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?
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.
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.
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. :)
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.
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!
I've had that same issue mulitple times in the past. What I've done is got orderes on bp's to hold lopressor. If the guy had been a the drip for a while, I would have called the doc to ask him if they'd like to try another med like amio. Just a couple weeks ago, same situation as you, I held the med and switched to amio. Pt converted after amio bolus. And everything then went fine.
NtannRN
46 Posts
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.