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  1. 0 looking for opinions - let's say you have a pt. on beta blockers. they come in for surgery and their HR is in the 60's-70's (which is their baseline) and their pressure is in the 70's/40's range. you've given fluid, blah, blah blah. my question is, which would be more appropriate for a pt on beta blockers to get, ephedrine or neosynephrine - to increase their bp? neo is of course a direct alpha agonist, so you have that going for you. ephedrine has some alpha action as well as beta action which would compete with the beta blockers for sites and reduce their effect, yada, yada, yada. any opinions?
  2. 31 Comments so far...

  3. Visit  sirI profile page
    0
    Quote from confusionabounds
    looking for opinions - let's say you have a pt. on beta blockers. they come in for surgery and their HR is in the 60's-70's (which is their baseline) and their pressure is in the 70's/40's range. you've given fluid, blah, blah blah. my question is, which would be more appropriate for a pt on beta blockers to get, ephedrine or neosynephrine - to increase their bp? neo is of course a direct alpha agonist, so you have that going for you. ephedrine has some alpha action as well as beta action which would compete with the beta blockers for sites and reduce their effect, yada, yada, yada. any opinions?
    I probably would go with the ephedrine simply for the reasons you outlined.

    My questions/concerns are: (1) how much fluid was given? (2) how old is this patient? {might need more fluid} (3) are there any comorbid issues? (4) has he been taking the beta blockers as prescribed? {taken more?} (5) on any other drugs?

    Based on the information you have supplied, it appears patient is low on fluids, vasodialated, or has a compromised cardiac output.
  4. Visit  Laughing Gas profile page
    0
    Neo.
  5. Visit  confusionabounds profile page
    0
    why neo? as for fluid status, etc. -- ignore it. it does not factor into my question. this is low bp caused by beta blockade and nothing else. based on the beta blockade being the cause - my question is neo or ephedrine?
  6. Visit  sirI profile page
    0
    Quote from confusionabounds
    why neo? as for fluid status, etc. -- ignore it. it does not factor into my question. this is low bp caused by beta blockade and nothing else. based on the beta blockade being the cause - my question is neo or ephedrine?
    Hello again,

    Since I have no idea to whom you were responding (no quote), I will have to assume you were speaking to both of us.

    I still think ephedrine is the drug of choice.
  7. Visit  TraumaNurse profile page
    0
    Neosynephrine would be my choice. No need to increase the pts heart rate above 60-70 with beta effects of ephedrine. Neo would bring up the BP nicely without any unwanted issues with rebound tachycardia.
  8. Visit  Laughing Gas profile page
    0
    Quote from TraumaNurse
    Neosynephrine would be my choice. No need to increase the pts heart rate above 60-70 with beta effects of ephedrine. Neo would bring up the BP nicely without any unwanted issues with rebound tachycardia.
    Agreed. If the patient is blocked, why flog the heart?
  9. Visit  jdpete profile page
    0
    Neo is what I would use as well, one thing, it just seems that giving just ephedrine never brings the pressure up good by itself when they are beta blocked----I also sometimes give 50-100 mcg of Neo and at the same time give 5-10 mg of Ephedrine

    plus, they are beta blocked for a reason and that reason is to protect the heart-----so I would be cautious with getting the heart rate up too fast anyway---that is why I sometimes like a little of both because your heart rate usually remains about the same (without a big increase or big drop) and with the Neo, the BP is increased dramatically, which is what you want if it is 70/40
    Last edit by jdpete on Sep 23, '05
  10. Visit  sproutsfriend profile page
    0
    Neo could be a good choice but also look at the diastolic BP before giving an alpha 1 agonists such as neo because a beta blocked heart can go into failure if the SVR gets too high.
  11. Visit  mwbeah profile page
    0
    Quote from confusionabounds
    looking for opinions - let's say you have a pt. on beta blockers. they come in for surgery and their HR is in the 60's-70's (which is their baseline) and their pressure is in the 70's/40's range. you've given fluid, blah, blah blah. my question is, which would be more appropriate for a pt on beta blockers to get, ephedrine or neosynephrine - to increase their bp? neo is of course a direct alpha agonist, so you have that going for you. ephedrine has some alpha action as well as beta action which would compete with the beta blockers for sites and reduce their effect, yada, yada, yada. any opinions?
    Ephedrine will act as a competitive antagonist with respect to beta-blockers and will treat the hypotension but may negate the beta blocker effects. Phenylephrine can be used if the patient has adequate ventricular function, otherwise increasing the afterload precipitously could cause you some problems. In this scenario, what was the patient's calcium labs? Working in a calcium (in small boluses) will help you by mobilizing into the smooth musculature of the vessels and promoting actin activity. If your in the OR already, I find that 500 cc of a colloid also helps. Sounds like the patient's HR is high (for that patient) and SVR is low. What was the urine output? CVP? A-line waveform? What kind of surgery was it, did it involve pressure on the vessels? What was your ET agent concentration, did it need to come down? How much narc on board? Is it immediately after induction? Did the surgeon ask you to give anything?

    Just some thoughts and questions you might be asked in the OR.

    Mike
  12. Visit  athomas91 profile page
    0
    i am in agreeance w/ Neo - the pt is beta blocked for a reason (possibly BP but could be for stenotic lesions etc...) where increasing the HR could be detrimental.
    good points mwbeah.
  13. Visit  gotosleep profile page
    0
    Phenylephrine infusion. you can avoid the precipitous bradycardia and increase in SVR with careful titration.

    I always get a giggle out of watching people give ephedrine to a beta blocked patient. It seems counter-productive in my opinion considering the purpose of beta blockers is to decrease myocardial oxygen consumption as much as possible.
  14. Visit  gotosleep profile page
    0
    Quote from mwbeah
    Ephedrine will act as a competitive antagonist with respect to beta-blockers and will treat the hypotension but may negate the beta blocker effects. Phenylephrine can be used if the patient has adequate ventricular function, otherwise increasing the afterload precipitously could cause you some problems. In this scenario, what was the patient's calcium labs? Working in a calcium (in small boluses) will help you by mobilizing into the smooth musculature of the vessels and promoting actin activity. If your in the OR already, I find that 500 cc of a colloid also helps. Sounds like the patient's HR is high (for that patient) and SVR is low. What was the urine output? CVP? A-line waveform? What kind of surgery was it, did it involve pressure on the vessels? What was your ET agent concentration, did it need to come down? How much narc on board? Is it immediately after induction? Did the surgeon ask you to give anything?

    Just some thoughts and questions you might be asked in the OR.

    Mike

    colloids are expensive and usually unnecessary.

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