95 y.o. female with an ORIF of her hip yesterday (I know, I know ... but that's another thread...) who developed chest pain on the floor, with hypotension. Highest Troponin I so far = 124.8 and still rising. Major ECG changes. Echo shows an EF of 35% with ventricular wall motion abnormalities and dilated cardiomyopathy. Dopamine ordered at 2 mcg/kg/min to maintain SBP 90-120 (currently in low-100s). Also has a NTG patch on.
I asked the internist on the case (no cardiologist) if I could take of the patch and she said "No! It's taking the place of the nitro drip!"
This seems crazy to me. I'm on a temporary assignment (only 4 shifts left, thank God!) from my staff position in a CVICU. Granted, I've not been in critical care for that long (three years), but it seems to me that we should not be using NTG. Especially in light of her EF and cardiomyopathy, I would think that continuing venous dilation isn't the best choice. Also, why have the dopamine fight the NTG? Even when working with open-heart patients immediately post-op the use of a NTG drip to prevent vasospasm is contraindicated by hypotension.
As I said, I realize that I'm not an old pro yet. So I'm asking some old pros: Is NTG the best choice in this situation?
Sep 30, '01
With her dilated cardiomyopathy, she is prone to develop failure, so maybe they want to decrease her preload as a means of preventing fluid overload to the heart. As you know, a person can develop tolerance to NTG over time, that is why patches are used to prevent this phenomenon, on 12 hrs off 12 hrs. The patch is also a slower release, since she probably would not tolerate a NTG drip. Is she on other meds that can be decreased? Like betablocker, or too much lasix? A systolic BP of 100 is OK as long as she is asymptomatic of dec CO, like dec pulses, dec UO, etc.
The bottom line is she WAS too old, and very high risk for any kind of general anesthesia (even if it was spinal as I have seen them do in the old folks, they still get decent hits of versed, and other drugs, which as we all know are not tolerated as well in the elderly) with a history of dilated cardiomyopathy, and surprise she had a peri-op MI, and to be honest, it would surprise me if she makes it home, even if she had the best cardiac team in the world!
She has an AMI, can't use clot busters, too many contraindications. Probably won't tolerate NTG drip, may not tolerate Imdur (what I most often see as the next step). She probably doesn't have the beans to tolerate an ACEI, so what CAN you do for her?? Not much unfortunately. Maybe a Dobutamine drip would be better. Dobutamine has the dual action of increasing contractility and CO, while also decreasing periph vasc resistance which can decrease preload and afterload. To get pt's off Dobutamine, Digoxin is trialed, but some pt's fail and are sent home on intermittemt Dobut infusions. Is she on Digoxin at least? Don't tell me she's bradycardic! Next she'll buy a PPM, right?!
Promise me something, when they start talking about taking her for cath or OHS, you will throw yourself over the bed and not let them take her!!!
Interesting case, thanks for sharing it.
Last edit by hoolahan on Sep 30, '01
Oct 16, '01
Sorry, didn't mean to berate or insult. I think I used to be more eloquent and persuasive. Funny how group qualities rub off. Just FYI, I too have had several jobs. I too have seen variations in treatment.
The question was, is ntg appropriate.. perhaps I should have just said yes.
Quite honestly, I see good potential for survival in the woman described (with appropriate treatment) but I admit that the rehab course would be quite slow and laborous.
Thank you for pointing out my abrasive qualities. I have been feeling a little burned lately on my latest job adventure. It seems there is never any sense of peace. As a group my current co-workers are extrememly militant, opinionated, bossy, and insulting. Constant conflict seems to arise out of no where from the most simple to the most complex situations. It seems I have adapted to my environment better than I had thought.
Sometimes I agree with them, sometimes I wonder what tangent we are off on now.
Maybe it is time to get out the classifieds.
Last edit by psnurse on Oct 16, '01