titrating cardizem

ark-two · Mar 20, 2006

Our Tele floor we pull the Cardizem gtt anytime the HR sustains 60 or less and BP of 90 or less. Usually what happens is that the MD gets a call because the nurse had to pull the cardizem and the HR goes up and then we have to call again to reorder the gtt. Usually, when this happens, we get an order to decrease gtt by 1/2 if hr lower than 60. Isn't this somewhat of a titration? Anyway, the other week we got a patient who needed IVIG!!! They trust that we are staffed well enough to monitor that/ (IVIG in our hospital requires q 10 min vitals for the whole gtt!!) We are understaffed, usually 1 RN and 2 LPN's for 23 patients.

UM Review RN, ASN, RN · Mar 20, 2006

The floor I work on, a tele floor, we hang, titrate, and manage a cardieziem drip, all while looking after normally 9 patients total. We have our HUC's watch the monitor's. It's never left unattended. Normally we tell them when we start them on a drip, or give anything that could affect a heart rate (like pushing lopressor), and they let us know if something happens. If for whatever reason, we need to put them on a frequent BP's, we throw a dynamap on them, and try to check in on them when it should be going off. Cardiziem is actually one of our very frequent drugs, so I guess we tend not to think too much about it. (We also do dopamine, dobutamine, nitro, heparin, integrillin, amniodarone, and various other critical drips.)

I don't think that's safe. It's a danger to your patients as well as a risk to your license.

Many A-fibbers cannot be Dinamapped for an accurate BP, for one thing.

The other drips you mention as being titrated on your unit are also very dangerous to titrate with a patient load as high as you say yours is. I can't tell you how common it is for us to have very acute problems happening simultaneously with a patient load of less than yours. How do you manage to get in to see those titrated patients when another is going bad?

Monitoring on the tele and monitoring the BP without eyeballing the patient is not what the standard calls for, regardless of your hospital policy. You can't trust the tele monitor or the monitor tech to do that assessment. That's your responsibility as a nurse.

I mention this because if you are a new grad, you need to understand that it only takes one mistake, one patient, for you to lose your patient or your license.

~Anne~ · Mar 21, 2006

I don't think that's safe. It's a danger to your patients as well as a risk to your license.
Many A-fibbers cannot be Dinamapped for an accurate BP, for one thing.
The other drips you mention as being titrated on your unit are also very dangerous to titrate with a patient load as high as you say yours is. I can't tell you how common it is for us to have very acute problems happening simultaneously with a patient load of less than yours. How do you manage to get in to see those titrated patients when another is going bad?
Monitoring on the tele and monitoring the BP without eyeballing the patient is not what the standard calls for, regardless of your hospital policy. You can't trust the tele monitor or the monitor tech to do that assessment. That's your responsibility as a nurse.
I mention this because if you are a new grad, you need to understand that it only takes one mistake, one patient, for you to lose your patient or your license.

I absloutely agree with you on that you need to eyeball the pt and check manual BP's . ( i hate those vital check machines , many times they are inaccurate like you said ) . And especially as a new grad, you should be learning to check, and getting comfortable with doing the BP yourselves anyway , and not always relying on the machines! I have to say one thing though in defense of our moniter techs , obvioulsy they cannot assess the pt , but we do highly trust them where i work , and sorta scary to say, but they know arrythmias better than some of our nurses do. So yes we do rely on them quite a bit when we have pts on a cardizem gtt to notify us immediatley of any changes so that we can then go in to assess the pt. We also rely on each other as nurses if there is more than one thing going on with a pt at that time.

Nightrn16 · Mar 22, 2006

I've been a nurse for almost 2 years, and while I agree a manual BP would be ideal, but when you have 9 other patients (in which the ones that aren't sick are needy) it's hard. I do try to eyeball the patient. When there is an abnormal BP, I do check it manually. Normally from 7-11, we have a patient care person, and I try to let them know about the BP, and most are good about keeping an eye on it for me (even doing it manually) if they know I've been busy.

When I start cardiziem, I do like I do with blood, for the first 15 minutes, the patient has someone stareing at them. I don't leave their side. When titrating, I try to stay near the room, but that doesn't always happen. As for titrating, when the patient's HR is starting to be affected by the drip, the HUC's let us know and we adjust accordingly.

In a perfect world, I would keep my eyes on the patient, but it's not perfect, and I often have 8 other patients on their call lights wanting one thing or another. And while I agree it's not safe, there's nothing I can do. The program that determines how many nurses vs patients we have has the final say. When we do have the staff, the program won't let us keep everyone. It sucks, but we deal. (This is why I'm currently looking for another job, 9 patients is too stressful on me, but that's in another thread lol.)

kstockdaleRN · Mar 22, 2006

We use Cardizem frequently, including boluses and drips with and without parameters. I work on cardiac telemetry. The only instance in which they are transferred to ICU is if the drip needs to be monitored frequently for heartrate AND BP. If the person's BP is unstable on Cardizem, then we don't have time, and I transfer. Or if the doc gives complicated parameters involving HR and BP, then i have to stick to my guns, we just don't have the time. We always have someone watching the monitors, but we don't have the staff to do BP's every 10 minutes.

ottoma4 · Sep 11, 2007

My tele unit has a similar policy. We do hang cardizem, but it has to be ordered at a specific rate with specific parameters. If the doc wants it titrated, basically meaning the pt will be very closely monitored and the drip will be adjusted according, at least somewhat, to the nurses judgement, they must be transferred to ICU. On the floor we often dont have time, due to hight pt load, to monitor a titrated drip closely enough.

