Asked to give an anesthesia medication

Hi all,

I was asked this week to push Glycopyrronium PRN for symptomatic bradycardia on a mother-baby floor if my patient became symptomatic for a hr in the 30s after a c-section (hr in the 50s prior). I told my charge RN that I did not think this medication was an appropriate PRN due to it is not in ACLS protocol and I work on mother-baby, not PACU, where the patient is not monitored by an ekg machine. She responded that I was making excuses because I 'didn't want to give a new medication that I hadn't given before'. I do not think that an unmonitored 'med-surg' type floor for healthy moms and babies was an appropriate place for this patient to be with episodes of symptomatic bradycardia (hr in the 30s). I also don't think I should have been ask to give a PRN anesthesia medication on this type of floor. Any thoughts? am I overreacting?

You can always check your facility's policies on high risk medications - they typically have a chart with the med and where it can be administered/who can administer/monitoring/etc. I don't see this med listed as an anesthestic, though. It's used during anesthesia to reduce secretions since it is an anticholinergic. You should always advocate for your patient if they may need a higher level of care - I always give my charge nurse a head's up if I have concerns about a patient.

Your CN sounds like an ***.

Why do you deem this an anesthesia medication? This medication is given all the time especially in end of life situations to dry up secretions.

[NICU Guy, BSN, RN]

16 hours ago, SweetElla said:

It's used during anesthesia to reduce secretions since it is an anticholinergic.

This what have seen it used in conjunction with succinylcholine administration. I don't work post-partum, but it seems like this would be common for C-sections under general. It seems like the bradycardia events would be short term until the anesthetic has been fully metabolized. Are you a new nurse or an experienced nurse new to OB?

[klone, MSN, RN]

This is an anticholinergic, similar to atropine, I would assume. It's not an anesthesia medication.

[KatieMI, BSN, MSN, RN]

1) this is not "anesthesia" medication. This is a medication you do not know.

BUT:

2) it is just basic clinical logic: if you gonna administer something acutely affecting heart in any way, you must have some mean to control its action, such as tele. Whatever it might be, known or unknown.

No tele monitor - no push. Plain, simple. Policy or not.

[WestCoastSunRN, MSN, CNS]

3 minutes ago, KatieMI said:

1) this is not "anesthesia" medication. This is a medication you do not know.

BUT:

2) it is just basic clinical logic: if you gonna administer something acutely affecting heart in any way, you must have some mean to control its action, such as tele. Whatever it might be, known or unknown.

No tele monitor - no push. Plain, simple. Policy or not.

indeed.

1 hour ago, LovingLife123 said:

Why do you deem this an anesthesia medication? This medication is given all the time especially in end of life situations to dry up secretions.

The OP is not familiar with the medication and the perioperative period is what s/he associates it with. Regardless, an unmonitored post-C/S patient out on the mother-baby floor with "symptomatic bradycardia" isn't an end of life patient needing his/her secretions dried up.

***

It seems like if the charge RN was any more familiar with use of glycopyrrolate in this scenario than the OP, maybe s/he would have given proper resources/instruction instead of making a dumb accusation. 🤨

***

12 minutes ago, klone said:

This is an anticholinergic, similar to atropine, I would assume. It's not an anesthesia medication.

Was just thinking of you when I first read the question. Is this a common thing that RNs working in this area would go around squirting robinul PRN for "symptomatic bradycardia" on unmonitored post-C/S patients? [Also, is this most likely lingering from spinal/epidural anesthesia?]

[klone, MSN, RN]

1 minute ago, JKL33 said:

Was just thinking of you when I first read the question. Is this a common thing that RNs working in this area would go around squirting robinul PRN for "symptomatic bradycardia" on unmonitored post-C/S patients? [Also, is this most likely lingering from spinal/epidural anesthesia?]

Nope. If we had a patient with symptomatic bradycardia, we would be advocating getting her on a tele floor, or at least on portable tele monitoring. And if the bradycardia is d/t the anesthesia, she should not have been moved to the floor from PACU. She's not stable yet.

I have administered Glycopyorrolate many times for bradicardia. It is not an “anesthesia” drug and certainly isn’t outside the scope of practise of an RN.

Just now, kp2016 said:

I have administered Glycopyorrolate many times for bradicardia. It is not an “anesthesia” drug and certainly isn’t outside the scope of practise of an RN.

Inquiring minds want to know: In what setting/circumstances?

Thank you (just trying to learn something here)

24 minutes ago, JKL33 said:

25 minutes ago, kp2016 said:

I have administered Glycopyorrolate many times for bradicardia. It is not an “anesthesia” drug and certainly isn’t outside the scope of practise of an RN.

Inquiring minds want to know: In what setting/circumstances?

Thank you (just trying to learn something here)

Agree. I am more familiar with using atropine for this, however, from what I have found after seeing this post glycopyrrolate seems to be as effective in mitigating the bradycardia, and is less likely than atropine to result in tachycardia.

