C'Mere & Play a New Game: "GIVE OR HOLD"?

[UM Review RN]

Do you give these meds or hold them and why?

Yes, you may call the doc, but at least take a guess as to what the doc will order.

Tell us what you decide--give or hold--and say why. Then add one or two meds of your own.

(If you have issues with someone else's answers, you may "CHALLENGE" but be prepared to back your answers up with evidence!)

Here are two to get you started. They don't necessarily go to the same patient. Assume the patients are alert & oriented X3, unless otherwise stated.

Don't forget to give the critical information necessary to make a decision.

1. Rhythmol 150 mg po. HR = 55, Rhythm = Sinus Brady with a 1st degree AV Block, BP 120/60.

2. Clonidine 0.2 mg po. HR 34-42. Rhythm SB with a BBB. BP 143/68.

[sirI, MSN, APRN, NP]

ivf high to hydrate, remeber dka will be spilling lots of urine. they will be losing electrolytes, especially potassium, two ways, one through spilling urine, the other when you start the insulin infusion, it will drive the potassium into the cells. mag and calcium frequently have to be replaced. bicarb to correct the acidosis, maybe push an amp or two then ad a few amps to the ivf.

low grade temp is not significant at this point, but you can always to a cbc with diff and urine c&s if concerned

What important piece of information do you need before you give bicarb in a pt. like this?

[sirI, MSN, APRN, NP]

Which leads me to ask more questions:

If the temp would be from the trigger--an infection--UTI? So you'd also give ATB's, but which ones and how soon? Would the patient be given something like Rocephin in the ER right away or would that be dealt with after the DKA had stabilized somewhat?

What would be considered "stablized"?

A second set of ABG's and labs?

You can always start the abx in ER when the indication is there. No need to wait for DKA to resolve/stablize. Part of the "resuscitation" efforts.:)

What labs????

[Indy, LPN, LVN]

I'm stumped but will throw in one from last night. (I'm about to go to work, will find out what did happen in a while.)

60 y.o. female in CHF, on Natrecor and Heparin drip. Natrecor is usual protocol dose (long calculation in there somewhere). It's piggybacked into NS to KVO = 20ml/hour. Lungs clear. Tele reading Afib low 100-120's not sustaining in 120's.

An hour or so after natrecor infusion started, pt starts having couplets, and 3 beat moments of vtach that are difficult to characterize as vtach. Looks like A fib but complex is probably technically wide enough to be vtach. By 7 am she's having them every few minutes or so. Pt's asymptomatic.

Stop or continue infusion? My oncoming nurse didn't say but I think she was leaning towards stopping.

[NP2BE]

Just checking, why add potassium to fluids? How did you arrive at that dose? When do you give the bicarb? If you do........

on the bicarb- im guess check po2/pco2 levels. but I would give the bicarb anyways, dka with ph of 7.0, more like to have complications from not giving bicarb. 2nd- the potassium, at least the way we do insulin infusions- the could be gettinh 10-20 units of insulin an hour iv, by the time they get to bs below 250, you will have driven large quantities of extracellular K into the cells not to mention what the aptient loss via excessive diuresis, they will need K, and may need a bolus on top of the 20meq in the fluids.

[UM Review RN, ASN, RN]

What important piece of information do you need before you give bicarb in a pt. like this?

Potassium seems to be a major player here. The first excerpt recommends getting a K+ level and treating if

(Yeah, I'm surprised--it only made sense after I thought about it. No sense in causing life-threatening arrhythmias while trying to cure the patient, is there?)

I guess because the pH is so low, the Pt. would need to have the bicarb, but according to the lower section of the article quoted, Bicarb can lower K+ so you'd need to see what the levels are before you began replacement?

Siri, please let me know if I'm on the right track here, ok? :)

(I really really need a life. I'm actually having fun with this! :uhoh21: )

From "Diabetic Ketoacidosis,"

http://www.aafp.org/afp/20050501/1705.html

potassium

Whole body potassium deficits typically are 3 to 5 mEq per L (3 to 5 mmol per L). Acidosis increases potassium levels and glucose administered with insulin lowers them. Before treatment of DKA, the level of potassium usually is normal or elevated. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L.3 Usually 20 to 30 mEq (20 to 30 mmol) of potassium is given for each liter of fluid replacement. If the potassium level is less than 3.3 mEq per L (3.3 mmol per L), potassium replacement should be given immediately and insulin should be started only after the potassium level is above 3.3 mEq per L.3

bicarbonate

Studies of patients with a pH level of 6.9 or higher have found no evidence that bicarbonate is beneficial,34 and some studies have suggested bicarbonate therapy may be harmful for these patients.35-37 The flowchart in Figure 13 advises giving no bicarbonate if the pH level is greater than 6.9. Because there are no studies on patients with a pH level below 6.9, giving bicarbonate as an isotonic solution still is recommended. Bicarbonate therapy lowers potassium levels; therefore, potassium needs to be monitored carefully.

