Asked to give an anesthesia medication

[laurencsmile]

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?

[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.

[laurencsmile]

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.

[kp2016]

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.

[Closed Account 12345]

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.

[Guest856929]

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.

[klone, MSN, RN]

Belladonna atropa is its full botanical name ?

[londonflo]

On 6/11/2020 at 2:58 PM, KatieMI said:

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.

I think the tele would be to assess the response and evaluate the effects of the drug; not control it's action. I am unfamiliar with what pharmacological therapy would be used if the patient had an adverse reaction. Would this be available in the mother-baby area?

We gave Robinul for years ( or atropine) in "pre-op shots". I can see where your brain made the "anesthesia" connection. And of course is not given in your area, from your experience. Can you fill us in on what the outcome was? Did the CRNA come to give it, was patient transferred to an monitored area, back to PACU? I can understand the hesitancy to transfer the patient to a non maternity area where there maybe more exposure for the new mother to covid and of course I assume her baby could not "room in".

[macawake, MSN]

2 hours ago, londonflo said:

I think the tele would be to assess the response and evaluate the effects of the drug; not control it's action.

English isn’t my first language and I believe that it isn’t KatieMI’s either, eventhough her English is good. The word control has dual meaning in my native language. It means both control and check. I suspect something similar made her use the word ”control”, not some rather ignorant notion that ecg/telemetry leads somehow connect with the patient’s body and has a direct influence on pharmacodynamics of a medication being administered. Katie doesn’t strike me as dumb or deficient in her nursing knowledge.

Perhaps I misunderstood your comment to Katie? It just seemed odd to me that you thought a nurse, any nurse, would actually believe that telemetry could somehow control a medication’s effect/action.

OP, I agree with many of the previous posters. I would definitely want a patient with symptomatic bradycardia in the 30’s on telemetry.

[londonflo]

53 minutes ago, macawake said:

. The word control has dual meaning in my native language. It means both control and check.

I mean no disrespect. It was just that every one commenting was so specifically about the OP's use of "anesthesia", It was corrected in almost every entry. I just wanted to make the distinction and get to the basics for the OP who does not use tele. I also wanted to reassure her that no question or information seeking is wrong when you are faced with something that is not routine on your floor. I worked with nursing students for many years and know the importance of clarifying words. Believe me, a phrase used without a qualm by an experienced nurse can be easily mistaken by someone not knowledgeable of a specialty usable terms.

Again I did not mean any disrespect, just clarity of the term. I did not know the dual meaning, but I am glad I now know so I can understand your word usage should you use the phrase again.