[KatieMI, BSN, MSN, RN]

24 minutes ago, JKL33 said:

Inquiring minds want to know: In what setting/circumstances?

Thank you (just trying to learn something here)

On med-surg floor and everywhere else. for patients when central acting of atropine is not desirable. Psychosis/delirium/bradycardic DT (it happens), for one example.

Robinul is s huge molecule which cannot cross blood/brain barrier and so has no central action.

thank you all for your input!

I am glad that this medication is more common than I had thought (it sounds like it is similar to scopolamine (I've used this a lot for nausea/end of life) and atropine but that it is less likely to cause tachycardia than atropine-which I personally have not seen used aside from ACLS situations) The problem I have is that it seemed inappropriate to push a medication that could result in tachycardia on a floor that does not use tele monitors or even remote tele.

When I used to work tele any time we gave a rhythm or rate changing drug we had to look at the strip while doing it, and this was not the case. So perhaps the best thing would be to suggest moving the patient to tele/pacu or at least doing remote tele until the bradycardia resolved.

9 hours ago, JKL33 said:

Inquiring minds want to know: In what setting/circumstances?

Thank you (just trying to learn something here)

I just re read the initial post (apparently I didn’t read it all) I’ve given glycopyrrolate instead of atropine in PACU and during RN moderate separations as it was on our standing orders and preferred over atropine by our anesthesia department. My patients were always monitored and were normally 1:1 or 1:2 nurse to patient ratio.

While it isn’t an “anesthesia” drug if your patient is bradicardic in the 30s post c- section they do not met discharge criteria (to a general bed) for any PACU I have ever worked in. The patient needs to stay in the PACU until the pulse rate is within an acceptable range or they need a monitored bed until they are stable.

You are correct, this would be a dangerous and inappropriate bed allocation. As your beds aren’t monitored how would you even know that were dangerously bradycardic, wait for a clinical sign of an unstable patient???

I would do an incident form to help ensure this doesn’t happen again. I would leave out the reference to “anesthesia drug” as people latch onto that phrase instead of reading the whole thing (like I did). Focus on

-Pt didn’t met PACU discharge criteria. The criteria varies between PACUs but bradycardia in the 30s isn’t OK to discharge anywhere accept ICU/ HDU

- Unsafe, Pts was ordered and anticipated to need a drug that requires cardiac monitoring and your unit does not have monitored beds.

If I had a newly postpartum, post-operative patient with symptomatic bradycardia in the 30s, on a unit without cardiac monitors and where many nurses aren't familiar with reading strips, nor are they ACLS certified, where patient ratios can be 1:6 regularly... I'd be calling a rapid response team to expedite this patient's transfer to an appropriate unit. It's just not a safe scenario and not worth the gamble.

On 6/11/2020 at 6:35 PM, laurencsmile said:

thank you all for your input!

I am glad that this medication is more common than I had thought (it sounds like it is similar to scopolamine (I've used this a lot for nausea/end of life) and atropine but that it is less likely to cause tachycardia than atropine-which I personally have not seen used aside from ACLS situations) The problem I have is that it seemed inappropriate to push a medication that could result in tachycardia on a floor that does not use tele monitors or even remote tele.

When I used to work tele any time we gave a rhythm or rate changing drug we had to look at the strip while doing it, and this was not the case. So perhaps the best thing would be to suggest moving the patient to tele/pacu or at least doing remote tele until the bradycardia resolved.

Glycopyrrolate, like scopolamine and atropine is an anticholinergic medication that is frequently used to treat bradycardia. Unlike the other two, Glyco does not cross the blood brain barrier because its molecule has a quaternary amine -meaning it is charged and therefore easily ionizable. The other two, atropine and scopolamine are tertiary amines and lack charges and therefore, they do cross lipid layers and the blood brain barrier more easily. As such, they have the potential of causing CNS effects like hallucinations and drowsiness. Glyco is also shorter acting and I think less potent, and that is why it is preferred by some anesthesia provider in addition to the reduced side effects. It is often used to counteract the effects of neostigmine (anticholinesterase or cholinesterase inhibitor) which is used to reverse muscle relaxants like rocuronium. It is a round-about way of maintaining physiological homeostasis with pharmacodynamics. There is a new drug called sugammadex that works efficiently to reverse roc without the bradycardia effects of neostigmine, but it is too expensive.

Nonetheless, I think it is dangerous to have such a patient in a non-tele unit, let alone giving IV push medications with the potential for serious side effects devoid of monitoring -an impending calamity is inevitable.

Fun fact, atropine comes from a plant called the beladona (sp) and people in ancient Rome used it to dilate their pupils to look more attractive hahaha.

Edited Jun 17, 2020 by cynical-RN

[klone, MSN, RN]

Belladonna atropa is its full botanical name 🙂