[traumagirll99]

I hope someone here can give me some info on this. I am working in a 22 bed ICU(mixed census of coronary/surgical/med- little of everything). This past week I was assigned to a pt who had suffered a SAH and was placed on a Lopressor Drip for b/p control. The drip had been started at 1300 and when I came on at 1900 her b/p was still elevated at 170s/100s. During the shift report the off going RN had told me that she had been titrating the drip and it was going at 0.7mcg/kg/min. After report I went in to assess the pt and found indeed that the drip was going at that rate but was loaded into the IV pump and labeled Levophed not Lopressor. The patient was in no distress. I must admit I was not familiar with using lopressor in a drip form usually we give it as a bolus push for b/p not cont infusion. when I reviewed the order the md had written it simply said Lopressor Drip to keep sbp less than 140. So i called the pharmacy and asked them if they had any reference info on giving lopressor this way so that i would be titrating it correctly and was told that the PHARM was unable to find any references for this use and had simply mixed the drip and sent it to the ICU.
Next I went to my own reference books and my charge nurse and we both had never heard of using Lopressor this way and could find no references in the books or on the computer.
well by this time my next b/p was still elevated and the pt's heartrate was now about 46 after having been in the high 50s all day (even before the drip was started). So i turned off the medication and paged the attending md. When he returned the call I explained to him that 1.the medication was having no effect on the b/p but had lowered her heartrate 2.i needed some clarification on how he wanted the drip given; mcg/kg/min mg/hr etc. After a pause he said "Wellhow do you all normallly give it?" I told him that we didn't and that pharm and the icu staff could find no guidelines or references for this use. Then came the question all ICU nurses love to hear "Well want to you want to Use?" I suggested nipride since labetolol had already failed. So that's what I ended up hanging andhad b/p control within the next 1hr.
So after my long vent my question is Has anyone been using Lopressor as an infusion not as a bolus? If so I would love to hear your facilities guidelines or any references you know of.

[lorilou22RN]

What!! I have never heard about Metoprolol given in gtt form. As with your facility, we give as a bolus only. I am really surprised that the pharmacy mixed up a gtt without any references relating to this, it seems a bit irresponsible on their part as well as the prior nurse who hang it without checking to see if this was becoming a nursing trend. Addl, if labetolol didn't work why would the Doc think Lopressor would? Nipride should have been started from the onset.

By the way, was the gtt lopressor, or levophed?

[Zookeeper3]

Never, and it's not on our approved list of drips so our pharmacy wouldn't have dispensed it. I love nipride for certain cases. The lopressor affects the HR so much, I would be so diligent I'd worry Jesus off the cross.

Good call, and 13 years in, have never done it... would have treated as you did. Pt. didn't need beta blockade, needed vasodilation! those goofy docs.

[Zookeeper3]

Originally Posted by lorilou22RN

What!! I have never heard about Metoprolol given in gtt form. As with your facility, we give as a bolus only. I am really surprised that the pharmacy mixed up a gtt without any references relating to this, it seems a bit irresponsible on their part as well as the prior nurse who hang it without checking to see if this was becoming a nursing trend. Addl, if labetolol didn't work why would the Doc think Lopressor would? Nipride should have been started from the onset.

By the way, was the gtt lopressor, or levophed?

I think the pump with collegent guardian was programmed as levo due to the mcg/min as lopressor would not be weight based(mcg/kg/min) .... not that I've seen a lopressor drip anyway!

