Combined use of nicardapine and esmolol drips for aortic dissection

[R8T3D_RN]

I had a patient the other night with an aortic dissection. Looks like the procedure is to put the pt on both nicardapine and esmolol at the same time. Esmolol to mostly bring down the heart rate but will also bring down the bp and nicardapine to bring down the bp.

This combination terrified me ! I asked the er doctor and the icu resident both and they said yes to start them at the same time. I was terrified that the pts bp would bottom out. Her initial bp was around 154/72 and the goal was systolic of 100-120 with hr in the 60s

So I talked to the icu resident told them I was not comfortable starting them together. Eventually we started the esmolol first and then when I maxed out the esmolol I started the nicardapine.

I found the esmolol dropped the pressure a little to 130-140 systolic and would not drop it any more so eventually I did start the nicardapine at 5mg/hr while esmolol was dripping at the max rate and it brought the pressure down into the 120s systolic. Then we transferred pt to icu

So question is how would you have handled these two drips together?

[R8T3D_RN]

BTW nicardapine terrifies me because of how efficient it works ! Which is why I was not comfortable staring them together with her initial bp systolic in the 150s

[Rose_Queen, BSN, MSN, RN]

What was the target BP range? Remember, the higher the pressure, the higher the risk of a true aortic rupture. And that means a dead patient. When I get called into surgery for these patients, we want a lower pressure until we've got them on bypass and can remove the area of dissection and replace the dissected portion with a synthetic graft.

[R8T3D_RN]

What was the target BP range? Remember, the higher the pressure, the higher the risk of a true aortic rupture. And that means a dead patient. When I get called into surgery for these patients, we want a lower pressure until we've got them on bypass and can remove the area of dissection and replace the dissected portion with a synthetic graft.

Target bp was systolic of 100-120.

[Guest374845]

B-blockade without simultaneous vasodilation (nicardipine) doesn't do anything to protect the patient from developing a retrograde enlargement of the defect back toward the heart.

Conversely, vasodilation without B-blockade can result in reflex tachycardia which your patient doesn't need either.

You don't know what you don't know, but be aware that delays due to your comfort level could have harmed the patient.

[R8T3D_RN]

Thank you for this. I will remember it for next time.

[grizun]

B-blockade without simultaneous vasodilation (nicardipine) doesn't do anything to protect the patient from developing a retrograde enlargement of the defect back toward the heart.

Conversely, vasodilation without B-blockade can result in reflex tachycardia which your patient doesn't need either.

You don't know what you don't know, but be aware that delays due to your comfort level could have harmed the patient.

This;)

[nurse2033, MSN, RN]

I would have started both, carefully, with a bag of saline and hopefully large bore IV at the ready.

[offlabel]

Just a point of order here. Ascending and other thoracic aneurysms dissect. Abdominal aneurysms rupture. There is a difference and although it might be just semantics for room staff in the OR/ICU, it makes a big difference with respect to the anesthesia and surgical repair. Goals of hemodynamic management are similar with respect to shear force and pressure. Taking the MAP to 60-65 is the goal and achieving and maintaining that as quickly as possible is optimal.

No surgeon or anesthetist will complain of a systolic blood pressure of 80 in this circumstance.

[offlabel]

Conversely, vasodilation without B-blockade can result in reflex tachycardia which your patient doesn't need either.

You don't know what you don't know, but be aware that delays due to your comfort level could have harmed the patient.

Agree with respect to delays because of fear based out of ignorance. That said, these patients are most usually unable to respond to MAP lowering measures with reflex tachycardia. HR's over low 100's are not common. Best thing is to begin vasomotor tone therapy first, see what happens if anything to HR and then add beta blockade if needed.

[Lev, MSN, RN, NP]

I have seen the combo for dissection, but the deal was give bolus of esmolol and start esmolol drip if the HR starts going up from the nicardipine.

[Lev, MSN, RN, NP]

IMHO, you should have started nicardipine first if you were only starting one. The goal is to control BP which is what nicardipine is best at.