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I recently had a patient who was started on Natracor gtt. His BNP was 4894!!! Bp in the high 80's and HR up to 200 for and steady in the 120-140. Cardiology was called and before the bolus of natracor was given and changed our standard parameters of hold for BP less than to to hold for BP less than 80. I didn't think Natracor worked for a BP of less than 90. After starting him on Natracor his BP actually went up and he started having v-tach and the increased HR. So, I kept a real close eye on him. He was made a DNR and cardi believed he was dying and would not make in a week. We gave him IV Dig for his HR only brought him down to the 110's. I noticed his urine output was decreasing and becoming concentrated. Any ideas as to what was going on with this patient? K- 5.5 BUN 48 CR 2.3 H&H normal. CXR-pulmonary edema and pneumonia. Was there any better way to treat him. I do realize that the increased HR was compensation for the low BP. I wondered if the po Digoxin would be better.
Thanks,
Jessica
PS- When I said his BP was higher, SBP was 96-92 for me
Where I work, natrecor was a fad. Every CHFer was on it a year ago, now nobody is on it.
It seems like the person needs more aggressive measures than a DNR status would allow, like maybe a vent and some serious diuresis for the CHF instead of natrecor first, and then maybe some more active conversion measures for the hr, maybe a Cardizem gtt. (I can't imagine a BNP that high w/out some serious lung compromise - and that might be causing the arrhythmias w/ all the stress of trying to keep up.)
If his BNP was over 4000 then his intrinsic 'natrecor' was already sky high to no avail. He sounds like he needs other interventions FIRST. The natrecor might help him get a handle on a tethered horse, but this horse is untethered and out of control. You need to get reins on the problem BEFORE you pull on the reins.
But that is dxing from afar.
Regardless, if the dr is giving up on aggressive tx, then he's right, the guy is prob gonna die. Obviously, there are compound cardiac issues that are working against each other.
Cardizem gtt would be nice if his bp wasn't so low. A fluid bolus with a BNP That high, BUN and CR, possible Dehydration? A Demadex gtt would pull the fluid off better, or even a Lasix gtt with possible dopamine? I'd have to look at his EF. He may of had a low EF and that is why they are not aggressive. Curious to see if he is still on our floor. The thing that really bothered me was the low urine output and concentrtion of the urine. More signs of dehydration. This patient was admitted to a med-surg floor before coming to TELE, but I think he would be more appropriately placed in CCU. DNR does not mean do not treat, unless the patient and family does not want him to be treated.
Cardizem gtt would be nice if his bp wasn't so low. A fluid bolus with a BNP That high, BUN and CR, possible Dehydration? A Demadex gtt would pull the fluid off better, or even a Lasix gtt with possible dopamine? I'd have to look at his EF. He may of had a low EF and that is why they are not aggressive. Curious to see if he is still on our floor. The thing that really bothered me was the low urine output and concentrtion of the urine. More signs of dehydration. This patient was admitted to a med-surg floor before coming to TELE, but I think he would be more appropriately placed in CCU. DNR does not mean do not treat, unless the patient and family does not want him to be treated.
Sounds like the BP could be a combination of out of control HR and use of natrecor. Holding the natrecor and starting a gtt like cardizem could IMPROVE the bp. But like I said, that's just my thoughts from afar.
Adding a little more to the mix, was the patient SEPTIC??? Maybe some of the problem was due to sepsis. A combination of meds may have been more effective. If the patient has a baseline Renal Insufficiency/Failure, the BNP will intrinsically be elevated. An Albumin/Pre-Albumin level would also be helpful in such a circumstance, as a Lasix/Albumin gtt can work wonders on patients who are overloaded if managed carefully. If the patient was in Cardiogenic SHOCK, Dobutamine would be a better choice than Dopamine, since Dopamine will increase Cardiac Workload. If the patient was septic, maybe a little Levo or Neo would also help. It also would have been helpful to know what the patient's Swan Readings were if they had a Swan, and maybe if you are at a really high tech institution a Mixed Venous Gas. That throws a lot into the mix, but those are all issues that would help you determine the best treatment plan for the patient.
