Need Advice on Metoprolol

[Stormy8]

So here's what happened last night to my patient....

I work night shift so I came on at 1900 and received report on this patient. She was in for s/p fall d/t hypotension and afib with RVR. The nurse replied that they were giving amiodarone and metoprolol po. Pt's HR 120s and BP 130's systolic. Denies any chest pain.

I go into the room around 2000 and check her BP and now it's in the 80's systolic. (side note, RN said she gave Lasix earlier per MD) I informed the MD and she ordered to give a bolus. Bolus given and pressure came back up high 120's systolic. Around 2200 I administer her night meds which consist of Metoprolol 50 mg PO. With her current pressure back up and her A fib HR 120s I feel it's safe to give.

2220 I recheck her BP and she's down in the 80s. MD aware. MD orders another bolus. Pt does respond to the fluids but pressure at 2300 80's-70s. Now she converted to SR 90s. Then she started to brady into the high 50s. Pt alert. Positive pulses. MD orders ANOTHER bolus. Pt doesn't respond to...End up starting her on a dopamine gtt.

Come to find out, MD wrote an incident report on me saying that since I gave the metoprolol, that caused her to become hypotensive and brady. After the fact that she said that she agreed to give the metoprolol saying that it was indicated at the time.

What is your advice? Do you think that the metoprolol would have worked so quickly?? PO? I feel responsible in a way for what happened. I'm willing to learn from my mistakes. Just feel thrown under the bus abit.

On a sidenote....pt is doing fine. This AM, her BP 120s but she converted back to A fib c RVR.......

Any suggestions would be appreciated.

[turnforthenurse, MSN, NP]

Given the patient's hypotension episode, I would have called the MD regarding the patient's 2200 metoprolol dose and with the current vital signs and ask if they wanted it given. The MD might have decreased the dose to 25mg or even 12.5mg. I think the 50mg dose would be a bit much considering the patient's hypotensive episode, which is why I would have called. If they said to go ahead and give the 50mg, I would have documented to CMA (cover my a**). "MD called with update on pt BP and HR, asked if ok to give 50mg dose of Lopressor. MD said to go ahead and give dose" or something like that.

[brainkandy87]

You gave a bolus to increase BP from 80s than gave Lopressor 50mg.......Live and learn

This. If you were having to bolus her to get her pressure to an appropriate level, it's a "hold the Lopressor" kind of night, even if the MD felt it was OK to give. There are other options to fall back on if her HR ended up getting too high.

[RnfromUK]

PO metoprolol working in 20 minutes? Possible depending on a few things including if the patient had an empty stomach, if they were on anything else that might increase the absorbtion rate or effect of the drug. Why were they on lasix? No edema or CHF was noted in your post so I dont know why that was given. Perhapes it was the combination of Lasix and Metoprolol which caused the BP drop.

Regardless of this, it sounded like you did ask the DR about giving PO Metoprolol and, aslong as this was documented, you acted correctly.

[CoffeePVCs]

Want to bump this thread, see a lot of beta blockers without parameters and it makes me nervous. Anytime we are considering hold a drug, we have to call MD. I would have called given hx of hypotension. Very interesting to hear the refresher on the FS curve, hypotension & FVE.

[link51411]

document what the doc said and you will be fine. I dont really agree with her even having the Metoprolol remaining at that dose in the orders to begin with. she should have changed the order to Diltiazem or maybe lower the dose or even DC the Metoprolol. I can see why the MD put you under the bus because they made a mistake.