Hypotension and antihypertensive meds

[Eirene, ASN, RN]

Hey guys;

I'm a new grad and have been practicing for a few months. I have a question about hypotension and meds. Below is the scenerio.

Yesterday, my patient (CHF) had a BP of 60/D. Mild confusion when she was totally oriented before. I put her in trendelenburg and started a 250ml of IV volus per PCU protocol. Her EF was 35%. The cardiologist came in (who is moonlighting for a cardiologist who is on vacation) told me to bump the bolus up to 500ml. I put a second line in and waited for the BP to come up.

BP finally came up to 104/42. She had Coreg and Imdur ordered. I cautiously administered Imdur but held the Coreg.

Her family physician came in and was upset that Cardiology made a big deal out of her BP, said I could have sent her into acute HF. On my assessment her lungs were totally clear and had very poor skin turgor. She was definitely hypovolemic.

He was also angry that I held her Coreg and told me to give it ASAP. BP was still stable, hanging out at the 100/40's.

Was in wrong in not administering the Coreg when it was due?

[mama_d, BSN, RN]

Tough situation.

Given the EF and hx of CHF, I'd probably have called the cardiologist and let him have handled the situation of whether or not to give Imdur, Coreg, or both. I've had parameters on those kinds of patients for Coreg to give it as long as SBP is >85. It's a difficult call to make, I'd have taken the route where I could have said "Dr. soandso instructed me to give/not give it when I called to verify dosages given the situation with her BP."

I try to look ahead and anticipate if I may need to hold meds when situations like that arise and get parameters to avoid further calls, especially since I work nights.

[Spatialized]

I would have given the Coreg, not the Imdur when the BP stabilized. It's the whole beat-blockade/reduced workload-thing that we're working towards with chronic HFers. We're trying to maximize the ability of the heart while minimizing the workload - make it work more efficiently. That's probably why the FP was ******.

Other than that, I think the intervention matched the issue. Yes, maybe a 500ml bolus may have put the patient into worse HF, but when they are hypotensive AND symptomatic you have to do something and a bolus is a good way to fill the pump.

You'll find that our HFers are better able to handle their meds, especially the "cocktail" (beta-blocker, ACEI, diuretic) combo that many are on and are functional at lower BPs than most. In many cases with these folks I see parameters around 80-90 SBP to hold, many times that's where they live.

Chalk it up to a learning experience.

Cheers,

Tom

[ghillbert, MSN, NP]

500ml is a large bolus to give to a CHF patient. I don't think I would have given the meds with a BP of 60/ though. It's up to the doc. As soon as the patient was euvolemic, I would have given the meds.

[Virgo_RN, BSN, RN]

I would have asked the cardiologist. Most likely, they would want the Coreg given and the Imdur held.