Giving Digoxin with an Amiodarone drip and HR of 48

[Ceteris Paribus]

I had a client a few nights back who had been transferred to our PCU after going into tachycardia in the 150's. (not sure what type of tach, but I'm pretty sure it was a narrow complex). The person was elderly, anemic and had lung Ca with mets to the kidneys, history of PE and many other things. Any way by the time I came on evening shift the client was in sinus brady at around 50 with a pressure of around 92/50, AOL 2-3, GCS 14-15 and with Amiodarone going at 0.5 mg per minute per protocol. Anyway, I'm supposed to give 0.25 mg of dig (the second of four doses) the first brought her out of the tach on the other unit. I called the cardiologist because I didn't want to give the dig with the Amio drip and borderline HR/BP. He responded "the dig won't affect the heart rate and you need to give it". He did have me run down the medications to make sure she wasn't also on a Beta or Ca++ blocker. I consulted with my charge nurse and was told that if this Doctor says to give the drug then that is what I need to do. So 0200 rolls around and it's time for another dose of dig and the HR is now 47-48 with the pressure 91/45. I'm told that this doctor hates to be called late and besides the protocol only specifies calling doc for HR under 40 (the Amiodarone protocol that is). I consult with several other nurses and end up not giving the dose and charting that the patient refused (she actually did, but with my explanation of the circumstances). If I ever encounter this situation again what are some better options for me. Also were my concerns about the low HR/BP without basis (with regard to giving the dig).

[Straydandelion]

It is a tough call, and honestly I don't know the parameters enough to say positively what is the correct and safest thing to do in that circumstances. As such, before I second guess, whether the doc doesn't like to be called or not, I would have called.

[suanna]

So, the doctor felt the the digoxin was warrented with a HR 50 and a BP of 92/50 but when the HR drops 2- points to 48, and the SBP drops ONE WHOLE POINT to 91 from 92 you felt this was just too much risk and skipped the med??? I know, the patient "refused", with encouragement fron the nurse in the middle of the night. Did you also tell the patient that his VS were the same as earlier in the evening and the doctor specifically felt it was improtant to continue loading the digoxin. You were appropriate and prudent to question the dose given the first vitals, I feel you were way out of line with encouraging the patient to refuse the next dose. The doctor is in charge of this decision. You voiced your concerns and the orders were clairified to continue loading the dig. If it were one of the several cardiac docs I work with, you had better not be standing too near the defib paddles when they find out about the held dose. As to the letter of the law- you cannot avoid calling the doc just because you chart " pt refused". The physician needs to be notified of the refusal and be allowed to adjust the course of treatment as necessary- maybe a move to a more acute unit, of have the resident come in to review the meds and thier purpose ( he could even come in himself). That is not your perogative as a nurse to withhold this information from him even if it is 2am.

[fiveofpeep]

what was hospital policy for the hr parameters for dig?

[mamamerlee, LPN]

There was no real change, was there? If I would have questioned this order (which I don't at this point) call the supe, then call the MD. The patient is not the reliable source to decide on her course of treatment here.

[medicrn13]

I called the cardiologist because I didn't want to give the dig with the Amio drip and borderline HR/BP. He responded "the dig won't affect the heart rate and you need to give it". ... I consulted with my charge nurse and was told that if this Doctor says to give the drug then that is what I need to do.

There is your answer. It's very easy to write "MD contacted, notified of vital signs, MD order to administer medication regardless of vital signs...Charge nurse aware..." Your butt is covered.

Agreed, with the MINIMAL change in vital signs from the previous dose of Dig, why hold this dose?

Good of you to question things though.

[Ceteris Paribus]

Well here were my thoughts:

I came from a hospital (about two months ago) where giving dig in this circumstances would have been unthinkable (against hospital policy). The hospital (small town) where I now work simply doesn't have a policy on this. I honestly felt that giving the dig. could have pushed the patient "over the edge". That's why I posted here because I wasn't really satisfied with my response (or the input from my co-workers) and want to respond better the next time. I've only been a nurse for about 18 months and this is the first time where I've been ordered to do something that I felt clearly put the client in jeopardy.

[Ayvah, RN]

One thing that may help in the future, is that when you are on the phone with the doc, before hanging up, ask him what parameters it would be ok to give vs if you should hold or call him. That way he could have said something like "call me if HR

[cardiacmadeline, RN]

Our hospital policy on dig is this-Prior to administering, you check an apical pulse. If lower than 50, you hold the medication. No need to call the doc and clarify. We would then leave a note for the rounding MD in the am so they are aware we held the dig.

Since you don't have a policy regarding dig, you did the right thing calling the doc, but I too would have asked for parameters on giving the dig so that you wouldn't have to call the MD in the middle of the night.

[Virgo_RN, BSN, RN]

I'm guessing that the doctor wanted to digitize for the purpose of increasing the force of contraction, not to slow conduction. The cardiologist probably thought it was pretty important that this patient have this medication. I agree with Ayvah, next time, ask for parameters. I will write those parameters as a telephone order in the patient's chart, then document in my narrative that the physician was notified of the HR and BP, and that orders were received.

I'm also thinking that rather than just looking at the rate, look at the rhythm. Is it sinus? With digoxin, be on the lookout for prolongation of the PR interval.

[JSTARZ]

ive never personally experienced this however i do recall from nursing school that measuring the PR interval for a pt with cardiac monitoring

is more important than the apical pulse in determining whether digoxin

should be held so i can agree with it being given in spite of the low pulse however i also recall that amiodarone is contraindicated with dig, point blank period! i probably would have refused to give that, wouldnt b the first and def not the last. if he wanted it given that bad in spite of my judgment he could have given the dose himself!

[highlandlass1592, BSN, RN]

Why do you think this nurse is safe from liability just because the doc says to give it? If a reasonable and prudent nurse deems an order a risk to the patient, they do have the right to withold a medication and seek an alternative. Just because a doc isn't concerned doesn't mean it's ok to give. Hence the need for protocols at this facility to cover the nurse. An MD recently told me to give a beta-blocker to a pt with an allergy to beta-blockers....he didn't believe the patient had a true allergy. I refused and respectfully told the MD he'd have to administer the drug himself. A reasonable nurse isn't going to medicate someone with a med they know they are allergic to. Had I carried out that order and the pt had an anaphylatic reaction (which happened to this patient in the past) I"D BE LIABLE! We have to remember we have our own licensing body we are responisble to, we are NOT responsible to doctors. Food for thought.