Held Coreg w/ BP of 100/55

[noyesno, MSN, APRN, NP]

[New grad here. Ortho/Neuro/Trauma floor.]

I held Coreg yesterday and I'm thinking I should have probably called the MD instead to see if the dose should be adjusted or if he wanted it held or not.

Here are the details:

-50 year old male, 140 lbs

-Patient had a nephrectomy

-On post op day 1 he had some minor chest pain, got stat labs drawn and his troponin was elevated

-Called a RRT and got a cardiologist on board

-Cardiologist ordered Coreg 6.25 BID

-The next day, in the morning, his BP was 100/55

-I looked to see what his BP went down to following his first dose of it on PM's and it went from 122/85 to 94/54

-Thought that was a pretty big drop and I worried what it would drop to if I gave it with a BP of 100/55

-He was also on a PCA that he was using very regularly which made me extra worried he would bottom out

-His hemoglobin was also 8.1 (had dropped from 16, urologist didn't want to transfuse, cardiologist did, urologist won and no transfusion was to be done) and it seemed like a bad idea for him to be anemic and also hypotensive

I should add, from reading the cardiologist progress note it appeared that the chest pain and elevated troponin was not related to CHF or anything but rather to his surgery and cancer. I know beta blockers shouldn't be held for CHF patients so if it wasn't CHF, I thought it would be okay. However, I also know beta blockers are given following a heart attack so I'm thinking I shouldn't have held it because of this.

Also, on post op day 1 the attending MD had discontinued the patient's lisinopril due to low BP (I think from the PCA).

My preceptor was okay with me holding the Coreg but I don't think she was very sure about it.

Overall, I'm not happy that I did not call the MD and I'm feeling a little dumb. Would like to learn from this situation.

Any pointers?

Thank you all in advance.

noyesno

[Turd Ferguson]

Probably calling the doc would have been a better option. Remember, beta blockers are not only used to reduce BP, but also reduce the workload and O2 consumption of heart muscle.

Don't beat yourself up about it, be accountable and learn from it.

[Anna Flaxis, BSN, RN]

Yes, I would have called the doctor on this one. There could have been a host of factors involved with the drop in BP after the previous dose; we don't really know that the Coreg caused it. Also, BPs can be so transient. I wonder if the nurse on shift at the time rechecked it, or checked in the other arm, or just accepted the reading without double checking?

Also, you didn't mention if you had any holding parameters. With no parameters from the ordering physician, I wouldn't just make a judgment call like that without checking with them.

[Forever Sunshine, ASN, RN]

I would have held it. If the B/P was lower such as systolic below 90.. then I would call the doctor.

[0402]

Our parameters actually say hold and notify MD if under X SBP. I work nights, so I'm usually just telling this to whoever is covering, but at least then, if it's borderline and the pt has other considerations, I can make sure the MD agrees or wants me to go ahead and give it anyway. 99% of the time, they just say- um, thanks. And I can chart- MD notified.

[Turd Ferguson]

I would have held it. If the B/P was lower such as systolic below 90.. then I would call the doctor.

I feel the opposite- holding the medication is a deviation from the plan of care prescribed by the physician. I feel the physician should know that you wanted to hold the medication and why. Maybe they were looking for a therapeutic outcome other than lowered BP from the beta blocker.

[hey nurse]

When I ran into this situation on the floor, if I expected to see the doctor within a couple of hours, I'd hold it until he came around and address any issues I was having with his patients at the time of his rounds and request parameters for the holding of BP meds. If he did not arrive on the floor in a reasonable amount of time I would go ahead and page and ask for parameters for BP meds and let him know about the situation at that time. Of course, if the BP was concerning to me (

[JB2007, ASN, RN]

I would need to know more info to decide if I would hold the med. The BP is low but I have give coreg when the BP was that low before. I guess my anwser is it just depends.

[Mulan]

At my place, we are not allowed to hold without an order, it's called practicing medicine without a license.

Next time, call the doctor, and also ask if he/she wants to give any parameters.

[calijaz]

I work on a Cardiac ICU. I would have given the Coreg. Holding a beta blocker for BP of 100/55 would not have been very popular with the cardiologist, and if I called him he probably would have asked me why in the world I called him. However if you are on the floor and your pt is not cardiac, this probably completely changes things. Also, Coreg 6.25 is a pretty small dose. The key with beta blockers is maximizing oxygenation to the heart muscles and allowing it to rest.

[merlee]

I would have called the doc for parameters.

[noyesno, MSN, APRN, NP]

Great responses. Thanks everyone.

Our docs rarely give parameters and the nurses on our floor hold BP medications all the time without consulting the docs. This is something I do not feel comfortable doing and will be calling to get parameters in the future.