NaHCO3 lead to SVT?

Specialties MICU

Published

Hi all,

Had a really rough/busy night last night, but I'll get straight to my question:

One of my patients has a suspected case of necrotizing fasciitis. Her lactic acid on admission was 10.8, and had orders to start her on 1/2NS with 2 amps HCO3 at 100 ml/hr. The nephrologist also made rounds and ordered an additional 2 amps of HCO3 IV. I hadn't started the fluids yet, and pushed the 2 amps of HCO3. Before I was able to leave the room, she went into SVT with HR in the 180-210's. She was responsive, blood pressure stable, no obvious distress and would have brief periods where she would break and go into ST in the 120's which was her baseline. This went on for about 30 minutes. I called for stat EKG and notified the doc who didn't want to order anything until the EKG was obtained. By the time the EKG was done, it just captured her in ST with HR129. She came out of the episode and remained in ST the rest of the night with only 2 more short bursts of SVT lasting 30 - 45 seconds. I did call the MD the last time this occurred and she gave a 1 time dose of Lopressor 5mg IV.

Since I'm new to ICU, my questions are:

1. I have seen NaHCO3 given in code situations where it raises the HR and BP almost immediately. Did giving this patient the HCO3 lead to her SVT? Is this an expected side effect, or was this a freak coincidence?

2. We tried to get the patient to cough and/or bear down to try to break the SVT, but while she was easily arousable, she couldn't cooperate with our instructions. Is there something else we could have tried to break her rhythm?

3. I feel bad about her being in SVT for so long (30-40 minutes), but I did ensure she was stable, called for EKG, and notified the doc. Per our ESO, we could give Adenosine, but I was hesitant to do this because she was essentially stable. She did end up converting back on her own, so I'm kindof glad I didn't take the risks associated with giving adenosine. Would someone else have done something different? What would your thought processes be?

Thank you!

Specializes in MICU for 4 years, now PICU for 3 years!.

I have given bicarb numerous times and have never seen someone go into SVT, so I have to think it was just a coincidence... she probably had been in and out of it for a while... she sounded pretty sick. Looking up Sodium Bicarbonate in Lexi Comp, SVT is not listed as an adverse effect...

As far as giving the adenosine, I'd probably have hesitated too. If she was stable, BP normal, and mentating well, I don't know that I would have given it, especially not if your MD wasn't at the bedside, which it sounds like he wasn't. But, if her BP was the least bit unstable, or she wasn't A&Ox3 (or whatever her baseline was) I'd probably give it... Hopefully others can share their experiences with this with you too!

Specializes in Critical Care (ICU and ER).

if i had a standing order for adenosine that didn't include hemodynamic parameters for holding the drug in the presence of svt then it would have been pushed. 30-40 minutes of svt as high as 210? you can't argue that the pt's heart didn't experience some ischemia.

in my icu we have a standard "acls protocol" order. now, to me, acls protocols cover tacy/brady arrhythmia, not just pulseless arrhythmias. so when i have an order for "acls protocol" they're getting adenosine, cardizem, lopressor, amiodarone, and so on and so on. that also means i'm following the acs and cva guidelines set forth by aha. you ordered me to follow the current acls protocols as set forth by the aha; you're going to give me a broad brush to paint with so i'm going to do my best to make it colorful.

Adenosine is usually only used to determine what the actual rhythm is, and because of the transient 2-5 second asystole and sense of "impending doom" that it causes patients, we only use it if necessary. So your critical thinking- from my perspective- was on the mark. Nice work not responding in a "knee jerk" manner. Just because it is a standing order or a written order does not necessarily mean that it is right for the patient.

Specializes in NICU.

Disclaimer...Newborn ICU nurse here...

I have been taught by our docs that hemodynamically stable SVT can be quite prolonged without causing the patient harm. We send babies with hx of SVT, medicated, but without any type of monitor or anything. The parents are taught visible symptoms of SVT and to check the HR a couple times a day, but the docs say a baby can be in SVT for 24+ hours before it will start to induce heart failure. Are these principles true for adults too? If so, I'd say your judgement not to give adenosine was good.

Other maneuvers we use to induce conversion in a baby are ice pack to the forehead or passing a feeding tube to induce a vagal reaction.

Also, my understanding that bicarb in a code situation is a buffer to metabolic acidosis (assuming adequate ventilation). So, my guess is that raises blood pressure and pulse by reducing tissue acidosis and promoting the heart's ability to more adequately perfuse the tissues, including it's own. Which would lead to improved HR and BP, correct? Am I understanding the very basic pharmacology correctly?

Specializes in Pediatrics, ER.

Does your policy permit carotid massage? You could also try ice to the bridge of the nose/forehead to initiate a vagal response.

Specializes in icu/er.

around my first wk in the icu i had a co-worker develop a spont conversion to rapid a-fib at work once. her hr was in 150's after we ran a fast 3 lead strip on her. we had her try manual vagal and eye ball pressure but to no avail. then another nurse placed a few ice packs around her neck then... snap! she converted to sinus right there. it was pretty cool. from then on we called him the "iceman".

Specializes in CVICU.

Also, my understanding that bicarb in a code situation is a buffer to metabolic acidosis (assuming adequate ventilation). So, my guess is that raises blood pressure and pulse by reducing tissue acidosis and promoting the heart's ability to more adequately perfuse the tissues, including it's own. Which would lead to improved HR and BP, correct? Am I understanding the very basic pharmacology correctly?

Sorta. My understanding is that profound acidosis renders catacholamines ineffective which can create shock that's refractory to all the pressors.

Specializes in CVICU.
if i had a standing order for adenosine that didn't include hemodynamic parameters for holding the drug in the presence of svt then it would have been pushed. 30-40 minutes of svt as high as 210? you can't argue that the pt's heart didn't experience some ischemia.

in my icu we have a standard "acls protocol" order. now, to me, acls protocols cover tacy/brady arrhythmia, not just pulseless arrhythmias. so when i have an order for "acls protocol" they're getting adenosine, cardizem, lopressor, amiodarone, and so on and so on. that also means i'm following the acs and cva guidelines set forth by aha. you ordered me to follow the current acls protocols as set forth by the aha; you're going to give me a broad brush to paint with so i'm going to do my best to make it colorful.

hmm. i hope you're only doing this in emergencies while you're trying to get someone on the phone. "seek expert consultation". while i think i know when and when it's not appropriate to start an amio gtt i don't get paid enough to take the fall when something goes wrong. yes i would give someone an amio bolus if they were suddenly going in and out of vt but that's about it. could you clarify when you would start a cardizem gtt or give metoprolol without an order?

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