This is one weird drug to me sometimes. You never know from patient to patient how it's going to work. We were discussing it at work the other night. I had a patient a while back who was at our sister facility where they don't do hearts, pt had a big MI,VFIB, coded, got CPR all the way over to us, went for emergent bypass. Needless to say, pt came out from OR with IABP, Dobutrex at 5 mcg. We had orders to wean the IABP and Dob per the surgeons parameters. It was interesting b/c this is a surgeon we don't see much, he was covering for the weekend, but routinely we leave the Dob at 5 until the IABP comes out, then start weaning it off. Anyway, when I come on shift, my pressures-aline,iabp,cuff are all correlating well and a sagging a little compared to what days had, hanging mostly in the 80's. I call the surgeon, b/c pt didn't need the volume, svr was up so I didn't want neo, got orders to increase the Dob and can start some low dose dopamine in a little while if upping the dob didn't help. My CI was great, so we only needed a little something to help with the bp.
Anyways, continue on through my shift, I wean the Dob back down to 5 mcgs, keeping bp about the same, went on the dopa with only about a 5-10 point change in my bp, but the uop is good, pt is alert, other numbers all look great. Next nurse comes in, surgeons RN is making rounds and 7a nurse asks if it's okay to half the dob. I kind of cringed to myself, b/c I could see a big change in my pressure during the night when I came off it slowly, so I'm thinking pts not going to tolerate halfing it cold turkey, plus, they were going to pull the IABP and it didn't make much sense to me to take away 2 cardiac augments so rapidly. But, I figured, I'm going home, its the daytime, surgeon will available to the day nurse all day long without having to get a call and woken up in the middle of the night like I'd have to do if pt starts heading south.
Long story short, when I leave an hour later, bp is in the 120's range with the dob at 2.5, I was amazed and asked the day nurse what happened. The reasoning was the dob was dilating the patient out, hence the low bp. I can't remember the exact numbers now on the svr, but I know it never got below 750-800 range, which I don't consider too dilated out. I did see some decrease in svr after I increased the dob, but the svr was variable, and the exact same svr the nurse had at 0800 I had several times during my shift with no where near that good of a bp. It's just interesting to me how titrating drugs sometimes what you're expecting with a med is not what you get. I don't know if it was just a timing thing, at this point, we're about 24 hours out from the initial cardiac insult, and the body just took a while to adjust maybe. The patient wasn't sedated or sleeping on my shift all night, pt would be wide awake with same bp regardless of being awake/sleeping. Absolutely nothing else had changed to explain having that good of a bp within an hour.
In the end, pt got the iabp out, dob was off and transferred out within 48 hours of surgery. Has anyone else ever had similar experiences with Dobutrex?
