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A-fib + metropolol + diltiazem gtt + soft bp

Specializes in critical care transport.

situation:

rhythm a-fib, with rate 100-130's

systolic lood pressure: 82 and 91 in different arms

ns going at 100/hr (for 2 days!)

diltiazem drip 5mg/hr

metropolol 50mg bid

i held metropolol d/t blood pressure, but i'm keeping an eyeball on the rate.

up diltiazem to 10mg/hr about 5 hrs into shift after heart rate reaches occaional (not sustained) 140's.

pt had screw put in femer, and was out of pacu for 2 hours when i got on shift.

systolic bp 2 more times during shift is 90's, 1 time making it to 102.

my question: which medication would you have held and why?

i asked my supervisor/ manager of the unit just how much diltiazem affects b/p and asked her what she would've done in my position. i've been a cardiac nurse for 1.5 years and have always held the metropolol if they are on a dilt drip, because i thought that dilt was the way of controlling rate in afib. anybody want to share their brain with a greenhorn?:twocents:

fiveofpeep

Specializes in critical care, PACU.

As a new grad, Id give both because the reason the patient has a crappy pressure is probably because the hr is exceeding the patient's ability to compensate. If hr is too high there is decreased filling time which = decreased amount of intravascular volume pushed out in each beat = decr CO = decr bp. Also, you lose 25% of cardiac output with afib so Id be thinking about amio if dilt wasnt working to help the bp in this manner. It's a hard line to cross though because all could make bp even worse.

Im sharing my idea because I will be starting in a couple months in the ICU and want to know if my decision making skills are on track. I definitely would clarify with my buddy or CN before going ahead but that is what my thought process is.

Good question OP. What do the icu gurus think?

buddiage

Specializes in critical care transport.

Totally see your point, but b/p actually IMPROVED as heart rate went slightly up. I'm glad you shared your view, because I also want to see just how many people would've done what. i'd love to take a vote on my unit, but that won't happen.

fiveofpeep

Specializes in critical care, PACU.

When patients with atrial fibrillation are hemodynamically unstable (e.g., angina, hypotension) and not responding to resuscitative measures, emergency electrical cardioversion is indicated.

source: http://www.aafp.org/afp/20020715/249.html

and accor to ACLS protocol for hemodynamically unstable patients you do cardiovert or amio...but has the patient been anticoagulated?

buddiage

Specializes in critical care transport.

she has a history of afib. had gone in and out of it. the plan was to wait until her INR came down so that she could get the surgical proceedure. after proceedure she was restarted on coumadin.

i might add her b/p had been on the soft side since admission, despite cardiazem and fluids going at 100/hr.

i'll add- you cannot cardiovert someone unless you know they do not have a clot in there heart somewhere, which means they get a TEE to see...and, our pts are always on heparin. plus...this lady is in and out of it from what I got in report, but she's been in it for 3 days now :-)

btw, i did a preceptorship in the icu, and learned so much. you will too.

Edited by buddiage

Dinith88

Specializes in CCU/CVU/ICU.

Maggiofliore is correct if patient were shocky...and the patient's shock related to the AF...but the patient isn't/wasn't. So...she can take her hand off the trigger and sit the ACLS manual back down on her desk.... :)

(but if the patient's AF WAS making her shocky/crash you wouldn't worry about echo/TEE either...so...she's kinda right in a different scenario... but...)

The problem you describe is kinda complicated and stinks of a trick question...with answers that can go either way and makes great fodder for eager cardio-critical-smarty-arguer-types.

I think some things to consider are: baseline cardiac function? Baseline BP's? On any other meds (ie ACE, ARB's, etc.)?, Was she taking lopressor prior to admission? Is she borderline hypotensive r/t post-op sedation? ,etc.

So, there're many variables here... and without knowing all of this, my best answer for you would be to bounce it off the cardiologist and come to a concensus (and cover yourself in the process)...

(another *alternative* answer in this case would be to load her with digoxin. It can slow her down and you wouldn't have to worry about her BP...)

buddiage

Specializes in critical care transport.

NO, no lisinopril, just metropolol. random things i remember: ef of 40%. I dont recall digoxin on her sheet.

My supervisor said she would've given the metropolol. I had heard (but was corrected by her today) that diltiazem affects bp, just not as profoundly as betablockers. For rate control, the Ca+ Channel blocker was, in my understanding, the way to go.

I was frustrated b/c I felt a little like I got my nose slapped by my supervisor, and I was mad at myself for making the mistake. I told two other nurses what I did, and nobody flinched, which made me wonder, is it me or is it our floor that could use some education on beta blocker vs calcium channel blocker.

