FNP pharm case study

[turnforthenurse, MSN, NP]

I was wondering if there are any NP students out there that can look at and critique my case study answers. I was never provided the correct answers for this case study despite reaching out to my instructors via e-mail - the case studies were meant to be discussed amongst study groups and then I would have to make an office appointment and drive approximately 1 hour to see my instructor in person. It's ridiculous. Other classmates that I have talked to have not completed this case study so I don't really have anything that I can compare to.

A 50-year-old male weighs 95 kg, 188 cm male with acute heart failure that decided to increase his dose of furosemide to 80 mg TID because he had so much peripheral edema that he could not walk without extraordinary pain. Now he presents heart rate of 240 bpm and 12‐lead ECG that reveals ventricular tachycardia. Laboratory values include potassium = 3.0mEq/L (normal 3.5 – 5 mEq/L); magnesium = 1.6 mEq/L (normal 1.8‐2.9 mEq/L); Serum Creatinine = 1.2 mg/dL).

Current Medications: Furosemide 40 mg BID; Quinapril 4 mg once daily;

What is his estimated creatinine clearance?

188cm = 74in

IBW = 50 + ((2.3)(74-60))

IBW = 82.2kg

>30% of IBW would be 106.8kg. The patient's actual weight is 95kg so there is no need to figure out an AdjBW.

(140-50)(95) / (72)(1.2) = 8550/86.4 = CrCl 98.9mL/min

How would you treat his ventricular tachycardia?

I would treat with an amiodarone bolus of 150mg IV over 10min and repeat if necessary. I would also correct the fluid and electrolyte imbalances which are more than likely the etiology of the ventricular tachycardia. Procainamide can also be given but I would be worried about the worsening of arrhythmia in the face of hypomagnesemia and hypokalemia. (is this correct? Am I correct on my thinking here? )

To assist in alleviating his ventricular tachycardia, what volume and type of intravenous fluid and electrolyte replacement would you initiate?

1500 + (20 * 75) = 3000mL

Patient requires a maintenance of 3000mL.

D5NS is a hypertonic solution that would help pull fluid from the interstitial compartment to the intravascular compartment and alleviate the third spacing. The fluid would be given at 125cc/hr.

Additionally, this patient requires potassium and magnesium supplementation. Although mildly low, the magnesium needs to be supplemented to help bring up the potassium level. 2gm of IV magnesium over 1 hr should be given.

Potassium requirements were calculated through the following equation:

(Goal K – Serum K) / SrCr x 100 = total mEq required

Based on a goal of 4.0 mEq: (4-3)/1.2 x 100 = 83mEq and I would change the dose to 80mEq since KCl supplements come in increments of 10mEq. If the patient can tolerate PO, a dose of 60mEq of KCl can be given and the remaining 20mEq can be given IV over 2 hours. Alternatively, KCl can also be added to the maintenance fluids as D5NS with 20mEq KCl.

Based on etiology of his ventricular tachycardia will he need medical management for prevention of recurrent VT?

Electrolytes should be replenished and levels maintained to help reduce the risk of arrhythmias. The patient will need to be monitored for additional arrhythmias while in the hospital and serial electrolytes should be checked during the patient's stay. This patient is on furosemide and not on a potassium supplement; he should be placed on a potassium chloride supplement of at least 20mEq divided BID.

I really appreciate it. Thank you! Never have I ever had to use Google so much and pull from so many different resources just to understand something because of an instructor's failure to explain

[Banana nut, BSN, RN, EMT-B]

I think you did an excellent job in your tx.

In the case study it said Vtac at 240bpm?

Is the pt having symptomatic V tac? Is it wide complex? I think acls protocol allows for adenosine 12mg along with amio drip?

I could be totally wrong im just brain storming.

[turnforthenurse, MSN, NP]

I think you did an excellent job in your tx.

In the case study it said Vtac at 240bpm?

Is the pt having symptomatic V tac? Is it wide complex? I think acls protocol allows for adenosine 12mg along with amio drip?

I could be totally wrong im just brain storming.

Thank you so much, I really appreciate it! Unfortunately, everything that is written above is all that I have been given. I don't have any additional PE findings or lab values. I was just working with what I already know!

[nursej22, MSN, RN]

Do you have any vital signs? A heart rate of 240 bpm would most likely lead to hypotension, if not pulselessness. Unstable VT would most likely be treated with electricity as well as amiodorone. In my experience, amiodorone IV boluses are usually followed by amiodorone infusion x 24-48 hours. And yes, most definitely, mag and K+ replacement.

As for fluids, heart failure patients seldom receive IV fluids, unless they are hypotensive. I am assuming you don't have a current ejection fraction, but either way I would be cautious with IV fluids, especially hypertonic. You may pull fluid into the vascular space, only to have it build up in the lungs because of poor cardiac output.

