Question about Cardizem Drip...

  1. Hi,
    I work on a tele/med unit, and have had several pts on Cardizem gtt's since my first day.
    Yesterday, I received report on a pt who originally was admitted for "sepsis" and was stable when I left the previous night.
    My report today was that the day shift called a "MRT" on her because she suddenly converted to A-Fib from NSR, and was flushed and "not quite right." Keep in mind in my facility a "MRT" stands for "Medical Response Team" and is made up of a team of nurses, respiratory therapists, the PCS, and if needed, an MD and an anesthesiologist. It's for when a pt is "not OK" but not coding.
    The MRT team, after calling the pts MD and consult with cardiology put her on a Cardizem drip at 10mg/hr.
    Previous to my shift the pt had an 8.8 second pause, then converted to sinus brady, then back to a-fib.
    When I got report, the pt had actually converted back to sustained sinus brady, but was having pauses, and was also bradying down to the 30-40's briefly at times.
    I called the MD first thing to tell him what the pt was showing on the monitor, because I have always been taught that side effects of a Cardizem drip can include bradycardia, and AV block (which could account for the pauses), but the other nurses did not seem that concerned even though I looked it up in our units IV drug reference to confirm.
    When I talked to the MD, he had me decrease the drip to 5mg/hr for 1 hour, then D/C the drip.
    I talked with the tele monitor to aske them to watch this pt closely (since I had 6 pts and could not watch the tele all the time), and explained to them that the pt was on Cardizem, and was now off of it, and I wanted to know if the pt continued to have the pauses and brady after the drip was D/C'd.
    Turns out I was right, and after a few hours off the drip, the pt maintained a HR in the 60's and no pauses. I was surprised at how much my tele monitors knew about drugs, etc.
    The pt remained asymptomatic, and at my offgoing report, I was able to tell the nurse that the pt was stable, but that the monitors would be on the lookout for anything abnormal.
    Sorry this is so long, I guess the bottom line question is do you other cardiac nurses see reactions to Cardizem often similar to my experience? Most pts I have had on this drip do fine, and convert to a NSR, without these side effects.
    Is this frequent? Or rare?
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    About al7139

    Joined: Jan '07; Posts: 623; Likes: 543
    Nurse; from US
    Specialty: 5 year(s) of experience in Emergency


  3. by   Virgo_RN
    I've had several Cardizem gtts over the last year, and have yet to see this happen.
  4. by   Spatialized
    Theoretically, yes. Remember, everyone's chemistry is different and their reaction to meds will be that way as well. We've had several patients that I remember who were on cardizem drips that either developed some sort of nodal block issues and/or bradycardia after converting when on the drip. I think in some of these folks there were previously existing issues with the conduction system, which the cardizem exacerbated, although the memory is kind of foggy right now.

    As for the other nurses not being concerned about it, that's their deal. It was your patient and you were concerned so you took action based on your assessment of the situation. Input is nice from other nurses, but the responsibility for the patient lands at your doorstep. If it makes you feel any better, I would have done the exact same thing.

    Turns out I was right, and after a few hours off the drip, the pt maintained a HR in the 60's and no pauses. I was surprised at how much my tele monitors knew about drugs, etc.
    Some tele techs can be a wealth of help and information. Others not so much. You have to learn who you can trust. Of the three I routinely work with, 1 I trust pretty much implicitly as he has forgotten more than I know already, the other I use as a confirmation of what I'm seeing and the third I try not to even deal with.

