Has anyone used Natrecor on their unit?

valaferdi · Apr 7, 2002

There was a patient on the Natrecor gtt where I work last week. However, I work in a CCU where the nurse to patient ratio is 1:2 or 1:3. This is a very new drug, but from what I researched this gtt needs to be monitored very closely. Our policy is to do q 1 hr vital signs with this type of gtt. Your nurse to patient ratio at your hospital will make this very difficult to give the type of care that this requires.

VickyRN, MSN, DNP, RN · Apr 8, 2002

...Though not very frequently. A lot of the doctors look upon it as "expensive nitroglycerin," so refuse to use it (COSTS $570 per bag). Have only seen it a few times since introduced.

According to the information sheet provided to us from the drug rep, Natrecor is indicated for the intraveous treatment of patients with acutely decompensated congestive heart failure who have dyspnea at rest or with minimal activity. It reduces PCWP and dyspnea. Natrecor should be avoided in patients with cardiogenic shock or in patients with a systolic BP

This is a quote from a pertinent article, More Than a Pump: The Endocrine Functions of the Heart:

http://www.aacn.org/AACN/jrnlajcc.nsf/bd5ca01ff707c8948825653f000cd2b6/1907c0e8c472feb888256a47005f5959?OpenDocument

"Cardiac Hormones

The heart is an endocrine organ. Two of the hormones it produces are atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). BNP was first discovered in animal brain tissue, a fact that accounts for its name, even though the peptide is generated by the heart. ANP is made in several body sites but is present in greatest abundance in the granules of myocytes in the atria of the heart. BNP is present in ventricular muscle tissue. ANP and BNP are made up of chains of 28 and 32 amino acids, respectively, that bind to receptor sites. Receptor sites for these hormones are present in all tissue types but are most prevalent in the heart, blood vessels, adrenal glands, kidneys, lungs, and central nervous system.1

Atrial Natriuretic Peptide

Renal-Adrenal Effects

When natriuretic hormones bind to receptors in the microvasculature of the kidney, urinary output is increased because sodium transport in the collecting ducts of the kidney is inhibited.2 ANP also blocks sodium reabsorption induced by angiotensin. Natriuretic peptides are considered counterbalances to neurohormones such as angiotensin, epinephrine, and endothelin.3 The renin-angiotensin-aldosterone cascade is blunted by the release of ANP, which diminishes the secretion of both renin and aldosterone.4

Cardiovascular Effects

In the cardiovascular system, ANP decreases heart rate and preload and promotes venodilatation and arterial relaxation. When activated in arteries and veins, ANP causes pronounced vasodilatation by promoting guanylyl cyclase activity. Guanylyl cyclase then triggers the production of cyclic guanosine monophosphate, which leads to smooth muscle relaxation.5 The dilatation that occurs shifts fluids from the heart into the vessels. ANP appears to decrease heart rate by augmenting the action of the vagus nerve.

Natriuretic peptides also apparently inhibit ventricular hypertrophy, decreasing the production of cardiac fibroblasts and smooth muscle cells in cases of cardiac wall stress. Natriuretic peptides have an antiproliferative effect on ventricular remodeling.3"

SOOO... The hormone BNP in Natrecor counteracts aldosterone and the body.... Effect is diruesis and natraesis (release of sodium from the body), resulting in lower BP. Due to this antagonist effect on aldosterone, natrecor may affect renal function in susceptible individuals. In pts with severe heart failure whose renal function may depend on the activity of the renin-angiotensisn-aldosterone system, treatment with Natrecor may be associated with azotemia. BNP also binds to cyclic GMP receptors in vascular smooth muscle cells, acting as a second messenger to dilate veins and arteries (hence, like nitroglycerin). In one test, Natrecor was more effective in lowering PCWP than nitroglycerin. Natrecor, as per the above article, also inhibits ventricular hypertrophy, helping to prevent ventricular remoldeling (similar to an ACE).

