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).

[highlandlass1592, BSN, RN]

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!

Actually, digoxin IS NOT contraindicated with amiodarone...however it is administered very carefully (for example, it may be a low dose admininstered every other day instead of daily). This is done with heart failure patients all the time. What usually transpires if Amiodarone is needed to be started is that the dose of Amio is usually lower than normal, dig levels are checked freqently and dig dosing is adjusted.

[highlandlass1592, BSN, RN]

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.

Your issue is one that definitely should be brought up with your pharmacy committee. You do need parameters, especially when these two drugs are administerd together. I agree with Virgo, the doc may have been looking at a contractility issue other than a rhythm issue. Some things to think about: the rhythm wasn't mentioned, was the patient symptomatic with this heart rate? Did you think to ask about stopping the Amio load? If the patient had converted, he may have been able to switch to po Amiodarone in the am. I echo your concern regarding this pt's rate but would again be curious about the rhythm. Another area to consider is if the dig load was a normal dose or half? In many pt's receiving Amio, we will decrease the load amount.

As for issues to discuss with the MD: I'd definitely bring up your concerns such as: "Dr.Smith, pt's Jane Doe's rate is now 48 with a slow brady with a normal PR interval. BP is 91/60 which is what she's been running. I see she's supposed to get Digoxin 0.25 mg IV and I'm concerned it would further her bradychardia and she may become symptomatic. I'd like to turn her Amio gtt off and then give the Dig to improver her contractility. Would that be ok?" (Doses listed are my own making). But by approaching your doc in a similar manner, the doc knows you're looking at the overall picture and at the same time advocate for your patient. You could also bring up when he'd like to check a dig level "since I know Amiodarone potentiates Digoxin and can elevate the level to a level of toxicity quickly". Sometimes, honestly we have to paint a picture for an MD to get them to see our concerns and what we'd like to do about it.

From this point, I'd definitely contact the head of the Pharmacy dept and express your concerns that this institution has no guidelines for the concurrent administration of Digoxin and Amiodarone and that you'd appreciate them conisdering guidelines to publish for staff RN's so they know how to deal with this and it could be a prescribing guideline for MD's as well. It will only help ensure a positive patient outcome. Just some thoughts on my end, hope they may help

[imaRN08]

i also recall that amiodarone is contraindicated with dig, point blank period

i have never heard of this.... we have pts who routinely receive both. we also have instances where they are on IV cardizem and amio. depends on the pt and the outcomes (or lack of) they are experiencing. I havent seen it often, but i have had a few pts on both gtts.

as far as giving the dig or not... i would have consulted with my peers and also would have probably ended up calling the Dr, weather he wanted to be "bugged" or not. our cardiologists are the same way, weather its important or not, they are still p*issed you call and "bother" them, but they are even more ticked when not called about a questionable medication. there was a reason he wanted it given. what would be an important consideration is if the pt was still in fib or had they converted? we typically notify if they are on cardizem or amio if the HR gets to be around 50; or if they are symptomatic.