[turnforthenurse, MSN, NP]

Do you have any vital signs? A heart rate of 240 bpm would most likely lead to hypotension, if not pulselessness. Unstable VT would most likely be treated with electricity as well as amiodorone. In my experience, amiodorone IV boluses are usually followed by amiodorone infusion x 24-48 hours. And yes, most definitely, mag and K+ replacement.

As for fluids, heart failure patients seldom receive IV fluids, unless they are hypotensive. I am assuming you don't have a current ejection fraction, but either way I would be cautious with IV fluids, especially hypertonic. You may pull fluid into the vascular space, only to have it build up in the lungs because of poor cardiac output.

Unfortunately, everything that is in my initial post is everything that I have been given for the case study. No additional PE findings, labs, or vitals were given. Is a maintenance amio gtt (1mg/min for 6 hours then 0.5mg/min for 18 hours) necessary if I suspect the etiology to be electrolyte-induced?

Yes, I would definitely be cautious with giving IVFs! Frequent re-assessments and strict I&O would also be needed! Thank you for the taking the time to look over this!

[nursej22, MSN, RN]

Unfortunately, everything that is in my initial post is everything that I have been given for the case study. No additional PE findings, labs, or vitals were given. Is a maintenance amio gtt (1mg/min for 6 hours then 0.5mg/min for 18 hours) necessary if I suspect the etiology to be electrolyte-induced?

Yes, I would definitely be cautious with giving IVFs! Frequent re-assessments and strict I&O would also be needed! Thank you for the taking the time to look over this!

Gack, I hate that sort of case study, because one would always look at the whole patient, right?

It will take some time for the electrolytes to correct, and surprisingly, po replacement works more quickly than IV, and in my experience, po is usually given in 40 mEq. doses, 4 hours apart. Given the prolonged time it would take for electrolyte replacement, I would continue the amiodorone gtt.

By the way, the amio dose for VF or pulseless VT is 300 mg. Of course, you have no way of knowing if this patient is pulseless or not.

[offlabel]

No one is gong to cardiovert this guy? I get there are no VS, but reason dictates he'll show signs of instability... moreover, giving him amiodarone as a bolus then infusion, or even just the infusion risks causing instability.

Goes without saying to fix Mg++ and K+ right away as they are the immediate cause of the vtach.

[Esme12, ASN, BSN, RN]

moved for best response

[turnforthenurse, MSN, NP]

No one is gong to cardiovert this guy? I get there are no VS, but reason dictates he'll show signs of instability... moreover, giving him amiodarone as a bolus then infusion, or even just the infusion risks causing instability.

Goes without saying to fix Mg++ and K+ right away as they are the immediate cause of the vtach.

Cardioversion is an option, but this is my pharmacology course and the focus is pharmacological treatment vs. other interventions. When we were talking about treatment for VF, she focuses solely on epinephrine 1mg Q3-5min or vasopressin 40 units to replace the first or second dose of epi and amio 300mg and no mention of defibrillation (or CPR!).

Thank you for taking the time to look over this!

[turnforthenurse, MSN, NP]

Gack, I hate that sort of case study, because one would always look at the whole patient, right?

It will take some time for the electrolytes to correct, and surprisingly, po replacement works more quickly than IV, and in my experience, po is usually given in 40 mEq. doses, 4 hours apart. Given the prolonged time it would take for electrolyte replacement, I would continue the amiodorone gtt.

By the way, the amio dose for VF or pulseless VT is 300 mg. Of course, you have no way of knowing if this patient is pulseless or not.

I agree - but I can only work with the information I was given. And i'm surprised that PO works faster than IV, I thought it was the other way around! IV has 100% bioavailability and doesn't have to go through first-pass metabolism to reach systemic circulation. When I used to work on the floor, we had K+ and Mg+ replacement protocols...for the K+, it was always recheck a K+ level 1hr after IV replacement and 2hrs after PO.

[BostonFNP, APRN]

As other have said there is really not enough clinical information to make many different answers right/wrong.

I think you did a good job of assessing the situation and developing a reasonable plan.

[offlabel]

Cardioversion is an option, but this is my pharmacology course and the focus is pharmacological treatment vs. other interventions. When we were talking about treatment for VF, she focuses solely on epinephrine 1mg Q3-5min or vasopressin 40 units to replace the first or second dose of epi and amio 300mg and no mention of defibrillation (or CPR!).

Thank you for taking the time to look over this!

I gotcha... theory v. reality... it is what it is... btw, the instructor here should advise that vasopressin is off of the ACLS guidelines.