I was hoping for anybody's point of view to give me a "I didn't look at it that way before" inspiration.

The better worded question is when is it appropriate to hold metropolol vs cardizem. I don't want to inspire an argument, just want people to share.

fiveofpeep

Specializes in critical care, PACU.

did you collaborate with the physician in deciding to hold to betablocker?

lpnflorida

Specializes in psych. rehab nursing, float pool.

My question is what was the dose of Metoprolol? I ask this as my loved one who was in ICU last month, was on a cardizem drip 5-10mg /hr for his long standing A-fib

. They had also instituted his home dose of Metoprolol which had for years been at 100 mg four times daily. They ended up lowering the dose of Metoprolol to 25 mg twice daily, not holding it. That was on the advice of his cardiologist. Never did get him to cardiovert, but that did not surprise us. As I said he had it for years.

Can't say I have helped your question much though.

ghillbert, MSN, NP

Specializes in CTICU.

OP, it's "metoprolol" not "metropolol" FYI.

I can't judge without being there and knowing more hemodynamics, underlying issues etc. I wouldn't hold either without discussing with physician if I wasn't sure.

FST6

Specializes in CVICU, Trauma, Flight, wartime nursing.

You might be missing the bigger picture here. Consider the variables that affect your BP:

1. Preload (volume present in the ventricles prior to systole - think of it as the

amount of volume available for the heart to push out)

2. Afterload (resistance the left ventricle has to overcome to pump blood to the body)

3. Contractility (the strength of ventricular contraction - stronger squeeze = better cardiac output)

Look at these three areas for an answer. Since your patient had a screw placed in the femur, I am assuming a femur fracture was present. How much bleeding was there before surgery? What was the EBL intraop? How much fluid resuscitation was given post-op? You may be dealing with a pre-load issue here. Elderly patients who are hypovolemic will sometimes develop A-fib due to the decreased volume (less ability to deliver oxygen to the body, including the heart). If she has chronic A-fib, than this is probably less of an issue. The presence of beta blockers can further complicate your situation by reducing myocardial contractility, reducing her cardiac output. Cardiac output is calculated by multiplying the stroke volume (amount of blood ejected from the left ventricle with each beat) x the heart rate. If your patient has decreased preload and therefore a lower stroke volume, the heart attempts to compensate by increasing the heart rate. This will increase the cardiac output. This situation may explain why your patient's BP improved as the HR went up. Not knowing anything else about your patient and judging by the history presented, I would venture to say she needed more volume. This would increase preload for the heart and also optimize Starling's law with her left ventricle. Some fluid boluses would have probably helped out and improved the BP. One thing you did not include in this scenario was her urine output. That would also be another indicator of how well your patient was resuscitated post-op. Of course, all these numbers mean nothing compared to how your patient tolerates the low BP. Was she A&O x 3 or was she disoriented? Did she have clear lung sounds or were there crackles in the bases? Did your patient have warm skin or was she cold and clammy? Those assessments will let you know if that BP is an emergency or being tolerated. It's the classic "treat the patient, not the monitor" situation.

As for the situation with calcium channel blockers, remember that there are three separate sub-classes of these drugs (benzothiazepenes, phenylalkylamines, and dihydropyridines). Cardizem belongs to the benzothiazepines, which causes vasodilation and also has cardiac depressent effects similar to beta-blockers. I would say that your desire to hold the metoprolol in the face of hypotension and the patient being on a Cardizem drip was a good one. Further reduction or myocardial contractility in the presence of possible hypovolemia and an existing EF of 40% would not be optimal for this patient. I hope this helps you get closer to the answers you are looking for. Cheers!

Edited by FST6
typos

buddiage

Specializes in critical care transport.

Pt had scant crackles in bases, but sats fine (97 to 99 percent), and no SOB. Lung assessment hadn't really changed since being there, and she had been on her back for a few days.

EBL- can't remember the number, but it was hardly worth mentioning.

As far as CHF, no echo had been done currently in our facility while I had her. I believe she had a previous EF of 60 percent.

Pt was warm and dry.

I am guessing that she was volume depleted, her urine output was OKAY, but for someone on NS 100/hr, I wasn't impressed with the output. Which reminds me, one of the reasons why I was concerned about killing her blood pressure is because I wasn't wanting to kill her kidney perfussion. I don't recall her labs exciting me much either. I believe her Cr was up a wee bit.

It's hard to convey everything without the chart in front of me ;0), but I did solicit for some food for thought.

I did not call the physician (I'm not afraid to, but I'm a night shifter and like to call only when I really need to).

