Multiple Drips - Did I do the right thing?

Specialties CCU

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I had a patient with cardiomyopathy and 2nd degree type 2 HB that went in for an elective PPM placement, during the procedure, she got a hemothorax and was brought to our unit. I had her that night. She was vented, on a bicarb drip, dopamine, neo and levo drips. An epi drip had just been weaned off about 2 hours earlier and was on standby. Paced rythm with stable BP at the time. I had orders to wean dopamine last.

A couple hours later, she starts getting tachy, HR 110-120, A-fib. Her systolic BP drops to the 50-60's. I turned up the neo and levophed, but decreased the dopamine because I thought it might be contributing to the increased HR. The BP was still not rising, so I started the Epi drip thinking she could use an inotrope? I was worried that the Epi might make things worse since she was tachy already. The BP did come up and the doctor called back after all this and gave an order for an amio bolus and drip to be started. The heart rate came back down I got the epi turned off shortly after.

She was not dumping much out from her chest tube, I did not have a CVP, but I think her volume status was ok.

What do you guys think about this, was it the right call to turn back on the epi drip? Was I right in initially turning down the dopamine and increasing the levo and neo?

Thanks,

B

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Specializes in CTICU.

If I was concerned enough about tachycardia to stop/reduce dopamine, I wouldn't start epi, no, which generally has a far more severe tachycardic effect. Of course it's hard to 2nd guess from here, without the numbers and patient info at hand - why was she on a bicarb drip? Why did they want dopamine weaned last? Why was she acutely hypotensive?

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She had initially been bradycardic and that was the reason to wean the dopamine last. She became acutely hypotensive I suppose because of the A-fib which started at a rate of 110-120 , but eventually got up to the 140's before I got the Amio started. She had a low EF to begin with and the rapid rate decreaded her preload. She was on bicarb because of no other reason than her respiratory acidosis from what I remember. Turning up the Neo and Levophed did not bring her pressure up much, so that is when I tried the Epi, which worked. Once the amio brought her HR down, the problem seemed to be fixed and the epi was turned off.

I think Dobutamine may have been the best option looking back, but I did not have an order for it and was waiting for the Doc to call back.

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She was on bicarb because of no other reason than her respiratory acidosis from what I remember.

Typically you shouldn't treat resp acidosis with NaHCO3 unless it's in a code and you need to correct the acidosis. I know you didn't do this...but just making an observation.

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Specializes in Critical Care.

I would of liked to have a CVP just to see if she was hypovolemic..if levo and neo didn't bring up your pressure that leads me to think that either she was dry or she needed a better inotrope than dopamine. I agree that dobutamine would of probabaly been a good thing to start if the doctor had called back. I think it sounds like she needed some volume, levo and neo are great drugs but you need to have enough circulating volume for the vessels to clamp down on, otherwise you're really not vasoconstricting on much of anything. And the Bicarb drip is an odd one. Usually to correct resp acidosis you can change some vent settings and help bring down the pCO2. I personally have never had a bicarb drip so idk what it can do side effects wise. But I think you did the right thing..you kept them alive and thats all we can do.

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Specializes in MICU/SICU.

Was the PPM placed under fluoroscopy or in a way that involved dye/contrast? I've seen a couple of patients recently come back on bicarb gtts - it's supposed to somehow help metabolize the dye out and/or protect the kidneys. Since the kidneys produce the bicarb my guess is it's something to do with that but I don't know the exact mechanism. Anyway, they stay on the bicarb for 6 hours then it's shut off.

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That could explain the bicarb drip possibly. I am not positive if dye/contrast was used.

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Specializes in MICU/SICU.

In any case, I would agree with EMTRN....you kept your patient alive using the tools you had....that makes it the RIGHT THING :)

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Specializes in CTICU.

I would definitely have considered some volume if the patient was going into more rapid AF and has a poor ventricle/low EF. I don't think I would have used epi since increasing the HR would only make things worse, and potentially if the patient is acidotic then epi isn't a great choice. Dobutamine sounds like it would be right.

You're right though, in the short term, it probably didn't do enough to matter.

I would urge you to make sure you know why your patient is on every infusion though - that's a great way to put everything together and learn more, which lord knows we all need to do all the time in ICU.

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Specializes in MICU/SICU.

I agree that volume sounds like it might have been appropriate, but for that a doctor's order would have been necessary....and in the OP, the writer said he was waiting for the MD to return the call. We can only use the tools we're given.

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Specializes in Critical Care.
Was the PPM placed under fluoroscopy or in a way that involved dye/contrast? I've seen a couple of patients recently come back on bicarb gtts - it's supposed to somehow help metabolize the dye out and/or protect the kidneys. Since the kidneys produce the bicarb my guess is it's something to do with that but I don't know the exact mechanism. Anyway, they stay on the bicarb for 6 hours then it's shut off.

We use a protocol all the time for dye loads...utilizes mucomyst po being administered x 4 doses then a bicarb gtt 3ml/kg/hr for one hour prior to dye load then 1ml/kg/hr during load then 6 hours after. It is supposed to protect the kidney function. We don't use it for pacer insertion but use it a lot for CT scans and then endovascular aneurysm repair as well as cath patients.

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Specializes in Critical Care.
I had a patient with cardiomyopathy and 2nd degree type 2 HB that went in for an elective PPM placement, during the procedure, she got a hemothorax and was brought to our unit. I had her that night. She was vented, on a bicarb drip, dopamine, neo and levo drips. An epi drip had just been weaned off about 2 hours earlier and was on standby. Paced rythm with stable BP at the time. I had orders to wean dopamine last.

A couple hours later, she starts getting tachy, HR 110-120, A-fib. Her systolic BP drops to the 50-60's. I turned up the neo and levophed, but decreased the dopamine because I thought it might be contributing to the increased HR. The BP was still not rising, so I started the Epi drip thinking she could use an inotrope? I was worried that the Epi might make things worse since she was tachy already. The BP did come up and the doctor called back after all this and gave an order for an amio bolus and drip to be started. The heart rate came back down I got the epi turned off shortly after.

She was not dumping much out from her chest tube, I did not have a CVP, but I think her volume status was ok.

What do you guys think about this, was it the right call to turn back on the epi drip? Was I right in initially turning down the dopamine and increasing the levo and neo?

Thanks,

B

I second the others. You work with what you've got. I too would have liked to seen a CVP...sounds like a dry situation. Epi does put more stress on the heart but treating the Afib was really what you needed to do and ultimately did. Reason I'm wondering about a volume situation is if the tank ain't full, the pressor won't work.

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