Which of the following treatment plans is appropriate for a 68-year-old patient with moderate to severe congestive heart failure following a major abdominal surgical procedure?

C. Afterload reduction with nitroprusside and inotropic support with dopamine.

D. Close perioperative monitoring and inotropic support with melrinone.

DISCUSSION: Treatment of congestive heart failure using epinephrine alone is contraindicated owing to the profound vasoconstrictive properties of epinephrine, which only exacerbate the heart failure. Diuresis with furosemide and inotropic support with dopamine is acceptable for patients with mild congestive heart failure; however, in the postoperative period pharmacologic diuresis can lead to profound hypovolemia requiring continuous invasive hemodynamic monitoring. The ideal choice for the postoperative management of patients with severe congestive heart failure is afterload reduction using nitroprusside and inotropic support with dopamine. This helps to stimulate the failing heart while decreasing the afterload pressure against which the heart must pump. Melrinone is a useful phosphodiesterase inhibitor, which has been shown to be useful in the treatment of mild to moderate congestive heart failure. Digitalis along with a diuretic in the postoperative period can be troublesome owing to the potential toxicity of digitalis while the patient has ongoing fluid and electrolyte shifts.