FST6 and others, thanks for your thoughts.

I'm not a huge fan of Dilt. I haven't been in the ICU for a long time but I have yet to see it actually do it's job. I prefer Amiodarone, just personal preferance I guess. We follow MAP's, (Mean arterial pressures) more than actual BP's for the most part. Anything > 60, even with a sbp 80-90, if the map is > 60 organs are still being perfused. I def. would have held the lopressor, I just had a very similar situation my pt.s bp dropping but she was having a great time with her PCA. Was you pt getting pain meds? They can significantly decrease bp.

Dinith88

Specializes in CCU/CVU/ICU.

Dilt is BETTER than Amio for rate control. I'm a huge fan of amio, but if the pt has chronic a-fib, Dilt is probably better because you're looking for rate control rather than conversion. Hypotension is also an issue with IV amio, so it doesnt necessarily make it favorable to Dilt when worrying about rate control in any hypotensive patient...

I've seen trauma patients drop their H/H 1-1.5 grams 48 hours after fracturing a long bone. It was a dramatic drop from one AM lab to the the next. Don't forget you were fluid resusitating her, so there would be some hemodilution there too.

I would have suggested decreasing and

changing her lopressor to IV q 4 hours for better control. In my experience, cardizem doesn't affect BP as much as lopressor.

Edited by classicaldreams
Correction

Many doctors will write to hold for a pressure

Was he in pain? Just another thing to thing about being post op. I would also think about fat emboli if he had those symptoms PLUS SOB.

clementinern

Specializes in Critical Care.

To be honest with you, I think I would have looked to treat the cause of the rate- despite the AFib, the pt had a lot of other potential reasons to be tachycardic and hypotensive. Was it anesthesia effect causing the low bp? Pain or fever causing the increased HR? At the beginning of your shift, when her pressure was in the 80's, I probably would have shut the cardizem off to see what happened. It doesn't sound like it was helping much anyway, and then maybe she would have been able to tolerate the beta blocker. When it comes to the lopressor- with a BP in the 80's I definitely would have held it- but if she sustained in the mid 90's I would have given it. It depends on other things- what were her lungs like? Was she in some CHF because of the NS at 100 for 2 days, plus the Afib on top of it? Maybe she needed lasix. Was she dry from being in the OR and needed MORE fluid? How was her urine output? o2 sats? I would need all of this info before I could make my decision. I think you have a lot of factors at play here and can't make a prudent decision based on BP and HR alone.

That said, if her lungs sounded ok and her sat was good and she was making good urine, was pain free and afebrile, I really would have liked to have gotten that lopressor into her. Good job, though, it's never a black and white decision. :)

Sirapples

Specializes in Agency, ortho, tele, med surg, icu, er.

Ill be honest, I dont work in CCU, but I do have some tele experience. One thing that is an issue is fear of doctors at night. Its our patients lives that are in our hands and if you have a clinical question like... do I hold this medication without peremiters in the face of this.... and you act on your medical interpretation of the reason why you would hold said medication, you are practicing medicine and not nursing.

I would of called the MD. Reason is this...

If something had of happened to this patient and it went to court, a lawyer would of asked... Why did you hold the metoprolol? Did you have guidlines set to hold that medication?

If you held it, and the answer was you had no guidlines... then his next question would be what md school did you graduate from to dictate medical decisions without perimiters.

An answer of, I didnt want to wake the doctor because I was scared... will not cut it.

You do ask a good question, but honestly the bigger picture is that you work at a facility where you feel fearful to call a doctor about witholding a cardiac medication on an icu floor.

I would of called the doctor, asked if he wanted an additional bolus of fluid, and asked if he wanted me to hold the metoprolol. Then again I dont know if this blood pressure is her baseline and when her last pain medication was.

Sirapples

Specializes in Agency, ortho, tele, med surg, icu, er.

ah sorry just read that wrong that you werent scared. my bad:)

WahooRN08

Specializes in CCU.

In my opinion, I would've given the Metop despite the Soft BP in the mid-90's, Metop in my experience contains more of a rate controlling beta effect than a BP changer. Don't get me wrong, Metop can drop a pressure, but no too terribly low. Remember, it's always a PIA looking at past scenirios and having them audited by others.

I currently work in a CCU, mainly with severe HF patients and pre-transplant work-ups. Some Cardiologist prefer a nice pressure in the low 80's (SBP), decreased afterload, blah blah blah...that's another issue.

Of course you have so many variables, but before holding any med, I would be sure to consult with the physician. There is always a method to their madness, generally speaking. Have a great holiday!

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