[ark-two]

I got the Starling's law and now it makes more sense. It was a complicated case and it was hard to watch a patient you have taken care of several times before be made a DNR for a condition you have treated him for before. I've been watching several of our frequent flyers become worse within the past couple of months and some even die. I felt that he was not given an option of aggressive treatment, but then again, the aggressive treatment is probably only a short term treatment to a long term problem. I enjoy asking questions on this site, because the people a very knowledgeable and willing to teach. It is always sad to lose the patients you get to know so well. Our hospital is a community hospital.
Another one of my patients who was also complicated. I admitted her with CHF/ + triponins/pneumonia. She was started on heparin in er. She started bleeding on Heparin-HIT! Heparin d/c'd and 1 unit blood transfused and had a reaction. I believed it was pulmonary edema-I was not the nurse performing the transfusion. BP 210/110 and she desated to the 70's. She was placed on bipap and I had her the next night. The nurse on the shift before me called cardiology due to HR of 150 with breathing TX. Cardizem bolus of 20 mg with gtt of 10. When I was getting ready to start the bolus I called Cardiology because her HR was 65. I was uncomfortable. He told me to give it and watch her and gave parameters.-we don't tritrate. I made the suggestion that she probably has an adverse reaction to the albuterol and needed xopenex instead. The nurse who had her the next night said cardiology switched her from duonebs to xopenex and dc'd the gtt. Oh-with her, her urine output decreased also and she was given a fliud bolus on the earlier shift. I was wondering if the opposite wasn't happening with her. We decreased her HR to the low 60's and she was not perfusing. Her bp went down at first with the gtt, but by the end of my shift sbp was 165. She is getting her cath today- her EF via echo was 60% and she also had high bun and cr. On 80mg of po lasix bid.

[TennRN2004]

Originally Posted by ark-two

About the albumin/lasix- how does that work, are they mixed together and given in gtt form?

We don't use an albumin/lasix gtt. Our common dose is 250 of albumisol with 20mg of lasix it's called a "cocktail" where I work. We just draw up the lasix and put it in the albumisol bottle and run free flowing through tubing at the desired rate. It's great for a patient like this who is fluid overloaded, but may be intravascularly dry. The high heart rate could be your dopamine, or it could be that the patient is dry in the vascular space from third spacing out. Did he have a lot of edema?

Also, your UOP could be caused from several different factors. He could be in renal failure from being dehydrated, or more likely from hypoperfusion related to the hypotension. Also, at 80 years old, his baseline renal function was probably not that great and he could have just taken a small hit to his kidneys for whatever reason (medications, infection, dehydration, low bp) and caused big time problems. With such a low EF, I would guess his cardiac output was just not strong enough to perfuse his vital organs, including his kidneys.

Also, I would not think Cardiazem is a good choice in treating this patient. He already has compromised cardiac function with such a poor pump and low EF. You don't want to give a calcium channel blocker and decrease his contractility any further. Try to figure out why the heart rate is high and address the cause- the tachycardia is a symptom of a bigger problem.
You could have tried Primacor (it helps the heart regulate calcium and causes a stronger contractility or pump), it will cause hypotension also (because it reduces your afterload, but this decreases the workload on the heart) so you'll definitely need your pressors. Dobutrex would also have been a good drug, in addition if you were really going to go all out treating, a balloon pump could have helped this patient.

[utahliz]

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[cardiacnurse05]

I am surprised at the idea that many of the people that responded think the bnp in the 4000's is extremely high. We see patients all the time with bnp's that are in the 20,000+ range. I am also surprised to hear of natrecor being used in new chf. We only use it in end-stage chf and is more of a palliative treatment. In fact, medicare won't even pay for it anymore in our patients that come to our chf clinic. Many who are not doing as well now. In the case of this patient, I wonder if an amiodarone gtt would have been more beneficial to help reduce the rates. It wouldn't have effected the bp. Without knowing the patient's history. His renal insufficiency and pulmonary edema could have been secondary to the uncontrolled rates.