Cardiac Nurses....have you ever....

Diary/Dairy, RN · Jan 2, 2008

It's PO lopressor, right???

If it was PO lopressor and that was the situation, I think I would hold and clarify with an MD.

Boston-RN, RN · Jan 2, 2008

Thanks for the response. I was actually asking more of "have you ever done" not so much of "should I".

OK I'll have to give the whole story again....

The pt has hx of rapid afib...can go from 90 to 160 in the drop of a hat. Her SBP is normally 90's. She has order for dilt 90, lisinopril 2.5mg, dig 0.125, 2hrs later lopressor 25mg.

At 830 her SBP was 92 and HR was 140's she was given her dilt 90mg, lisinopril was held for parameters dig level was pending so that wasn't given yet and lopressor is due at 10.

So she gets back from taking shower and I take her BP it was SBP 60 and HR 120-130's. MD walks in and I tell him about the SBP...he says give her IV bolus 250ml x 2 (EF of 35%) and to give the lopressor to slow down heart and it should bring up the pressure. I go to my resource person because I didn't feel comfortable with order and NP got involved. NP says don't give the lopressor give Dig 0.125 without the lab results and give the IVF slowly because of EF and MD was there and they kind of didn't agree with each other but agreed give the IV bolus's and see where we go. SO she gets the dig the IVF x2 and SBP comes up to 70....NP says just give GT flush and recheck doc calls and says give another IV bolus of 250 and give lopressor....so the NP and MD finally talk to each other and agree 250ml bolus and no lopressor....dig level came back sub theraputic and we give IVP dig 0.125.....no changes.....

So I now my question is: has anyone ever given PO Lopressor 25mg for HR of 120-130's with SBP of 60 and seen it effectively drop HR and correct BP without pt bottoming out?

cvryder · Jan 3, 2008

NO, and I'd have done exactly what you did. Sounds like she is about ready to buy herself a pacemaker!

TachyBrady · Jan 3, 2008

While I don't recall any one specific scenario such as you describe I can guess at the MD's reasoning:

1. correct the underlying cause of dehydration and decreased HR will follow

2. by lowering an excessively high HR, cardiac output will increase

If you were concerned about dropping her pressure further, why did you give the diltiazem?

It sounds like the MD and NP were tackling the problem from 2 different perspectives. Which one is right? Who knows but it is confusing and unsettling to have both of them giving conflicting orders. They should have conferred and mutually agreed on one course of action FIRST.

It is not uncommon to have several chiefs stirring the pot and each one having a different opinion. Does that mean that one is right and the rest are wrong? No, it just means they are taking different approaches. If plan A doesnt work, then go to plan B or C or D.

al7139, ASN, RN · Jan 5, 2008

Ok, I am a new tele nurse also, BUT

If the pt sSBP is

Amy

jmgrn65, RN · Jan 5, 2008

Ok, I am a new tele nurse also, BUT
If the pt sSBP is
Amy

Most cardiologist will want the lopressor given with SBP 90s. If no parameters then the best is to check with physician first, or you may find your self with a smaller behind the hard way. :bugeyes:

As far as giving it with the sbp in the 60's no and not for hr 120's that is real high and if pt asymptomatic, then dig and the diltizem should do the trick.

newtelenurse · Jan 6, 2008

Most cardiologist will want the lopressor given with SBP 90s. If no parameters then the best is to check with physician first, or you may find your self with a smaller behind the hard way.
As far as giving it with the sbp in the 60's no and not for hr 120's that is real high and if pt asymptomatic, then dig and the diltizem should do the trick.

ditto. beta blocker effects rate more than bp. Our hospital is now saying we have to call the doc if we plan on holding a med. Docs are saying we are taking too much liberty with the nursing judgements, they have to make the parameters...

TachyBrady · Jan 7, 2008

Ok, I am a new tele nurse also, BUT
If the pt sSBP is
Amy

I have to disagree on a couple of points here..... many patients live perfectly well with a BP in the 90s and some even in the 80s. The reason these patients' pressures are so low is because they take a beta blocker daily. Lowering heart rate and BP are expected and desired effects and result in easing the work of the heart. Coinciding considerations are whether the patient is symptomatic and whether this HR and BP are their norm. Rebound tachycardia can occur in patients who do not recieve, for whatever reason, their normal beta blocker dose. Be careful to not cause more problems with your good intentions.

What other drugs (other than dig) lower HR with out lowering BP?

I dont' think I've ever seen a normotensive patient bottom out simply from a dose of lopressor or other beta blocker. Perhaps there was something else going on in the patients you mention?

Lopressor is the trade name for metoprolol, a beta blocker. In its original studies, lopressor was proven to lower blood pressure as well as benefit angina and MI patients. I'm not sure what year lopressor came out but much research has been done since then. Beta blockers, including metoprolol, are now indicated for rate control for certain rhythms as well as is the first line treatment for acute MIs and angina. Many of our patients are ordered "lopressor" for rate control. Of course our pharmacy substitutes metoprolol.... in the end it's all the same. Sometimes you have to think outside of the box.

Last but not least, who do you report your doctors to when you don't agree with their treatments?

Virgo_RN, BSN, RN · Jan 8, 2008

What was her MAP? Did you look back in the charting to see if her BP had been that low before, if she had received her metoprolol, and what happened?

Boston-RN, RN · Jan 12, 2008

What was her MAP? Did you look back in the charting to see if her BP had been that low before, if she had received her metoprolol, and what happened?

She didn't have invasive monitoring for me to determine her MAP. This was her lowest BP (her previous low was mid-70's) at SBP of 60 she was assymptomatic. I did not give the lopressor. The MD and NP finally agreed to not give the lopressor. I did not feel comfortable giving lopressor to a pt with and SBP of 60 and having 3 other pts to be responsible for at the same time. If they wanted her to get it so bad they could have transferred her to the unit with lower ratio so she could be monitored more closely.

The patient was transferred to rehab after that shift and signed to refuse further cardiac monitoring because she was peeved we were checking her vitals so often. And yes she is a 55 y.o. w/ mets and a full code.

The original point of my posting was to see if anyone had past experience with the approach of lopressor with a HR in the 120-130 range helped the HR without bottoming a pt's SBP when their SBP was low.

Virgo_RN, BSN, RN · Jan 12, 2008

MAP is a simple mathematical calculation. You do not need invasive monitoring to determine MAP, simply the BP. It was a dumb question, though because in order to have a MAP of 60, her BP would have had to have been 60/60.

A patient with a BP of 85/65 would have a MAP of 65, so even though the patient is hypotensive, they are still maintaining adequate end organ perfusion. If they are asymptomatic and a fluid bolus is contraindicated (ie CHF), then this person might be allowed to "live" in this range.

I would have been uncomfortable giving metoprolol to a patient with an SBP of 60 too, but when thrown into situations like that, I tend to ask questions and look at more data than just one number.