Multiple Drips - Did I do the right thing?

[nursingdude78]

I had a patient with cardiomyopathy and 2nd degree type 2 HB that went in for an elective PPM placement, during the procedure, she got a hemothorax and was brought to our unit. I had her that night. She was vented, on a bicarb drip, dopamine, neo and levo drips. An epi drip had just been weaned off about 2 hours earlier and was on standby. Paced rythm with stable BP at the time. I had orders to wean dopamine last.

A couple hours later, she starts getting tachy, HR 110-120, A-fib. Her systolic BP drops to the 50-60's. I turned up the neo and levophed, but decreased the dopamine because I thought it might be contributing to the increased HR. The BP was still not rising, so I started the Epi drip thinking she could use an inotrope? I was worried that the Epi might make things worse since she was tachy already. The BP did come up and the doctor called back after all this and gave an order for an amio bolus and drip to be started. The heart rate came back down I got the epi turned off shortly after.

She was not dumping much out from her chest tube, I did not have a CVP, but I think her volume status was ok.

What do you guys think about this, was it the right call to turn back on the epi drip? Was I right in initially turning down the dopamine and increasing the levo and neo?

Thanks,

B

[highlandlass1592, BSN, RN]

She had initially been bradycardic and that was the reason to wean the dopamine last. She became acutely hypotensive I suppose because of the A-fib which started at a rate of 110-120 , but eventually got up to the 140's before I got the Amio started. She had a low EF to begin with and the rapid rate decreaded her preload. She was on bicarb because of no other reason than her respiratory acidosis from what I remember. Turning up the Neo and Levophed did not bring her pressure up much, so that is when I tried the Epi, which worked. Once the amio brought her HR down, the problem seemed to be fixed and the epi was turned off.

I think Dobutamine may have been the best option looking back, but I did not have an order for it and was waiting for the Doc to call back.

Last thought: if you had epicardial wires, you could have tried to ATP or atrial pace this pt out of the Afib. I wasn't sure if the elective pacer insertion was due to complications from heart surgery or not, sometimes we see that in our pt's. If you didn't have epicardial wires, was it a possibility to get an EP person to try to pace the pt? I know we have EP in house in an emergency they can come and interrogate/change settings. I don't know if this is something you have available or not, just an added thought at 4 am. :-)

[ghillbert, MSN, NP]

I agree that volume sounds like it might have been appropriate, but for that a doctor's order would have been necessary....and in the OP, the writer said he was waiting for the MD to return the call. We can only use the tools we're given.

I don't think anyone is being critical, we are just thinking aloud what we could have done in response to the OP's question and information.

[whip65]

Last thought: if you had epicardial wires, you could have tried to ATP or atrial pace this pt out of the Afib. I wasn't sure if the elective pacer insertion was due to complications from heart surgery or not, sometimes we see that in our pt's. If you didn't have epicardial wires, was it a possibility to get an EP person to try to pace the pt? I know we have EP in house in an emergency they can come and interrogate/change settings. I don't know if this is something you have available or not, just an added thought at 4 am. :-)

I love night shifts- and I love to be prowling allnurses on night shifts even more! Just a thought but does ACLS say with a symptomatic (SBP 50-60) narrow complex tachycardia call for a possible cardioversion? Apparently other interventions worked- but if this was a new onset of a-fib... although I realize hypovolemia might have been the original problelm. I don't know. What a great site that everyone can bounce ideas off of each other!

[aCRNAhopeful]

Thanks for sharing this case with us! This is a good one for me as a new ICU nurse to think over and I have a few questions as a result. First off it sounds like you did what you could with what you had available to you and it worked so congrats on that. Also, it sounds like you definately picked up on the nature of the hypotension right away by understanding this pt has cardiomyopathy and a terrible EF, therefore --> VERY ineffective filling pressures with that fast of a heart rate. With that in mind, how many of you seasoned ICU nurses out there would have just started a NS bolus to try to eek out just a bit more filling to get by until the doctor calls? This intervention of course depends on the patient not being overloaded already and a lot of other things but the OP thought the pt's volume status was pretty good so we can go with that. Another thought: I don't really understand the rationale behind the starting dobutamine, while I don't think it would hurt I don't see how it's going to fix the underlying problem and if the HR continued to climb into the 140s by the time the doc called back I really don't see how it would have worked. And regarding A-pacing: I thought it was impossible to effectively pace someone in afib. If the pathology behind rapid afib is multifocal ectopic impulses shooting away in a frenzy, then how would adding the impulse of a pacemaker do anything to stop that and somehow take over as the focus at a slower rate? I don't mean to sound like I'm being critical of anyone's advice but just would like to make sure I have a good understanding of everything going on here. Would love to hear some other people's thoughts.

[aCRNAhopeful]

OK one more thought... I forgot to mention cardioversion. Like the previous poster said wouldn't this be an indication for emergency cardioversion? A heart that bad could arrest at anytime with a BP like that. I guess I would want to try something less invasive but slap on the quick combo pads at the same time just in case. Has anyone out there every cardioverted anyone without a physician present per ACLS protocols? How about doing it without an order per ACLS protocols? I've asked other nurses that question before and have always got the response of "NO WAY would I ever cardiovert someone without an order". But what if you have an impending cardiac arrest in a patient like this?? Is an ACLS nurse qualified to cardiovert if it there is not time for pharmocologic interventions? Seems to me that was the whole point of ACLS but I guess I'm not sure how this actually plays out in the real world. I think I need to investigate that next time I go to work.

[fiveofpeep]

at least in my unit, we never cardiovert without an md despite the standing order because as I was told when I asked, the nurses are fearful that asystole might replace a previous life sustaining (if not crappy rhythm). they seem to be more happy with adenosine while waiting for the md to call back, but remember too that ACLS says to seek "expert opinion" when dealing with afib with RVR.

[armyicurn]

Was the PPM placed under fluoroscopy or in a way that involved dye/contrast? I've seen a couple of patients recently come back on bicarb gtts - it's supposed to somehow help metabolize the dye out and/or protect the kidneys. Since the kidneys produce the bicarb my guess is it's something to do with that but I don't know the exact mechanism. Anyway, they stay on the bicarb for 6 hours then it's shut off.

I second the above comment. I've seen this on my floor with pt undergoing procedures with dye/contrast.

[medflight]

All in all at the end of the day you have to be satisfied with your decisions. You keep your patient alive and ultimatly corrected the situation. You are the only one who has all the information needed to re-evaluate the sequence of events. We can all give an opinion but we are doing so on assumptions of bits and pieces of the patients condition. It's always nice to ask for others input and opinions but keep in mind just what they are and at the end of the day it's you and your decisions that matters to that patient

[CABGx4, ASN, BSN, MSN, CRNA]

she sounded hypovolemic. if the hemothorax could have caused her to lose enough volume, plus insensible loss which doesn't ever get enough attention, or if the chest tubes clotted and she could have tamponaded causing tachycardia. levo also causes tachycardia. why was she in metabolic acidosis? lots of variables, but i don't thing epi was the tx of choice. a liter or two, maybe hextend or spa would have helped out.

[RN1980]

follow your unit policy and protocols, i have seen many a fine nurse save a pts life by doing actions they were taught in acls/pals but were later critizied by administration. but at the end of the day you have to do what you feel is right and what you can live with.