185Heart failure (HF) is a prevalent diagnosis among home care patients and is a costly condition associated with both high morbidity and mortality. As the U.S. population ages and as the risk of HF increases with age, it is predicted that the number of HF cases in the United States will increase from about 5 million in 2012 to over 8 million by 2030 (Heidenreich et al., 2013). The trajectory of HF consists of exacerbations followed by periods of stability and, as disease exacerbations increase, HF worsens and may require more aggressive treatment to manage and control HF symptoms. In terms of home infusion therapies, diuretic therapy, such as periodic infusions of a loop diuretic, and positive inotropic drugs may be administered for symptom management in advanced HF, to reduce hospitalizations and improve functional status (Katz, Waters, Hollis, & Chang, 2015). Defined as drugs that increase cardiac contractility, the most commonly home-administered inotropes are dobutamine and milrinone (Katz et al., 2015; Lyons & Carey, 2013).

Cardiac infusion therapies may be administered in home care and home hospice settings and clearly, a great deal of home infusion therapy for patients with HF is considered palliative (Ciuksza, Hebert, & Sokos, 2015; Katz et al., 2015). However, while the majority of cardiac infusion therapy is among the older, chronically ill adult population, infusions are also home administered to both adults and children as a bridge to a specific cardiac intervention, such as transplantation or placement of a left ventricular assist device (LVAD; Birnbaum et al., 2015; Hashim et al., 2015).

After reading this chapter, the reader will be able to:

UNDERSTANDING CARDIAC INFUSION DRUGS

As with all highly specialized infusion therapies, home care nurses who administer cardiac infusion drugs should be experienced in cardiac care and should complete specific agency education and competencies. Inotropic infusion administration in chronic HF management is controversial as it is associated with an increased risk of cardiac death due to arrhythmias. Current HF guidelines recommend the use of long-term inotropic therapy only in those patients with advanced HF refractory to other therapies (Heart Failure Society of America, 2010; Yancy et al., 2013). In a more recent report describing the outcomes of 197 patients discharged on inotropes over a 6-year period, the researchers concluded that survival for those patients who were not candidates for transplant or an LVAD fared better than earlier reports with a median survival of 9 months (n = 98 palliative patients; Hashim et al., 2015). For those patients who were awaiting a transplant or LVAD placement, inotropic infusions were evaluated to be effective with 55 of 60 patients successfully maintained on the inotropic infusion until the planned cardiac intervention.

The basic mechanism of inotropic drugs is to increase contractility of the heart in order to increase cardiac output. Dobutamine and milrinone do this through different mechanisms of action (Table 13.1). Positive inotropic drugs are administered as an intermittent or continuous infusion. When administering intermittent infusion regimens, practices vary regarding the frequency and duration of the infusion.

Diuretic therapy is a mainstay in HF management, and loop diuretics (e.g., furosemide and bumetanide) are preferred for most HF patients (Yancy et al., 2013). To manage fluid volume excess, oral diuretics are temporarily increased. Some patients may become less responsive to diuretic therapy, such as in the context of high dietary sodium intake or in impaired renal function. In such situations, intravenous (IV) diuretic therapy may be administered as needed or on a regular schedule, in conjunction with inotropic therapy (or alone) to maintain fluid volume stability. Subcutaneous administration of furosemide has been reported as successful in diuresis and reduction of hospitalizations in palliative care settings (Farless, Steil, Williams, & Bailey, 2012; Zacharias, Raw, Nunn, Parsons, & Johnson, 2011). The major risk with diuretic administration is electrolyte imbalance. Low potassium and magnesium levels are associated with increased risk of cardiac arrhythmias (Yancy et al., 2013).

187Table 13.1

Comparison of Dobutamine and Milrinone

Sources: Gahart, Nazareno, and Ortega (2016); Lyons and Carey (2013).

188Fast Facts in a Nutshell

PATIENT SELECTION CONSIDERATIONS

The complexity, cost, and risks associated with positive inotropic drug infusions demand careful evaluation as patients transition to the home setting. Criteria include:

■  The patient and family are motivated, willing, and capable of participating in self-infusion management.

       Cardiac drug infusions may be continuous or longer intermittent infusions (lasting hours) and are delivered via a central vascular access device (CVAD) using an electronic infusion device. Because the home care nurse does not normally stay in the home for the duration of the infusion, there must be a level of patient or caregiver participation in infusion administration, CVAD-related care, and monitoring.

       189A patient in advanced HF should not be left alone during the infusion.

       The caregiver is available to troubleshoot problems in the event of adverse drug reactions, infusion pump problems, or deterioration in condition.

■  The patient is clinically stable on the intended home infusion regimen prior to hospital discharge and subsequent home care admission.

       Any arrhythmias resulting from the infusion are identified and managed.

       Electrolytes and renal function tests are stable.

       The patient demonstrates a satisfactory hemodynamic response to the intended therapy (documentation of response required for some insurance payers).

■  An appropriate vascular access device (VAD) is selected.

       A CVAD is required for inotropic infusions; dobutamine is classified as a vesicant drug (Gorski et al., 2017).

       A peripheral catheter is usually appropriate for patients requiring intermittent diuretic administration. Subcutaneous administration has also been reported.

■  Resuscitation status and self-determination are established in the event of an emergency.

       Potential risks of inotropic infusion therapy should be addressed including the risk of arrhythmias and other adverse outcomes such as central line complications including bloodstream infection (BSI).

       For patients with advanced HF, families should be counseled that inotropic infusion therapy is palliative, not curative.

■  The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.

       Inotropic drugs and related supplies are generally delivered to the patient home on a weekly basis. Some drugs may require storage in the refrigerator.

■  Reimbursement is verified. Private third-party payers vary in coverage.

       Inotropic infusion therapy may be covered under the durable medical equipment benefit for external infusion pumps under Part B of the Medicare program. Some third-party payers, including Medicare, require very specific documentation as follows:

           Improvement in hemodynamic parameters such as increase in cardiac index, decrease in pulmonary wedge 190pressure, and improvement in level of dyspnea with the inotropic infusion (See Table 13.2 for a description of terminology related to hemodynamics.)

           Attempts at discontinuing the inotropic infusion in the hospital

           History of repeated hospitalizations for HF exacerbations requiring inotropic support

(Katz et al., 2015; Lyons & Carey, 2013)

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