Natrecor may cause hypotension. Therefore, blood pressure should be monitored closely during infusion. Symptomatic hypotension occurs in 4% of patients and asymptomatic hypotension rate is 8%.

Natrecor may affect renal function in susceptibel patients--increased risk of elevated creatinine. Other listed side effects are ventricular tachycardia (3%), non-sustained v-tach (3%), headache (8%), abdominal pain (1%), and nausea (4%).

Recommended starting dose is a bolus of 2 mcg/kg over 60 seconds, followed by a continuous infusion of 0.01mcg/kg/minute.

Natrecor is INCOMPATIBLE with heparin, insulin, ethacrynate sodium, bumetanide, enalaprilat, hydralazine, and furosemide, and the preservative sodium metabisulfite. Natrecor binds to heparin and therefore could bind to the heparin lining of a heparin-coated catheter, decreasing the amount of Natrecor delivered to the patient for some period of time. Therefore, Natrecor must not be administered through a central heparin-coated catheter.

Hope this helps . In answer to your question on safety, we only administer this medication in our ICU unit (2:1 pt ratios) or cardiac stepdown (4:1). These patients require constant EKG monitoring and q15 minute BP's (at least to start...). So, any higher patient ratios than this (IMHO) is UNSAFE.

maryangel · Apr 8, 2002

Wow.........thanks so much for all the info. We are having one more meeting before the final decision is made about using the drug on our floor. Your input is greatly appreciated.

pattylynn15 · Apr 17, 2002

I work in a very busy CCU. We use Natrecor for our CHF/Heart Transplant Candidate patients. We have had good luck so far in that our patients have responded well to Natrecor. We have not seen big fluctuations in vital signs. We do vital signs Q 1 hour when patients are first put on the drip.

I am curious why your MDs would not want the patient in an ICU to follow swan ganz parameters in order to follow how well the patient is responding to the drug. We had one patient who did not show significant improvement in response to the drug, so we stopped it.

The patients who respond to the drug, seem to show a visible improvement over the first 24 hours. As of now, we start the drug in CCU. Stable drips that are not being titrated go to our sister unit, Cardiac Telemetry. We also have medical telemetry floors where we do not send our CHF patients.

OUr cardiac telemetry floor is trained in use of these medications, and also in caring for Heart Mate LVAD patients awaiting transplant.

wildfire11 · Apr 30, 2002

I work on a 34 bed telemetry unit. We have just started using natrecor. I have only used it on one patient and we had very good results. The staffing ratios we aim for are 1:4 days, 6 evenings and 6-8 nights. Currently, we have had a large exodus so staffing is poor on the nights. We don't have an official policy on how often vital signs are taken. We stay with the patient for the first half hour and then do vitals every couple hours. Perhaps, we will refine our policy as we use the drug more. We also do nitro drips, amiodarone, dopamine, dobutamine and pronestyl. Once we start an amiodarone drip, they must transfer to the CCU. Will keep you posted as we develop our policy.

oh-agnurse · Jul 21, 2002

We have been using natrecor for awhile and we are a tele/ post interventional unit. Our vitals are q4 and accurate I/O's, with daily weights (weight based) and to see the output, telemetry, and labs.

kfeem1 · Dec 25, 2004

I work in a 33 bed telemetry unit, "stable" tele. The only drips we use are Dobutamine, Heparin, Cardizem. The physicians have decided to use Natrecor to treat CHF instead of Dobutamine. Currently if a patient is on this drip, they have to be in the unit for frequent vital signs, closer monitoring, etc. Our cardiologists want us to give the drip on our floor. Our nurse/pt. ratio is 1:5 or 6 on days and 1:8 or 9 on nights. Has anyone used this drug on their unit? and if so, do you think the ratio we have would be acceptable? Thanks for any input.

