Nesiritide

INTRODUCTION

Indications

Acutely decompensated CHF in hospitalized patients who have dyspnea at rest or with minimal activity; has been used with digoxin, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. Should not be used for intermittent outpatient infusion, scheduled repetitive use, as a diuretic or to improve renal function.

Action

Binds to guanyl cyclase receptors in vascular smooth muscle and endothelial cells, producing increased intracellular guanosine 3′5′-cyclic monophosphate (cGMP) and smooth muscle cell relaxation. cGMP acts as a “second messenger” to dilate veins and arteries. Therapeutic Effects: Dose-dependent reduction in pulmonary capillary wedge pressure (PCWP) and systemic arterial pressure in patients with heart failure with resultant decrease in dyspnea.

Adverse Reactions/Side Effects

CNS: anxiety, confusion, dizziness, headache, insomnia, drowsiness. EENT: amblyopia. Resp: APNEA, cough, hemoptysis. CV: hypotension, arrhythmias, bradycardia. GI: abdominal pain, nausea, vomiting. GU: ↑ creatinine, renal failure. Derm: itching, rash, sweating. Hemat: anemia. Local: injection site reactions. MS: back pain, leg cramps. Neuro: paresthesia, tremor. Misc: fever.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess respiration, and notify physician or nursing staff immediately if patient exhibits any interruption in respiratory rate (apnea) or other severe respiratory symptoms (coughing up blood).

• Assess signs and symptoms of CHF (dyspnea, rales/crackles, peripheral edema, jugular venous distention, exercise intolerance) to help document whether drug therapy is effective in reducing these symptoms.

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report a slow heart rate (bradycardia) or symptoms of other arrhythmias, including palpitations, chest pain, shortness of breath, fainting, and fatigue/weakness.

• Assess blood pressure periodically and compare to normal values (See Appendix F). Report low blood pressure (hypotension), especially if patient experiences dizziness, fatigue, or other symptoms.

• Monitor signs of anemia, including unusual fatigue, shortness of breath with exertion, and bruising. Notify physician or nursing staff immediately if these signs occur.

• Monitor signs of renal failure, including decreased urine output, increased blood pressure, muscle cramps/twitching, edema/weight gain from fluid retention, yellowish brown skin, and confusion that progresses to seizures and coma. Report these signs to the physician or nursing staff immediately.

• Assess signs of parasthesia (numbness, tingling). Perform objective tests, including electroneuromyography and sensory testing to document any drug-related neuropathic changes.

• Assess any back pain or leg cramps to rule out musculoskeletal pathology; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

• Monitor ...