[sirI, MSN, APRN, NP]

Potassium seems to be a major player here. The first excerpt recommends getting a K+ level and treating if

(Yeah, I'm surprised--it only made sense after I thought about it. No sense in causing life-threatening arrhythmias while trying to cure the patient, is there?)

I guess because the pH is so low, the Pt. would need to have the bicarb, but according to the lower section of the article quoted, Bicarb can lower K+ so you'd need to see what the levels are before you began replacement?

Siri, please let me know if I'm on the right track here, ok? :)

(I really really need a life. I'm actually having fun with this! :uhoh21: )

From "Diabetic Ketoacidosis,"

http://www.aafp.org/afp/20050501/1705.html

potassium

Whole body potassium deficits typically are 3 to 5 mEq per L (3 to 5 mmol per L). Acidosis increases potassium levels and glucose administered with insulin lowers them. Before treatment of DKA, the level of potassium usually is normal or elevated. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L.3 Usually 20 to 30 mEq (20 to 30 mmol) of potassium is given for each liter of fluid replacement. If the potassium level is less than 3.3 mEq per L (3.3 mmol per L), potassium replacement should be given immediately and insulin should be started only after the potassium level is above 3.3 mEq per L.3

bicarbonate

Studies of patients with a pH level of 6.9 or higher have found no evidence that bicarbonate is beneficial,34 and some studies have suggested bicarbonate therapy may be harmful for these patients.35-37 The flowchart in Figure 13 advises giving no bicarbonate if the pH level is greater than 6.9. Because there are no studies on patients with a pH level below 6.9, giving bicarbonate as an isotonic solution still is recommended. Bicarbonate therapy lowers potassium levels; therefore, potassium needs to be monitored carefully.

You are absolutely 100% correct. If you do not know what the K+ level is, you will more than likely cause a fatal outcome if you indiscriminately administer bicarb without first knowing the K+. Give K+ and get to at least 3.3, then start the insulin drip. Bicarb is controversial at this time. And, as you pointed out in the article, probably not necessary for this DKA.

This patient has a K+ of 2.5.:)

[UM Review RN, ASN, RN]

This patient has a K+ of 2.5.:)

This patient probably isn't looking very good on the monitor, either! :uhoh21: I expect a flattened T-wave, possible U-wave, PACs and/or PVCs....

OK, I'm gonna take a leap here and assume that this patient is still in the ER, so they can replace K+ faster than we can on the floor.

So Pt needs 40 mEq K+ bolus IV in 100 ml of D5 over 1-2 hours X1. Then K+ level one hour after bolus is complete?

[sirI, MSN, APRN, NP]

This patient probably isn't looking very good on the monitor, either! :uhoh21: I expect a flattened T-wave, possible U-wave, PACs and/or PVCs....

OK, I'm gonna take a leap here and assume that this patient is still in the ER, so they can replace K+ faster than we can on the floor.

So Pt needs 40 mEq K+ bolus IV in 100 ml of D5 over 1-2 hours X1. Then K+ level one hour after bolus is complete?

The rapid infusion replacement for this patient with severe deficit especially with s/s impending arrest would be:

Initial infusion: 2 mEq/min, then 10 mEq IV over 5-10 min. With a max IV replacement 10-20 mEq/hr. Recheck K+ in 15-30 min., then every hour.:)

[nursepenny]

I'm stumped but will throw in one from last night. (I'm about to go to work, will find out what did happen in a while.)

60 y.o. female in CHF, on Natrecor and Heparin drip. Natrecor is usual protocol dose (long calculation in there somewhere). It's piggybacked into NS to KVO = 20ml/hour. Lungs clear. Tele reading Afib low 100-120's not sustaining in 120's.

An hour or so after natrecor infusion started, pt starts having couplets, and 3 beat moments of vtach that are difficult to characterize as vtach. Looks like A fib but complex is probably technically wide enough to be vtach. By 7 am she's having them every few minutes or so. Pt's asymptomatic.

Stop or continue infusion? My oncoming nurse didn't say but I think she was leaning towards stopping.

You didn't say, but I am gonna assume the Natrecor and Heparin were running into seperate sites, as they are incompatible.

To my understanding, Natrecor is used as a diuretic for CHF. I have not found any reference where Natrecor causes arrythmias....just bottoms BP out.

This came from the nesiritide web site. http://www.rxlist.com/cgi/generic/natrecor_ids.htm

Please set me straight if I am wrong, as we give a lot of Natrecor here.

The Natrecor bolus must be drawn from the prepared infusion bag.

Natrecor (nesiritide) is for intravenous use only. There is limited experience with administering Natrecor for longer than 48 hours. Blood pressure should be monitored closely during Natrecor administration. See the article below

If hypotension occurs during the administration of Natrecor , the dose should be reduced or discontinued and other measures to support blood pressure should be started (IV fluids, changes in body position). In the VMAC trial, when symptomatic hypotension occurred, Natrecor was discontinued and subsequently could be restarted at a dose that was reduced by 30% (with no bolus administration) once the patient was stabilized. Because hypotension caused by Natrecor may be prolonged (up to hours), a period of observation may be necessary before restarting the drug.