No Swan's was done. He was in his 80's and a frequent flyer with CHF. No sepsis was involved because Blood cultures were neg, stool cult were neg, and sputum culture was wnl, along with ua nml. I understand the reason's for dopamine, dobutamine, Levapheed, not sure what neo is. We don't deal with these drips on our floor. I have had other patients who had similiar CHF problems. Ex: we had a 37 yoa male with cardiomegaly, frequently in for CHF with low bp. Usually they were put on a Bumex drip to diurese(spelling not right?) with a comb of lasix with BP parameters. THe only people I usually see on Natracor anymore, are not doing well at all or it is first time CHF. I've dealt with several Lasix drips and like them because of the diuretic effects, just watch K and supplement as necessary. I kinda feel I am at a disadvantage because I do work night and do not get to talk to many MD's and we do not have intensivists or residents at our hospitals. We do have house md's, but they get upset if you wake them up and ask questions. That is why I've put this case scenario here. I really want to understand. What both of you are saying is opposite of what I've been taught. Cardizem would make bp lower, but as Timothy said, not necessarily. I do like the Lasix/albumin gtt. Never seen one of these, but I do know albumin helps increase bp, they use it in dialysis all the time. Thanks and appreciate the input and learning experience. I'll look up the drugs mentioned. About the albumin/lasix- how does that work, are they mixed together and given in gtt form?
No Swan's was done. He was in his 80's and a frequent flyer with CHF. No sepsis was involved because Blood cultures were neg, stool cult were neg, and sputum culture was wnl, along with ua nml. I understand the reason's for dopamine, dobutamine, Levapheed, not sure what neo is. We don't deal with these drips on our floor. I have had other patients who had similiar CHF problems. Ex: we had a 37 yoa male with cardiomegaly, frequently in for CHF with low bp. Usually they were put on a Bumex drip to diurese(spelling not right?) with a comb of lasix with BP parameters. THe only people I usually see on Natracor anymore, are not doing well at all or it is first time CHF. I've dealt with several Lasix drips and like them because of the diuretic effects, just watch K and supplement as necessary. I kinda feel I am at a disadvantage because I do work night and do not get to talk to many MD's and we do not have intensivists or residents at our hospitals. We do have house md's, but they get upset if you wake them up and ask questions. That is why I've put this case scenario here. I really want to understand. What both of you are saying is opposite of what I've been taught. Cardizem would make bp lower, but as Timothy said, not necessarily. I do like the Lasix/albumin gtt. Never seen one of these, but I do know albumin helps increase bp, they use it in dialysis all the time. Thanks and appreciate the input and learning experience. I'll look up the drugs mentioned. About the albumin/lasix- how does that work, are they mixed together and given in gtt form?
You're right in that cardizem has a tendency to lower BP. But the high HR does so EVEN MORE. If it corrects the HR, then the cardizem should improve BP.
So, let's say this pt, w/ a HR of 90 has a decent SBP, 110, and that cardizem drops the number 10 pts, to 100, under normal conditions. If your pt's SBP is 80 because his HR is 160 and you correct the HR w/ a gtt of Cardizem, then your SBP should IMPROVE to 100 (what his BP would be with cardizem on board if his HR was normal). Does that make sense?
If the cause of the low BP is a rapid HR, then correcting that HR more than offsets the problem caused by giving cardizem. Result: higher BP. Same is true for dig, cordarone, etc.
Now, if you are giving maintenance doses of those drugs, all you might see is the lowering effect. But, if you use them in an active conversion, they should yield better BP, assuming the drug actually works and converts the pt and assuming that other reasons (sepsis, etc.) aren't contributing to the low BP.
Think Starling's law. Heart fibers are rubber bands, the more filling time between beats, the better the stretch, the better the return. Lower HR = more filling time, and more stretch = higher BP.
This is a complicated case. I think he needs to go to the unit. His potassium is elevated. This needs to be corrected. Also his Cre is high. Lasix should be carefully administered with the Cr elevated. The lasix could make it worse. He's sick and needs invasive monitoring or DNR.
This is a complicated case. I think he needs to go to the unit. His potassium is elevated. This needs to be corrected. Also his Cre is high. Lasix should be carefully administered with the Cr elevated. The lasix could make it worse. He's sick and needs invasive monitoring or DNR.
The OP did mention that he was made DNR and sent home on hospice.
Natracor and low bp
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