by buddiage

Situation:

Rhythm a-fib, with rate 100-130's
Systolic lood pressure: 82 and 91 in different arms
NS going at 100/hr (for 2 days!)

Diltiazem drip 5mg/hr
Metropolol 50mg BID

I HELD metropolol d/t blood pressure, but I'm keeping an eyeball on the rate.

Up diltiazem to 10mg/hr about 5 hrs into shift after heart rate reaches occaional (not sustained) 140's.

Pt had screw put in femer, and was out of PACU for 2 hours when I got on shift.

Systolic bp 2 more times during shift is 90's, 1 time making it to 102.

MY QUESTION: WHICH MEDICATION WOULD YOU HAVE HELD AND WHY?

I asked my supervisor/ manager of the unit just how much diltiazem affects b/p and asked her what she would've done in my position. I've been a cardiac nurse for 1.5 years and have always held the metropolol if they are on a dilt drip, because I thought that dilt was THE way of controlling rate in afib. Anybody want to share their brain with a greenhorn?

Re: A-fib + metropolol + diltiazem gtt + soft bp

As a new grad, Id give both because the reason the patient has a crappy pressure is probably because the hr is exceeding the patient's ability to compensate. If hr is too high there is decreased filling time which = decreased amount of intravascular volume pushed out in each beat = decr CO = decr bp. Also, you lose 25% of cardiac output with afib so Id be thinking about amio if dilt wasnt working to help the bp in this manner. It's a hard line to cross though because all could make bp even worse.

Im sharing my idea because I will be starting in a couple months in the ICU and want to know if my decision making skills are on track. I definitely would clarify with my buddy or CN before going ahead but that is what my thought process is.

Good question OP. What do the icu gurus think?

Re: A-fib + metropolol + diltiazem gtt + soft bp

Totally see your point, but b/p actually IMPROVED as heart rate went slightly up. I'm glad you shared your view, because I also want to see just how many people would've done what. i'd love to take a vote on my unit, but that won't happen.

Re: A-fib + metropolol + diltiazem gtt + soft bp

When patients with atrial fibrillation are hemodynamically unstable (e.g., angina, hypotension) and not responding to resuscitative measures, emergency electrical cardioversion is indicated.

source: http://www.aafp.org/afp/20020715/249.html

and accor to ACLS protocol for hemodynamically unstable patients you do cardiovert or amio...but has the patient been anticoagulated?

Re: A-fib + metropolol + diltiazem gtt + soft bp

she has a history of afib. had gone in and out of it. the plan was to wait until her INR came down so that she could get the surgical proceedure. after proceedure she was restarted on coumadin.

i might add her b/p had been on the soft side since admission, despite cardiazem and fluids going at 100/hr.

i'll add- you cannot cardiovert someone unless you know they do not have a clot in there heart somewhere, which means they get a TEE to see...and, our pts are always on heparin. plus...this lady is in and out of it from what I got in report, but she's been in it for 3 days now :-)

btw, i did a preceptorship in the icu, and learned so much. you will too.

Re: A-fib + metropolol + diltiazem gtt + soft bp

Maggiofliore is correct if patient were shocky...and the patient's shock related to the AF...but the patient isn't/wasn't. So...she can take her hand off the trigger and sit the ACLS manual back down on her desk....

(but if the patient's AF WAS making her shocky/crash you wouldn't worry about echo/TEE either...so...she's kinda right in a different scenario... but...)

The problem you describe is kinda complicated and stinks of a trick question...with answers that can go either way and makes great fodder for eager cardio-critical-smarty-arguer-types.

I think some things to consider are: baseline cardiac function? Baseline BP's? On any other meds (ie ACE, ARB's, etc.)?, Was she taking lopressor prior to admission? Is she borderline hypotensive r/t post-op sedation? ,etc.

So, there're many variables here... and without knowing all of this, my best answer for you would be to bounce it off the cardiologist and come to a concensus (and cover yourself in the process)...

(another *alternative* answer in this case would be to load her with digoxin. It can slow her down and you wouldn't have to worry about her BP...)

Re: A-fib + metropolol + diltiazem gtt + soft bp

NO, no lisinopril, just metropolol. random things i remember: ef of 40%. I dont recall digoxin on her sheet.

My supervisor said she would've given the metropolol. I had heard (but was corrected by her today) that diltiazem affects bp, just not as profoundly as betablockers. For rate control, the Ca+ Channel blocker was, in my understanding, the way to go.

I was frustrated b/c I felt a little like I got my nose slapped by my supervisor, and I was mad at myself for making the mistake. I told two other nurses what I did, and nobody flinched, which made me wonder, is it me or is it our floor that could use some education on beta blocker vs calcium channel blocker.

I was hoping for anybody's point of view to give me a "I didn't look at it that way before" inspiration.

The better worded question is when is it appropriate to hold metropolol vs cardizem. I don't want to inspire an argument, just want people to share.

Re: A-fib + metropolol + diltiazem gtt + soft bp

did you collaborate with the physician in deciding to hold to betablocker?

Re: A-fib + metropolol + diltiazem gtt + soft bp

My question is what was the dose of Metoprolol? I ask this as my loved one who was in ICU last month, was on a cardizem drip 5-10mg /hr for his long standing A-fib

. They had also instituted his home dose of Metoprolol which had for years been at 100 mg four times daily. They ended up lowering the dose of Metoprolol to 25 mg twice daily, not holding it. That was on the advice of his cardiologist. Never did get him to cardiovert, but that did not surprise us. As I said he had it for years.

Can't say I have helped your question much though.

Re: A-fib + metropolol + diltiazem gtt + soft bp

OP, it's "metoprolol" not "metropolol" FYI.

I can't judge without being there and knowing more hemodynamics, underlying issues etc. I wouldn't hold either without discussing with physician if I wasn't sure.