The recommended dose of Natrecor is an IV bolus of 2 µg/kg followed by a continuous infusion of 0.01 µg/kg/min. Natrecor should not be initiated at a dose that is above the recommended dose.

Prime the IV tubing with an infusion of 25 mL prior to connecting to the patient's vascular access port and prior to administering the bolus or starting the infusion.

Bolus followed by infusion: After preparation of the infusion bag, as described previously, withdraw the bolus volume (see table below) from the Natrecor infusion bag, and administer it over approximately 60 seconds through an IV port in the tubing. Immediately following the administration of the bolus, infuse Natrecor at a flow rate of 0.1 mL/kg/hr. This will deliver a Natrecor infusion dose of 0.01 µg/kg/min.

To calculate the appropriate bolus volume and infusion flow rate to deliver a 0.01-µg/kg/min dose, use the following formulas (or refer to the following dosing table):

Bolus Volume (mL) = 0.33 x Patient Weight (kg) Infusion Flow Rate (mL/hr) = 0.1 x Patient Weight (kg)

[NP2BE]

The rapid infusion replacement for this patient with severe deficit especially with s/s impending arrest would be:

Initial infusion: 2 mEq/min, then 10 mEq IV over 5-10 min. With a max IV replacement 10-20 mEq/hr. Recheck K+ in 15-30 min., then every hour.:)

not to split hairs here but I will give you that bicarb may cause controversy bc of new research. But I am giving it along with K+ and an insulin infusion. there K+ is going to go up with the IVF. and yes if their K+ is lower then 3.3 then a rapid 40 meq bolus over 2 hours is a good idea also. But if they have arrythmia, it wont be because you just gave bicarb, it will be because their k+ was low for a significant amount of time. a sharp decrease in K may cause some ventricular iritability, but its usually a prolonged period of low k+ that you see ekg changes unless accompanied by other preexisting conditions.

But that is good to know about bicarb lowering K+ further. I know everyone is getting away from the use of bicarb, but I bet i can find research to counter the research on its use. My point being, there is not enough evidence to justify not using it, at least in my view

[NP2BE]

You didn't say, but I am gonna assume the Natrecor and Heparin were running into seperate sites, as they are incompatible.

To my understanding, Natrecor is used as a diuretic for CHF. I have not found any reference where Natrecor causes arrythmias....just bottoms BP out.

This came from the nesiritide web site. http://www.rxlist.com/cgi/generic/natrecor_ids.htm

Please set me straight if I am wrong, as we give a lot of Natrecor here.

The Natrecor bolus must be drawn from the prepared infusion bag.

Natrecor (nesiritide) is for intravenous use only. There is limited experience with administering Natrecor for longer than 48 hours. Blood pressure should be monitored closely during Natrecor administration. See the article below

If hypotension occurs during the administration of Natrecor , the dose should be reduced or discontinued and other measures to support blood pressure should be started (IV fluids, changes in body position). In the VMAC trial, when symptomatic hypotension occurred, Natrecor was discontinued and subsequently could be restarted at a dose that was reduced by 30% (with no bolus administration) once the patient was stabilized. Because hypotension caused by Natrecor may be prolonged (up to hours), a period of observation may be necessary before restarting the drug.

The recommended dose of Natrecor is an IV bolus of 2 µg/kg followed by a continuous infusion of 0.01 µg/kg/min. Natrecor should not be initiated at a dose that is above the recommended dose.

Prime the IV tubing with an infusion of 25 mL prior to connecting to the patient's vascular access port and prior to administering the bolus or starting the infusion.

Bolus followed by infusion: After preparation of the infusion bag, as described previously, withdraw the bolus volume (see table below) from the Natrecor infusion bag, and administer it over approximately 60 seconds through an IV port in the tubing. Immediately following the administration of the bolus, infuse Natrecor at a flow rate of 0.1 mL/kg/hr. This will deliver a Natrecor infusion dose of 0.01 µg/kg/min.

To calculate the appropriate bolus volume and infusion flow rate to deliver a 0.01-µg/kg/min dose, use the following formulas (or refer to the following dosing table):

Bolus Volume (mL) = 0.33 x Patient Weight (kg) Infusion Flow Rate (mL/hr) = 0.1 x Patient Weight (kg)

Not having too much experience with natrecor, id say some CVP monitoring is in order. But this sounds like a problem that has to have more pieces of the puzzle in place like patient history, EF, other meds, . etc But again, natrecor not my strong suit, i dont use it much. I thought it was more then a diuretic though, doesnt it improve cardiac output through use of a natural substance produced by the body as well as cause diuresis?

[hrtprncss]

Just Wanted To Say That This Is A Great Thread!!!