Help with titration

[Butterfly922]

Hi! So I am a new grad in the ED just off orientation for a week. I have never had to titrate a drug before until the other day of coorifice when no one was really around to help.

Patient situation: initial BP 298/156.

Patient was given multiple medications while down in the ER. We were holding patients in the ER because all of our inpatient beds were full so I had to carry out regular med orders.

Order: Labetelol

Instructions: start at 1mg per min then titrate by mg per minute to keep Systolic BP Between 180-200. HOLD UNDER 180.

So when I asked another nurse how to interpret this she basically said just follow the instructions. The patient was on vitals q15 and and for some reason at the time I thought it meant every time I got a new BP to titrate up 1mg to the max of 3mg/min which I found out by looking up the drug. But an hour later the patients systolic was in the 160s. And I had to stop the medication.

So so my question is did I do that wrong or right? Could I have left it on 1mg/min based on my discression?

[jadelpn, LPN, EMT-B]

Is there a policy on critical drips in your ED?

I would err on the side of caution and do blood pressures every 5 minutes while a patient is still considered critical.

I would speak to the provider as far as the max dose, and double check the timing of the BP's.

When faced with this, especially the first couple of times, I would ask for clarification from the provider, and your charge nurse for assistance.

[ArmaniX, MSN, APRN]

I have never given a labetolol drip. Does your hospital have a drip policy that tells you how to properly titrate your medication.

I would find it more appropriate for this patient to have continuous blood pressure monitoring (arterial line) for more precise measuring. The order (goal) was to maintain the blood pressure between 180 - 200.

You stated that with each BP you went up 1mg/min up to the max of 3 mg/min. So within 45 minutes you maxed the patient on the labetolol?

I'm not am expert but I feel this was erroneous. The patients BP dropped below the goal of 180 into the 160s. To go from a sBP of 290s to the 160s seems like way to fast of a transition and I'd have been worried about rebound hypertension or any other number of problems depending on the patients clinical scenario.

Whether what you did was right or wrong, I don't know. I think you were wrong in administering a drip that you were unfamiliar with in terms of policy/guidelines. If no harm occurred to the patient great. But I feel in the future you should seek input or familiarize yourself with how to quickly look up policy and drip guides (I assume all hospitals have a drip guide?).

Also I understand the ED is it's own beast but safety should always be number 1.

[Swellz]

I had a nightmare shift once where I had a lot going on and a patient on a drip I'd never managed before. I won't get in to details, but bottom line is I kept getting contradictory information and no useful guidance from my coworkers, the docs, and pharmacy. I tracked down the clin spec on the cardiac floor and ultimately got the answers I needed. Never do something without knowing how or why. I've been there, it's frustrating and nerve-wracking, but you have to persist for your patient.

It sounds like you needed more specific parameters, which should have come from the doctors. Asking a coworker was a good idea, but if her answer didn't help, you can ask her to clarify or ask another coworker. Better yet, your charge nurse or clin spec.