[al7139]

I work on a tele unit. We see hypertensive pts all the time. NEVER once have I heard of or used a Lopressor drip. We give po to pts that are under control, but we still have parameters for those meds.
If we admit a pt with severe hypertension we may get prn IV lopressor to get the B/P and hr down, but we have even stricter parameters on that.
IV boluses are one thing: it acts in 1-2 minutes, and lasts 3-4 hours, giving the time for other drugs to take effect.
I shudder to think what would happen on a Lopressor drip to a pt.
If I got an order like that, I would have been calling the doc, and if that wasn't effective, I would go to my team leader, explained to order, and implemented my right to refuse to administer this tx. If someone else felt comfortable doing it, go for it, but I would document that I turned over the decision to a superior.
In my opinion, this was a potentially dangerous order, and if the MD you called then said what do you want to do...I would be worried. Yes, we know what our pts need, but If a MD asks me what to do, I say "youre the doc, you tell me".
You were right to question this, and dont' feel that you have to do anything you are uncomfortable with.
Amy

[lorilou22RN]

Originally Posted by Zookeeper3

I think the pump with collegent guardian was programmed as levo due to the mcg/min as lopressor would not be weight based(mcg/kg/min) .... not that I've seen a lopressor drip anyway!

I thought the post said that the gtt/med was labeled as Levo, not the pump. Thanks

[Flagellum Dei]

My wife almost got me a shirt for Christmas that read: "I'm a nurse - I keep the doctor from killing you".

I don't think I've ever seen metoprolol in a continuous infusion, and I don't really think it's the best choice for pressure control. As the OP discovered it is more rate specific than say, labetalol which I have used in a continuous infusion. A better choice might have been nicardipine which is very effective, easy to dose and much more stable in effect and toxicity than nitroprusside. (but pricey)

Regardless, someone needed to be the nurse here (and it sounds as though someone eventually was). Any time a nurse gets an order that is this out of the routine, questions need to be asked and chains of medical command followed until a reasonable conclusion is reached.
Kudos to TG for the pick up - this should be a good lesson for all of us. If an order comes for a modality that no one seems to know how to do (and the OP did a good job of exhausting resources here -pharmacy, other RN's) and no one has even ever heard of - then it's probably bad practice.

Best to all,

Pete Fitzpatrick
RN, CFRN, EMT-P
Writing from the Ninth Circle

[traumagirll99]

thanks everyone for the info and feedback. To answer the question only the pump was labeled levo the drip was Lopressor 10mg/50ccNS.
I worked last night and this pt was still in the ICU, I didn't have her but I saw the attending on his rounds and I asked him where he had gotten the idea to use Lopressor this way and he said that he couldnt recall. He really didnt seem to want to talk about it.

[Dinith88]

Originally Posted by traumagirll99

thanks everyone for the info and feedback. To answer the question only the pump was labeled levo the drip was Lopressor 10mg/50ccNS.
I worked last night and this pt was still in the ICU, I didn't have her but I saw the attending on his rounds and I asked him where he had gotten the idea to use Lopressor this way and he said that he couldnt recall. He really didnt seem to want to talk about it.

My first inclination was that the doc was thinking labetalol (beta blocker) and wrote lopressor (beta blocker)...then i saw you had already tried labetalol and it failed. All i could do after that was shake my head.

I'm unable to really comprehend the comedy of errors that you're describing. The doctor, the pharmacy...and the nurse who hung it.
These people might as well have taken the patient out back to shoot him (but probably been stopped in the hall by your good nursing judgement )

And i want that t-shirt that flagellum Dei mentioned. Badly.

[JohnW]

Is it common for you guys to use nipride for heads? Some of our neurosurgeons try to stay clear of it citing a risk of increased ICP.
.
The fact that the patient actually tolerated the lopressor gtt (per you, her HR dropped from the mid50 to mid40) I would actually think that this is a person who in not BB niaeve and probably needs some blockade. I would probably have grabbed some nitro, but with the idea that esmolol or labetlol would probably be needed once the lopressor wore off. I would probably (assuming you a NGT and there are no other issue) be looking to start some PO hypertensives asap, - then a drug like hydralzine can used for "breakthrough" hypertension.

Also, in terms of the metrop gtt, that's a huge drug error and I hope you filled an incident report. These are the types of errors that kill people. Please watch out for your patients and make sure this series of errors can't happen again.