I had an elderly patient a few nights ago that was in sustained SVT with a heart rate in the 160's. It wouldn't respond to two diltiazem boluses or a metoprolol bolus. (I had Glucagon and Calcium at bedside...ya never know!)
Anyway, the admitting doc ordered a cardizem titration drip. I spent a little time upping the rate until I hit the max of 15 mg/hr. That d*** heart rate still wouldn't go down. I got new orders for a Amiodarone drip, but I only had one line. She was an extremely hard stick and the whole ER was taking turns. As she was starting to deteriorate, I called the pharmacy to find out if I could piggyback it while looking for another line and was told I couldn't because the was not enough information on the compatiblities. While this patient was CTD, a new hire RN orientee said that she used to do it in the ICU she worked at all the time, and that it should be okay.
Would you guys have taken the chance on piggybacking those meds because of the pt's condition?
(A little more information: BNP 2200, Elevated cardiac enzymes, WBC 24, lungs filling, and sats out at 92% on NRB. Doc wouldn't order for a central line to be placed by the ED physician.)
I have been tossing this one around in my head for the past couple of days trying to figure out what I could have done to improve on the patient's care.
Was it a teaching hospital? I have found that in most private hospitals you have to beg, borrow, cheat, and steal to get a central line put in.
I agree- It has to be a private hospital, if it were a teaching hospital, residents would be pushing eachother out of the way to throw a central line in...
That's funny cause I had a pt. in the same situation and he also had a K rider and insulin drip. I asked one of the more experienced nurses and he said no. Talked to the pharmacist and she said she had no info and not to do it. Apparently if there's no info it hasn't been studied thoroughly so if you do piggyback them, then it's your liscense you have to think about. I didn't chance it, but I could start another line. You have to just really advocate for your pt. and get the central line placed. You wont do your pts. any good if you don't have a lisense to practice with.
Why couldn't you bolus the amiodarone? Briefly stop the dilt, flush the line and give the amiodarone 150mg, flush again, restart the dilt.
Also, a second attempt at adenosine 12-18 mg to determine rythm would seem to have been indicated. If it was new onset a-fib or flutter, you could do a cardioversion attempt. I too would have been concerned about sepsis and sinus tach being a possible rythm, especially if she might have had pneumonia.
Should have called a cardiologist for advice. I haven't worked ICU in more than 5 years but it seems like afterload reduction was indicated, possibly with a combination of dobutamine and nipride (what with the 92% on NRB). What did her xray look like? Did she have rales most of the way up? JVD?, etc,
She needed a PA catheter. I wonder why they didn't want a central line?
Specializes in Cardiothoracic Transplant Telemetry.
Did you know when the onset of afib was? The reason I ask, isn't cardioversion contraindicated if the onset of the afib is unkown? This is due to the risk of throwing clots and then PE.
The onset is also an issue with the amio, as it too will convert the rhythm with the same set of problems
Specializes in ER, Outpatient PACU and School Nursing.
we just had a 31 weeker 22 y/o with SVT rate of 175 sustained-sent down by OB for sob/cp. we tried adenocard unsuccessfully- then went to cardizem bolus and brought the heartrate down, so we started a drip on her. Of course we had OB there with us monitoring baby. Was a new situation for us. Her Echo turned out fine, only thing was she was eating corn starch out of the box on a daily basis... can you say PICA?
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ERRNTraveler, RN
672 Posts
I agree- It has to be a private hospital, if it were a teaching hospital, residents would be pushing eachother out of the way to throw a central line in...