Which pressor to use???

[cardiacRN2006]

Hey guys! I work in a MSICU, but we had a pt the other day who was actively infarcting. Had been cathed a few weeks prior, diffuse CV disease, med management only.

He went into resp distress on floor, hypotensive, low HR, transferred to unit. Was on 4 pressors in the night, but became stable by morning for me and was only on dobutamine at 5mcgs.

Fast forward to middle of the day when the pt suddenly became hypotensive and tachycardic. SBP of 60. All 4 of my pressors are still on the pumps (not attached to pt). SOooooo, my question is, how do you know which one to re-start, dc, or titrate up? Dobutamine, levo, dopamine, epi were all available to me. I'd like to hear some suggestions before I tell you what happened.

[augigi, CNS]

Agree it's difficult to choose without adequate information. However, you got to just treat what you see in the patient with what you have, and avoid making things worse. With evolving ischaemia, I'd definitely avoid using epi/dob/dop and increasing cardiac work, and just use the levo in the first instance.

[ghmccart]

study your meds, and research them, it is up to you

[phiposurde]

Very interesting thread. I have more question then answer actually !! Here goes: what did the ecg shows?? I find it strange that the person in shock present with bradycardia as well. You aslo state that there was an active MI.. how come He didn't go back to the cath lab?? What was his po2 on the ABG? Was he intubated? If so, what was the trend of the capnograph? What kind of respiratory distress what he in?( laboured breathing, low sat, ect) If so, I believ he could have benefitiate from some bi-pap.

As for the main question, I never really played with IABP but woudn't he be a very good canditate?( Non compensate shock, low EF, possible cardiogenic shock). I do agree that he would have been a good candidate for more invasive monitoring. As for the CVP assessment, even if there was no actual monitoring, his JVP could have help. Is it very important to know cause pressor are useless if you have nothing the press. You can't press and empty reservoir. I think I would have use:

dopamine at 5-10 for it's inotropic effect. Stop the epi cause it increase the o2 demand, SVR and present risk for ectopic beat. Having already PVC in such a fragile heart I woudn't want to add v-tach to that. I would keep him on the levophed for now but keep in mind of the multi organ shut down with all that constriction, the increase SVR and the risk again for v-tach. But it has a inotropic effect what we want here. I would stay away from the phenylephrine beacause it has all the bad effect of levophed with no inotropic effect. I would consider maybe a lidocaine drip related to the PVC and the risk with the other pressor. Amiodarone with be a poor choice beacuse of his effect on the av conduction( negative chronotrope) and negative inotrope. As for the NTG, am not sure. It depend of the result of the ECG. If the patient present with inferior MI or R side MI I think it is very bad idea. But if the patient do present with CHF and not improve with the inotrope effect of the pressor maybe Primacor could be use cause it increase the CO and decrease the SVR which would help reverse the side effect of the levo. As for dobutamine, not sure. This guy heart seem in a very bad place right now. but if his oxygenation is very good increasing the o2 demand with the inotrope effect could have less effect. Plus, the Bipap could help with oxygenation and help with some of the preload and afterload. anyway that was my 2 cents!!8)

[cardiacRN2006, ADN, RN]

Ugh, I don't even remember this pt anymore, to be honest. This thread is more than 7 months old. But we didn't have any kind of hemodynamic monitoring, we had no cath lab available, and certainly no access to an IABP. I wasn't talking about what to do with all the info at hand, I was asking what to do for the IMMEDIATE situation. I was in the room when the hypotensive event happened, and had all the meds hanging up on my pump, but not attached. I had received some very good info from this thread, and I have appreciated it all. Thanks for your detailed answers guys!

study your meds, and research them, it is up to you

Umm, I was a brand new nurse still on orientation when this thread was first posted, and I just wanted opinions of what experienced nurses preferred and why. I'm aware that it was up to me...I didn't come over and post this thread on allnurses mid-shift. I took care of my patient and sought answers from other people later.

[phiposurde]

No CVP, pt was vented AC 16, not overbreathing the vent. Also was on 4 of versed (which I cut down) and 50 of Fentanyl (also cut down). EKG was SR with lots of PVCs, then right to ST during this event. No st elevation, but troponin was 11.5! The whole situation lasted about 10 minutes, but I did have to through the pt in trendellenberg for a while.

It is not recommend anymore to have patient in tredelemburg

http://www.caep.ca/page.asp?id=DF61785B363D4460835A593243E70058

[heartrn4duke]

Sounds like an RV infarct in that case fluids and dobutamine for fill and squeeze. Intubate if needed. RV infarcts need fluid. Dopamine for quick response. Dopamine has some alpha effects too and is good for RV infarcts.

[jen123321]

Tranducing CVP's is a nursing judgement where I work...all you have to do is set up the pressure tubing and hook it up, you really don't need a dr's order to do that.

[cardiacRN2006, ADN, RN]

Sounds like an RV infarct in that case fluids and dobutamine for fill and squeeze. Intubate if needed. RV infarcts need fluid. Dopamine for quick response. Dopamine has some alpha effects too and is good for RV infarcts.

The pt was intubated.

jen123321, we do need an order for the CVP, plus the pts c-line was in the groin.

[TopherSRN]

we do need an order for the CVP

sounds like you need some autonomy as well. If you paged a physician, and they said 'What his CVP?' would you really respond with "i dont have an order to xduce one'? I get all the information I possibly can before I page one of our surgeons, as well they expect me to. Suuuuuurely you can verbal xducing a CVP??

[cardiacRN2006, ADN, RN]

sounds like you need some autonomy as well. If you paged a physician, and they said 'What his CVP?' would you really respond with "i dont have an order to xduce one'? I get all the information I possibly can before I page one of our surgeons, as well they expect me to. Suuuuuurely you can verbal xducing a CVP??

I think everyone missed the part where I said we were a MSICU, not a CCU. We rarely use CVPs, and sure I can take a verbal order to do anything, but the Drs never ask for them and we rarely use them.

So yes, if I paged the Dr and he asked for the CVP (has never happened on a pt without a CVP), I'd sure as heck tell him that I needed an order for it.

[jen123321]

Ok the CVP argument is getting old!...whether you have an order or not...Dr's and certainly residents (do you work at a teaching hospital?) don't know it all and forget things too. If you are actively resuscitating someone with fluid and using various gtts, you need to know more about the fluid volume status of the patient...so, that being said...if you are an ICU nurse you should be using your critical thinking skills (I'm not being a smartass.) and know that a CVP reading could help this situation and I guess you need an order for that at your institution so next time the MD walks by or the resident on call is paged for something just suggest that a cvp reading might be valuable! No pressors will work if there's nothing in the veins... micu/sicu patients often require cvp transducing...if the pt has a central line with any hemodynamic instability, it can't hurt...I hear you on the femoral line...it's not the best reading, but it will suffice.

[cardiacRN2006, ADN, RN]

Ugh, you're right, it is getting old...

Again, this thread was started 7 months ago when I was still on orientation.