What would you have done??

Tait, MSN, RN · Jun 27, 2011

I wish I could offer some advice, but I have no ICU experience or experience titrating drips.

Sounds like it was a delicate balancing game and you chose an approach the doc didn't like. Not sure there was a winning combination in this one without consulting the doc in question about exactly what he wanted done.

Double-Helix, BSN, RN · Jun 27, 2011

It's our policy to call the MD whenever the pt has abnormal vital signs that require holding a medication. So I would have called the MD and gotten his opinion at 5 or 6 am when the labetalol was due and go from there.

In general, I hold BP meds according to the parameters of the med. Generally BP are systolic

NPinWCH · Jun 27, 2011

I don't do inpatient med, but I'm with you. I would have held the labetolol and the clonidine especially and increased the drip and then waited the hour or so for the doc. OR I would have called him, explained the situation and asked him what he wanted to do.

With the BP that low already I don't see he would want the clonidine given. I use it in the office to get BP down fast and it's very good at that, though it's an in-and-out drug; lowers the BP quickly, but doesn't last very long.

I don't think you made a wrong choice, maybe not what the doc wanted, but it was safe...next time call him and let him make the call.

nerdtonurse?, BSN, RN · Jun 27, 2011

I'd have pulled up the vitals from the prior night (if they were there) to see if this person consistently drops down when they are in deep sleep. However, I'd be worried I had a person having reflex bradycardia due to the nipride (was it just started, had it been running for a while?). I know we've given indomethecin to counter act the bradycardia if we need the decreased preload/afterload benefits. Labetalol up to around 300mg won't really affect a HR in my experience, but you get up around 600 and it can. So, I probably would have called unless this was the patient's proven pattern and they didn't have a history of negative HR impact from the labetalol. If they'd been getting boat loads of beta blockers over a long period of time and were fine, you could have popped reflex tachycardia. Hard call without looking at the patient and getting a good feel for how reactive they were and how bad the heart function was.

And some docs whine no matter what you do (call / don't call). When in doubt, I always tell folks, "Yup, I'm calling, he's going out on the end of the limb with me."

Biffbradford · Jun 27, 2011

Damned if you do, damned if you don't. What time did the doc round? 0700ish? Could have buzzed him at 0600 while he was brushing his teeth. I swear, I've spoken to more docs while they were in the bathroom ... Chalk it up to experience and next time you'll be that much wiser. :cheers:

Sun0408, ASN, RN · Jun 27, 2011

I so agree with all of you.. I spoke with the on call that was there at 6 and he said "wait til he gets here" (typical) because the MD in question rounds early; usually between 5:30 and 6:15..

This pt was new to us, just arrived around 2300, came up to us on the gtt.. BP was high but HR was WNL. Once he was settled, I gave the labetalol and clonidine at 2330.. No problems with HR and BP was well controlled.. At 5am, the pt was awake and watching TV when his HR began to drop. He had been on the gtt for about 8 hours at this point ranging from 0.5 to 1.5mcg.. Nipride had BP ranges but nothing re: HR...

So yeah, damned it ya do, damned if ya don't...

Thanks for the posts.. I am one to call but I would not have gotten the MD in question LOL... So waiting was my only option to be "safe".. Live and learn, I think he and I need to have a heart to heart..

nurseprnRN, BSN, RN · Jun 27, 2011

"nipride had bp ranges but nothing re: hr..."

that's because nitroprusside doesn't directly affect heart rate. it's a vasodilator. if you look at the situation and think what the actions and indications for beta blockers (like labetolol) are, this situation makes a lot of sense.

labetolol, beta blocker, decreases heart rate and contractility, thus decreasing blood pressure, but also (and this is important) cardiac workload, because if the myocardium is prevented from working hard and fast, it uses less oxygen. good idea in a heart with compromised coronary arteries. is this what he had?

