[RNBEAUTY2003]

NEw to ICU- had my first very sick patient yesterday ALONE. No preceptor. I did very well. On Drager ( which I'm still trying to make sense of), Multiple drips including Vec drip with TOF monitoring, swan ,etc. Anyway- with everything that was going on- patient dropped his CI - started Dobuta at very low dose 2.5mcg/kg/mg. Patient already had B/p issues ( 190's)so of course his B/P sky rocketed (230's) . Nothing was controlling it. Started Nipride gtt- read our unit book about it prior to hanging and started at 1mcg.kg ( this was double strength concentration). Went down hall for a second , came back- pt B/P 70/38! all this within 3 minutes. Stopped it, let pt recover- which he did immediately- and restarted at .50mcg/kg/min. Just amazed how quickely this drug works. A wonderful learning experience for me as well. Any comments anyone. Would love to hear your point of view or any tips.

[begalli]

Nipride (SNP) is a powerful drug and some people respond dramatically to it. When I start a gtt, I usually start at a low dose of about .20-.40 mcg/kg/min or just a few ml/min. (Are you sure your book said 1.0 or did it say 0.1? Just curious.)

We frequently use SNP with Epi to help improve a CI. SNP can be a very dangerous drug however at higher doses. If you ever notice that your patient is not oxygenating well and your SNP is running near 2mcg/kg/min, consider cyanide toxicity. Because cyanide is a product of the breakdown of SNP by the body, cyanide toxicity even at low doses and especially if your patient has any type of renal impairment can easily occur.

This has happened to me twice in the last couple of years! You can start seeing symptoms as quickly as 10 minutes after starting the drip. I also read somewhere that at doses of about 3mcg/kg/min, pulmonary shunting can occur again causing respiratory problems. My experience has also been that people on higher doses tend toward being restless or agitated if not sedated well even when I'm not running epi.

SNP's good cause it has a very short half-life (1-10 min) so when your patient does drop their pressure all you really need to do is titrate your gtt down or pause it momentarily and then restart it at a lower rate.

It takes a while to learn everything about the vent. It's a whole seperate beast! But it sounds like you had a great patient for one of your first solitary experiences. Good for you!

[imnmk_rn]

Good job with your first solo patient - I have to admit, we seldom give a patient with quite that many things going on to someone new off orientation on our unit.

A quick couple of comments on Nipride - we use it very frequently especially as we are a med/surg/neuro ICU and our neuro patients tend to run high when they're at risk for bleeds. Anyway, like Begalli noted, nipride is very potent but has a short half-life, so you can always start slow but also remember that you can just shut it off and start at lower doses. About the cyanide toxicity... do you not have your nipride mixed with sodium thiosulfate? I thought it was a requirement. This is actually the antidote for cyanide toxicity. Our nipride gtts are always mixed with sodium thiosulfate and we run patients on HIGH doses of nipride at times (I have seen 5 mcg/kg/min and up) for long periods of time, and we do not ever have incidences of cyanide toxicity.

[javajunkie]

I am personally afraid of Nipride. Maybe because the one time I titrated up 1/2 a mic or so, I left the room to grab something and when I got back my patient was diaphoretic and getting ready to lose her lunch because her pressure went from 140 to 60. Good afterload reducer though. Super good in this case.

[Bonnie Nurse]

I keep a little laminated ring with handy information on little credit card sized cards. All the major pressors on them with start drips rates, and weaning parameters most commonly used. I've used it a lot.

[RNperdiem]

Beware with using anything that might flush the line and deliver a little extra nipride to your patient. Just flushing the CVP can show a drop the pressure.