Can you please inform at to parameters. We titrate on our telemetry unit, but with no policy for our hosptial. Administration tells us to use "nursing judgment" not good enough for me. Cannot find any information for titrating. Thanks Ottoma

All_Smiles_RN · Sep 12, 2007

Can you please inform at to parameters. We titrate on our telemetry unit, but with no policy for our hosptial. Administration tells us to use "nursing judgment" not good enough for me. Cannot find any information for titrating. Thanks Ottoma

Typically a cardizem gtt is started at 5cc/hr. I monitor BP every 5 mins for the first 15, with me at the beside. Many pts tolerate cardizem just fine, other's their BP goes in the toilet quickly. I'll move up to every 15 min BP checks then for the rest of the first hour. After an hour, if their rate is still above 100, I'll go up to 10cc. Recheck BP in 15 mins, then every 1/2 hour. After another hour, I'll bump up to 15cc/hr if the HR is still above 100 (and when I'm saying above 100, I mean 120-130. A higher HR would require further intervention in my opinion). I'll check BP again in 15 minutes and then hourly if they've been handling the cardizem well until this point. Me personally, I call the doc if 15cc is not cutting it for further orders.

So my pt has been going at 15cc/hr now and the HR is down to 70. I'll drop it to 10cc/hr and see how his HR holds up (or should I say down). I believe most practitioners have the end goal of keeping the rate controlled with PO instead of IV, so I do titrate down to the lowest rate possible for adequate rate control while maintaining SBP greater than 90.

My little scenario here is assuming the pt is asymptomatic and holding their BP. My floor is a PCU with a 4:1 ratio. Like everyone says, you're nursing judgement comes into play. My goal was just to give you an example of how I manage cardizem. Others probably do it differently. I hope this helped.

ottoma4 · Sep 12, 2007

Thanks for your help.

Nightcrawler, BSN, RN · Sep 12, 2007

The floor I work on, a tele floor, we hang, titrate, and manage a cardieziem drip, all while looking after normally 9 patients total. We have our HUC's watch the monitor's. It's never left unattended. Normally we tell them when we start them on a drip, or give anything that could affect a heart rate (like pushing lopressor), and they let us know if something happens. If for whatever reason, we need to put them on a frequent BP's, we throw a dynamap on them, and try to check in on them when it should be going off. Cardiziem is actually one of our very frequent drugs, so I guess we tend not to think too much about it. (We also do dopamine, dobutamine, nitro, heparin, integrillin, amniodarone, and various other critical drips.)

We manage all of the drips that you describe, but our ratio is 4-5:1, and we do not titrate anything other than nitro and cardizem. Both have to have parameters set by the MD, and we won't go above 50mcg of nitro. Heparin dosages are managed by pharmacy at our facility, amio drips are managed by protocols, and after the bolus the integrillin will hang for a prescribed time and doesn't need titration. Dopamine and Dobutamine are a different matter. We will start the drips on the floor and monitor pts for their initial reaction over the first hour. We have strict limits on how high we will take the gtts, and we will not accept orders to titrate the gtt. We accept "renal" dosing only, and if the patient requires frequent orders from the doc to change the rate to keep vss, then they have to go to the unit. The docs hate this because they already see us as an enormous, cost effective ICU. Since we let them start the gtts, they want to make us manage them, and we just don't have the time to safely do that. I don't know how many times I have heard physicians say that they will transfer, since it is merely a staffing issue. YES its a staffing issue, because your patient is really a 1:1 and has been for the last 24 hours! Argh

ri66it · Sep 15, 2007

on our tele unit we are 5:1 pt ratio- we do take cardiazem gtts and titrate but not greater than 20gtt/hr- we take dopamine gtts but no titration,renal dose only.lasix gtt we also titrate- all other gtts go to icu;)

tanner1334 · Oct 25, 2007

I'm currently working on a cardiac gtt policy for our Telemetry/SDU. Do any of you have cardiac gtt policies or the criteria you use to determine what you take, when they go to the unit etc.?

ckc6977 · Nov 8, 2007

We start, titrate and d/c our Cardizem gtts as well. The MD's typically place computerized orders to tell us when to titrate. For example: titrate to HR 110, SBP >/= 100. We usually titrate the gtt by 5mg/hr (5ml/hr). Our maximum rate for Cardizem on our floor is 15mg/hr. If they need to be titrated higher than that, we have to send them to CCU. Typically, that does not happen. The MD's will try another medication instead. My personal fave: Digoxin. We have monitor techs that monitor the pt's HR/rhythm and advise us of any notable changes. We monitor VS typically q2H or if we ever need to increase the gtt.