Cardizem gtt; is this reasonable? - page 3

Hello all, Had a pt. on diltiazem gtt, 10mg/hr, HR 96, A fib. Pressure was trending down, SBP 94. MD order was to titrate gtt for HR 90-100, and we have unit specific protocol. Checked with... Read More

  1. Visit  Virgo_RN profile page
    0
    I followed up and had a chat with my CN about the situation. What I walked away with were a couple of things; 1) I should consider the source. 2) Even though the MD (a hospitalist, not a cardiologist) had written an order with vague parameters, I could not be faulted for following protocol.

    I had another dilt gtt recently, where the patient converted back to NSR and we stopped it due to bradycardia. I did call the cardiologist for some parameters for night shift this time, which the next nurse appreciated.

    Hey, I'm learning!
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  3. Visit  CloudHidden profile page
    0
    I'm am just about to graduate so I'm totally not trying to sound like I know everything (or anything for that matter!) but I am just confused here. I though you didn't want to convert an a-fib until it's been determined there's no clot in the atria that we're now going to send flying into the circulation. Obviously I don't know the specifics of your patient, but I know there are some sort of parameters, i.e. if we know for a fact they've been in a-fib less than 24 hours, or they've been on anticoagulants x amount of days and maybe there is some sort of imaging or something they do to rule out a clot (I have no idea on that last one just a guess). So anyway, I guess my point is I thought conversion was sometimes actually considered an adverse effect of the gtt, and that it is mainly for rate control and hemodynamic stability in rapid a-fib patients who are not yet ready to be converted. Maybe that's why the doc wanted to be conservative with the gtt and left such high HR parameters (even though I agree expecting you to keep it within 10 bpm is a little lofty), because he didn't want the patient converted, just hemodynamically stable until ready for conversion. That's just what I have been taught and observed in my CCU internship, we didn't want those people to convert that was a bad thing.
    And also yeah like somebody else said we would always call the doc for any rhythm change. Maybe that along with the whole clot thing was what the guy's problem was. Sorry not trying to criticize or say I agree with his attitude, but I really am curious as to why none of the experienced cardiac nurses questioned this?

    Also, and sorry I'm really not trying to sound like a smart-ass, but from what I know from my schooling and cardiac internship and working as a tech in intensive care for four years, if a doctor writes specific parameters those are the ones you follow. If they wanted you to follow unit protocol they wouldn't have written specific parameters. But either way I think the responsibility for all of this is on your charge nurse, she was the one actually titrating the pump. So yeah you didn't do anything wrong IMO but I'm thinking the charge nurse might have, depending on if this was a patient they actually wanted to convert.

    Somebody please tell me if I'm wrong so I can just sound stupid on here instead of when I'm on a unit!
  4. Visit  Angie O'Plasty, RN profile page
    0
    Quote from CloudHidden
    I'm am just about to graduate so I'm totally not trying to sound like I know everything (or anything for that matter!) but I am just confused here. I though you didn't want to convert an a-fib until it's been determined there's no clot in the atria that we're now going to send flying into the circulation. Obviously I don't know the specifics of your patient, but I know there are some sort of parameters, i.e. if we know for a fact they've been in a-fib less than 24 hours, or they've been on anticoagulants x amount of days and maybe there is some sort of imaging or something they do to rule out a clot (I have no idea on that last one just a guess). So anyway, I guess my point is I thought conversion was sometimes actually considered an adverse effect of the gtt, and that it is mainly for rate control and hemodynamic stability in rapid a-fib patients who are not yet ready to be converted. Maybe that's why the doc wanted to be conservative with the gtt and left such high HR parameters (even though I agree expecting you to keep it within 10 bpm is a little lofty), because he didn't want the patient converted, just hemodynamically stable until ready for conversion. That's just what I have been taught and observed in my CCU internship, we didn't want those people to convert that was a bad thing.
    And also yeah like somebody else said we would always call the doc for any rhythm change. Maybe that along with the whole clot thing was what the guy's problem was. Sorry not trying to criticize or say I agree with his attitude, but I really am curious as to why none of the experienced cardiac nurses questioned this?

    Also, and sorry I'm really not trying to sound like a smart-ass, but from what I know from my schooling and cardiac internship and working as a tech in intensive care for four years, if a doctor writes specific parameters those are the ones you follow. If they wanted you to follow unit protocol they wouldn't have written specific parameters. But either way I think the responsibility for all of this is on your charge nurse, she was the one actually titrating the pump. So yeah you didn't do anything wrong IMO but I'm thinking the charge nurse might have, depending on if this was a patient they actually wanted to convert.

    Somebody please tell me if I'm wrong so I can just sound stupid on here instead of when I'm on a unit!
    Diltiazem is a form of chemical cardioversion, so I'd have to assume that its use presumes that the doc wanted the patient to convert.

    If the patient converts on the cardizem gtt, then all's well, and the patient's probably already had a shot or two of Lovenox and begun Coumadin. There's really no way to tell if patients have been throwing microclots, they're just assumed to be doing so and are treated immediately with anticoagulants.
  5. Visit  Virgo_RN profile page
    0
    It's been a little while, but as I recall, the patient was on LMWH and warfarin.
  6. Visit  SWEnfermera profile page
    0
    Good job! It sounds like you did everything perfectly!

    With this patient, an investigation into what exactly made him go into Atrial Fib is warranted. Is it atrial stretch? (caused by CHF), is it an accessory pathway?

    The physician my want to treat the underlying cause and start the patient on a medication to prevent his A-fib from returning whether it be a B-Blocker, Calcium channel blocker or Amiodarone.
  7. Visit  jaybeck profile page
    0
    Everything you did was fine. Cardizem is kind of hard to keep someones rates between 10 beats/min. Safe practice. Good charge nurse decisions.
    Jay
  8. Visit  turnforthenurseRN profile page
    0
    You had parameters and did exactly what you were supposed to do. You followed the MD's orders and did nothing wrong. That nurse was just being an *** and on a power trip, it seems. I'm sorry he treated you that way.
    Last edit by dianah on Sep 16, '12 : Reason: Terms of Service, use all *s
  9. Visit  MomRN0913 profile page
    1
    Why wouldn't the doc want to see a patient convert to a NSR with a hr in the 70's with a stable BP? Isn't that the goal?
    turnforthenurseRN likes this.


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