  5. by   experiencedrn
    Yes this can and does happen, I have had it occur with several patients one just this week. Great catch on your part. I do have one concern, you work on a tele unit and cary a load of 6 patients, I find this very dangerous. We have a max of 4, with ample support staff.
    And, you are correct a well trained tele tech is worth their weight in gold.
  6. by   Nightcrawler
    You have to remember that cardizem is a calcium channel blocker, and that its primary focus is to slow the conduction through the AV node, even in patients who have otherwise normal conduction systems. Once they convert to sinus rhythm, they have a very high likelihood of developing pauses, especially if they convert to a sinus brady. The slower the rate, the more likely they are to have pauses.
  7. by   decartes
    I agree with nightcrawler's post and your actions with titrating the drip off. In my facility, we slowly titrate the Cardizem to off when the afib rates are controlled or converted back to NSR. Of course, you would need a MD's order to do that.
  8. by   al7139
    Thanks for your replies...
    I am still a new nurse so I love that I can run things by you all who have more experience than me.
    I have several favorite tele techs who I trust to be alert to anything strange, and contact me if I miss something. They are also great to call if I am seeing something that I don't recognize.
    To experiencedrn; I see your point about the pt ratio, but also you have to realize that we generally do not get patients that are considered unstable. Most of the unstable pts are either in ICU or PCU, and only come to us after the crisis is over, or if they are admitted at a stable level. Like any unit the pts condition can change quickly, and this pt was very stable on admission, but unfortunately her condition changed, and I was just glad I could spot the problem, and take measures to correct it. We have pts on drips for their heart, but if they are in need of titration they go to a higher level of care. Also keep in mind that we are a tele/medicine unit, and our pts are a mix of heart and medical issues, so not everyone is a heart case. When I get report, I usually prioritize by who is my sickest pt. Anyone who is on a drip such as Cardizem I consider to be very sick, so I was watching for any problems with this pt.
    Thank you all for your affirmation that I was not being an alarmist.
  9. by   FENT
    The doctor ordered cardizem drip for a post op pt VS 130/88 HR 68 R20
    I follow the doc order and started the drip but the charge nurse got mad WHY?????
  10. by   emmanuil
    cardizam drip if HR is over 100
  11. by   WALKIETALKIE11
    The first time I started a Cardizem drip was quite an experience. Pt was afib running at 180, pushed the 24.5 cardizem bolus and then started on cardizem 10ml/hr drip that was ordered. I stayed with the pt the first 15 minutes and checked his vitals they were all good. 132/78, hr 140's. Went to check on my other patients, cardizem pt called out to use the bathroom. I got him up to the bathroom, instructed him not to bear down. Patient said he didn't feel good and felt dizzy. At this time my monitors called me to say his heart rate was ay 58, then 54, now 47....called a staff assist and turned off the drip because pt was VERY symptomatic. Got him back to bed, could not hear a blood pressure whatsoever! Charge nurse couldn't hear a b/p either. hooked the dinamap up and still couldn't get a b/p. Finally, a b/p of 58/44 popped up!!!! Called the cardiologist and got a fluid bolus ordered. After 2 250 ml boluses running at 500, b/p came up to 74/ step was an icu transfer. he went to icu and next day came back out on the unit. I'm def. assuming a vasovagal response!!! I'm lucky I work with such a great team and my monitor techs are awesome!! As soon as there is any changes in a patients heart rate they let us know!
  12. by   MMARN
    Quote from FENT
    The doctor ordered cardizem drip for a post op pt VS 130/88 HR 68 R20
    I follow the doc order and started the drip but the charge nurse got mad WHY?????
    What was the MD's reason for ordering the gtt to begin with?
  13. by   SnowShoeRN
    To the OP, it sounds like you used your best judgment and that was a good call.

    On our unit, we don't even have techs monitoring the ...well...monitors. It's us nurses who have to keep a look out for our patients and each others'. And the dilt/cardizem gtt patients are always being watched FIERCELY. It's kind of an unspoken policy on our floor that once they have a heart rate consistently in the 70's, the gtt gets turned off.

    (Incidentally, I have no idea why someone would order a dilt gtt for a pt whose HR is 68...)

    As for patients vagal-ing out, that's happened to us too. Most of the time we don't let even our dilt gtt patients get out of bed to urinate or defecate. We've just found their BP's and HR's to be too labile.
  14. by   anonymurse
    One thing that's a common procedural error is paying attention to the HR number on the monitor. At our place, that's the HR of a sliding 6-second window. But when a MD asks for a HR, he's asking for BPM (beats per minute), and that's the standard, measuring HR over a 60-second period.

    Now if you will look for the HR graph in the pt's details, you will see the HR for a sliding 60-second window. Yeah, your tech just called you in a panic because he saw 160 for a moment on the screen, but look at the true HR--might be 110, 90, 130, whatever. So rule #1 is: don't panic. And don't tell the MD the pt's in the 160s if you want appropriate orders. If there's any way to measure BP too and have it sent to the screen, do it, especially in the first hour of initiation.

    Second, when you catch a new pt from the ER, always check the med admin record. Always. Sometimes you'll find they've been given a beta blocker just before they came up, and here you have a stat order for a cardizem push and drip. Again, check the HR over 60 seconds. Not too bad, say 130 or less? Wait a while to assess the effect of that beta blocker on HR/BP, especially if they're naive to cardiac meds.

    But really it's not a good practice to give a pt a PO beta blocker, then put them on a cardizem push/drip. Google it. If their HR is high enough to begin with, start with the cardizem and hold the blocker. Cardizem has a short half-life compared to PO beta blockers, which might hang in there 12 hours with no way to reverse the effect.

    Third, communicate with the MD. Compare notes. Suggest. Negotiate. Don't guess. When they wrote the orders, they didn't have as much information as you now do. Help 'em out. Sometimes, even if they aren't willing to forgo the drip, they'll d/c the push and let you start at a lower rate. And, um--we ARE talking about afib and svt, and not sinus tach, right? Saw that twice last week, cardizem drip/push for mild sinus tach. We got 'em d/c'd.
    Last edit by anonymurse on May 11, '11