I think the Cardiologist that want you nurses to initiate Natrecor on a Telemetry unit with a 1:6-9 ratio depending on shift, don't have a clue what nurses do. I work ICU/CCU, and recently we been using Natrecor a lot for decompensated CHF patients. Because, this medication can drop the BP fast, most of our Cardiologist order a bolus over a half hour rather than over 60 seconds as recommended by the drug company. In our unit, any drips that effect the BP we do hourly vital signs, however, even though it's not our policy, when I start Natrecor, I take VS q 15 minutes for an hour, then hourly.

Preparation: First withdraw 5ml D5W from 250 ml bag and mix it with the 1.5mg vial of Natrecor. Take the reconstituted 5ml and add to the 250ml bad and invert the bag several times to ensure a proper mix.

I find the fastest way to calculate your bolus and maintenance drip is as follows: 1. Bolus volume (ml) = patient weight (kg) divided by 3

Example: 109kg / 3 = 36.36 ml round off to 36 ml

2. Infusion flow rate (ml/hr) = 0.1 x patient weight (kg)

Example: 0.1 x 109kg = 10.9 ml/hr

I give the bolus, depending on how the doctor order the bolus IV push over 60 seconds or over 30 minutes. If he order it IV push, withdraw the bolus volume (as in the example above)from the bag, then push it into a lower port on the IV line over 60 seconds. If he order it over 30 minutes, what I do is first set my IV pump up for the maintenance flow rate (primary). Use example above 10.9 ml/hr VTBI = 214ml (250ml - 36ml bolus), then set the secondary rate using the example above at 72ml/hr and VTBI at 36ml. This will run in the 36ml in a half hour. Setting it up this way allow you to run in the bolus in the specified time then it automatically switch over to the maintenance dose, without you having to be there.

DutchgirlRN, ASN, RN · Dec 25, 2004

I work on a Med/Surg/Telemetry floor and our ratio is 6:1 . We have Natrecor gtts frequently. We are not allowed to initiate the gtt nor bolus the gtt, that has to be done in CCU. Once they've been on the gtt for 4 hours they can come to the floor. The vital signs are Q 4 hours. So far no problems. I appreciate all the information. I am going to pass it on to my nurse manager. Merry Christmas !!

VickyRN, MSN, DNP, RN · Dec 25, 2004

I work on a Med/Surg/Telemetry floor and our ratio is 6:1 . We have Natrecor gtts frequently. We are not allowed to initiate the gtt nor bolus the gtt, that has to be done in CCU. Once they've been on the gtt for 4 hours they can come to the floor. The vital signs are Q 4 hours. So far no problems. I appreciate all the information. I am going to pass it on to my nurse manager. Merry Christmas !!

I'm sorry, but this sounds so unsafe to me.

DutchgirlRN, ASN, RN · Dec 25, 2004

I'm sorry, but this sounds so unsafe to me.

Don't be sorry you are probably right. I do want more information so I can present it to my nurse manager. They've tried to throw peritoneal diaylsis on us to do also with a 6:1 ratio. The only time we get a break is when we have a epidural and then the ratio is 4:1 . The only reason for that is because several years ago (I wasn't there but was told) that a patient with an epidural died. I don't know the details but that is when the ratio changed. Thanks for your input.

CVL RN · Dec 27, 2004

We initiate Natrecor in the Cath Lab usually in conjunction with Bi-ventricular Pacer or ICD placement. This patient population has an ejection fraction less than 20% and a significant history of CHF. It is usually started in the cath lab where vitals are monitored closely. Only one of our physicians uses it with any frequency. I find that after the initial bolus and starting the infusion, vital signs level quickly and remain stable. Patients are often transferred to the telemetry floor on a stable dose. On rare occsions, patients come to us already on Natrecor gtts which have been started in ICU.

I think that having this gtt initiated on telemetry without frequent initial vital signs could be asking for trouble. It requires close monitoring which isn't really possible with the patient load described. Hope this helps.