, Duke K, Spaniol JR. Heart failureguidelines and implications for surgically treating heartfailure. AORN J. 2009;90(6):874-892.20. Hernandez AF, Newby LK, O’Connor CM. Preoperativeevaluation for major noncardiac surgery: focusingon heart failure. Arch Intern Med. 2004;164(16):1729-1736.21. Hernandez AF, Whellan DJ, Stroud S, Sun JL,O’Conner CM, Jollis JG. Outcomes in heart failure patientsafter major noncardiac surgery. J Am Coll Cardiol.2004;44(7):1446-1453.22. Fleisher LA. Implications of preoperative heart failure:the next frontier in perioperative medicine? Anesthesiology.2008;108(4):551-552.23. Dal Corso E, Bondiary AL, Zanolla L, Vassanelli C.Nurse educational activity on non-prescription therapiesin patients with chronic heart failure. Eur J CardiovascNurs. 2007;6(4):314-320.24. Feenstra J, Heerdink ER, Grobbee DE, Stricker BH.Association of nonsteroidal anti-inflammatory drugswith first occurrence of heart failure and with relapsingheart failure: the Rotterdam Study. Arch Intern Med.2002;162(3):265-270.Kim Naab, MS, RN, PCCN, is a cardiac interventionstaff nurse at Piedmont Hospital,Atlanta, GA. Ms Naab has no declared affiliationthat could be perceived as posing apotential conflict of interest in the publicationof this article.788 AORN Journal

EXAMINATIONCONTINUING EDUCATION PROGRAMPerioperative Care of the PatientWith Diastolic Heart Failure1.4www.aorn.org/CEPURPOSE/GOALTo educate perioperative nurses about caring for patients with diastolic heart failure(DHF) who are undergoing surgery.OBJECTIVES1. Discuss the pathophysiology of DHF.2. Describe the etiology of DHF.3. Identify underlying disorders associated with the development of DHF.4. Describe perioperative management of the patient with DHF.5. Differentiate between symptoms of DHF and systolic heart failure.The Examination and Learner Evaluation are printed here for your convenience.To receive continuing education credit, you must complete the Examination andLearner Evaluation online at http://www.aorn.org/CE.QUESTIONS1. Almost ______ of people with heart failure areolder than 65 years of age.a. 50% b. 60%c. 70% d. 80%2. A condition that interferes with the heart’s abilityto relax is classified asa. diastolic heart dysfunction.b. systolic heart dysfunction.3. Diastolic dysfunction and DHF are interchangeableterms that refer to a preclinical state thatinvolves abnormalities in cardiac filling.a. true b. false4. Abnormalities associated with DHF include thefollowing:a. delayed relaxation and increased chamberstiffness.b. high systolic pressures and low diastolicpressures.c. low systolic pressures and high diastolicpressures.d. normal relaxation and decreased chamberstiffness.5. To confirm DHF, conditions that must be presentinclude1. congestive heart failure symptoms.2. diastolic dysfunction.3. systolic dysfunction.4. preserved systolic function.a. 1 and 2 b. 3 and 4c. 1, 2, and 4 d. 2, 3, and 4© AORN, Inc, 2011 June 2011 Vol 93 No 6 ● AORN Journal 789

June 2011 Vol 93 No 6 CE EXAMINATION6. Common causes of DHF include1. ischemic heart disease.2. hypertension.3. hypertrophic cardiomyopathy.4. pericarditis.5. restrictive cardiomyopathy.6. valvular heart disease.a. 1, 3, and 5 b. 2, 4, and 6c. 1, 2, 3, and 5 d. 1, 2, 3, 4, 5, and 67. The symptom of DHF that usually is noted first isa. ankle and leg edema.b. dizziness or lightheadedness.c. exercise intolerance with shortness of breath.d. whole body edema.8. _____________________________ should beaggressively treated before surgery to reduce therisk of perioperative heart failure.a. Atrial fibrillationb. Hypertensionc. Activity intoleranced. Chronic renal insufficiency9. Perioperative nurses must be prepared to helppromote positive surgical outcomes for a patientwho already has a compromised cardiovascularsystem by1. positioning the patient in the lawn chair positionduring induction if at all possible.2. initiating thermoregulatory measures beforesurgery.3. maintaining preoperative parameters as closelyas possible.4. maintaining thermoregulatory interventions inthe OR and during recovery.a. 1 and 2b. 1, 3, and 4c. 2, 3, and 4d. 1, 2, 3, and 410. Patients with a history of heart failure shouldavoid nonsteroidal anti-inflammatory drugs becausethey1. cause a decrease in renal blood flow.2. increase vascular resistance.3. inhibit prostaglandin synthesis.4. worsen the patient’s hemodynamic status.a. 1 and 3b. 2 and 4c. 1, 2, and 4d. 1, 2, 3, and 4The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewellhave no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.790 AORN Journal