nitroprusside is a vasodilator, both venous and arterial. when bp is decreased in the arteries by this vasodilation this means the heart pumps against less resistance on the other side of that aortic valve... and this would be good because... (yup) a heart with lousy oxygen supply needs to work less hard. dilating the veins decreases venous return to the heart, and you may remember that the more blood that returns to the heart, the more the muscle stretches, and the more it contracts to send that blood out. hmmm, yet another way to make the heart muscle work harder...still a bad idea. also, remember that the coronary arteries are perfused in diastole, and if diastolic pressure is too low, the coronaries fill less well. another bad idea, eh, giving the heart less oxygen when it's working harder?

so. your patient was getting a pair of meds to make the heart work less hard. when his hr went down, holding the labetolol was probably a good idea unless his bp was still in target range, in which case you note it, keep watching carefully, and let the doc know that vs are (stable, dropping or....) and leave the nitroprusside where it is. if you hold the labetolol and increase the nitroprusside, you are making the heart work harder in two different ways, and letting it get paid less for its effort in the bargain. the hr didn't go up because the nitride was increased, it went up because the bp was down and there was no beta blocker "brake" on. that is why the doc was annoyed at you.

Sun0408, ASN, RN · Jun 27, 2011

"nipride had bp ranges but nothing re: hr..."
that's because nitroprusside doesn't directly affect heart rate. it's a vasodilator. if you look at the situation and think what the actions and indications for beta blockers (like labetolol) are, this situation makes a lot of sense.
labetolol, beta blocker, decreases heart rate and contractility, thus decreasing blood pressure, but also (and this is important) cardiac workload, because if the myocardium is prevented from working hard and fast, it uses less oxygen. good idea in a heart with compromised coronary arteries. is this what he had?
nitroprusside is a vasodilator, both venous and arterial. when bp is decreased in the arteries by this vasodilation this means the heart pumps against less resistance on the other side of that aortic valve... and this would be good because... (yup) a heart with lousy oxygen supply needs to work less hard. dilating the veins decreases venous return to the heart, and you may remember that the more blood that returns to the heart, the more the muscle stretches, and the more it contracts to send that blood out. hmmm, yet another way to make the heart muscle work harder...still a bad idea. also, remember that the coronary arteries are perfused in diastole, and if diastolic pressure is too low, the coronaries fill less well. another bad idea, eh, giving the heart less oxygen when it's working harder?
so. your patient was getting a pair of meds to make the heart work less hard. when his hr went down, holding the labetolol was probably a good idea unless his bp was still in target range, in which case you note it, keep watching carefully, and let the doc know that vs are (stable, dropping or....) and leave the nitroprusside where it is. if you hold the labetolol and increase the nitroprusside, you are making the heart work harder in two different ways, and letting it get paid less for its effort in the bargain. the hr didn't go up because the nitride was increased, it went up because the bp was down and there was no beta blocker "brake" on. that is why the doc was annoyed at you.

thank you... the pt had no hx of anything other than htn and degenerative spine disease.

when i stated i had ranges for the gtt, i was indicating i had no other parameters for the other medications.. sorry...

again, thanks for the info.. i am still learning and ask lots of questions plus ran it by my charge; who also agreed to hold until talking with that md.. i can understand wanting to gtt off once his bp was controlled with his oral medications but giving the labetalol with such a low hr seemed "unsafe".. time to read up some more :) i did ask about the gtt, and i was told to increase because it would help increase hr when it was low.. at that point his bp was in the one teens over 70's to 80's.

jenleighs86 · Jun 28, 2011

I would have done exactly what you did. I have worked in a medical ICU and a combined general ICU. That MD was probably just upset because he was thinking he was going to be able to move the pt out to the floor sooner and the drip was still on. I would never give a pt with a HR less than 60 a beta blocker. You did the right thing. He could change the plan when he got there but the plan shouldn't include a beta blocker so there is no reason for him to be having a fit.

wanderlust99 · Jul 3, 2011

I would have held the labetalol as well w/a heart rate in the 40-50s....you did the right thing there for sure. But I don't quite understand increasing the Nipride to increase the HR, and wonder why the charge nurse would say to do that??

GrnTea explanation was great!