Natracor and low bp

ZASHAGALKA, RN · Mar 23, 2006

Where I work, natrecor was a fad. Every CHFer was on it a year ago, now nobody is on it.

It seems like the person needs more aggressive measures than a DNR status would allow, like maybe a vent and some serious diuresis for the CHF instead of natrecor first, and then maybe some more active conversion measures for the hr, maybe a Cardizem gtt. (I can't imagine a BNP that high w/out some serious lung compromise - and that might be causing the arrhythmias w/ all the stress of trying to keep up.)

If his BNP was over 4000 then his intrinsic 'natrecor' was already sky high to no avail. He sounds like he needs other interventions FIRST. The natrecor might help him get a handle on a tethered horse, but this horse is untethered and out of control. You need to get reins on the problem BEFORE you pull on the reins.

But that is dxing from afar.

Regardless, if the dr is giving up on aggressive tx, then he's right, the guy is prob gonna die. Obviously, there are compound cardiac issues that are working against each other.

~faith,

Timothy.

ark-two · Mar 24, 2006

Cardizem gtt would be nice if his bp wasn't so low. A fluid bolus with a BNP That high, BUN and CR, possible Dehydration? A Demadex gtt would pull the fluid off better, or even a Lasix gtt with possible dopamine? I'd have to look at his EF. He may of had a low EF and that is why they are not aggressive. Curious to see if he is still on our floor. The thing that really bothered me was the low urine output and concentrtion of the urine. More signs of dehydration. This patient was admitted to a med-surg floor before coming to TELE, but I think he would be more appropriately placed in CCU. DNR does not mean do not treat, unless the patient and family does not want him to be treated.

ZASHAGALKA, RN · Mar 24, 2006

Cardizem gtt would be nice if his bp wasn't so low. A fluid bolus with a BNP That high, BUN and CR, possible Dehydration? A Demadex gtt would pull the fluid off better, or even a Lasix gtt with possible dopamine? I'd have to look at his EF. He may of had a low EF and that is why they are not aggressive. Curious to see if he is still on our floor. The thing that really bothered me was the low urine output and concentrtion of the urine. More signs of dehydration. This patient was admitted to a med-surg floor before coming to TELE, but I think he would be more appropriately placed in CCU. DNR does not mean do not treat, unless the patient and family does not want him to be treated.

Sounds like the BP could be a combination of out of control HR and use of natrecor. Holding the natrecor and starting a gtt like cardizem could IMPROVE the bp. But like I said, that's just my thoughts from afar.

~faith,

Timothy.

ark-two · Mar 24, 2006

Appreciate the input. I didn't get to look any farther as far as lab wise or so forth, he was sent home with hospice. Thanks!! Just tryin' to learn!

SEOBowhntr · Mar 25, 2006

Adding a little more to the mix, was the patient SEPTIC??? Maybe some of the problem was due to sepsis. A combination of meds may have been more effective. If the patient has a baseline Renal Insufficiency/Failure, the BNP will intrinsically be elevated. An Albumin/Pre-Albumin level would also be helpful in such a circumstance, as a Lasix/Albumin gtt can work wonders on patients who are overloaded if managed carefully. If the patient was in Cardiogenic SHOCK, Dobutamine would be a better choice than Dopamine, since Dopamine will increase Cardiac Workload. If the patient was septic, maybe a little Levo or Neo would also help. It also would have been helpful to know what the patient's Swan Readings were if they had a Swan, and maybe if you are at a really high tech institution a Mixed Venous Gas. That throws a lot into the mix, but those are all issues that would help you determine the best treatment plan for the patient.

ark-two · Mar 25, 2006

No Swan's was done. He was in his 80's and a frequent flyer with CHF. No sepsis was involved because Blood cultures were neg, stool cult were neg, and sputum culture was wnl, along with ua nml. I understand the reason's for dopamine, dobutamine, Levapheed, not sure what neo is. We don't deal with these drips on our floor. I have had other patients who had similiar CHF problems. Ex: we had a 37 yoa male with cardiomegaly, frequently in for CHF with low bp. Usually they were put on a Bumex drip to diurese(spelling not right?) with a comb of lasix with BP parameters. THe only people I usually see on Natracor anymore, are not doing well at all or it is first time CHF. I've dealt with several Lasix drips and like them because of the diuretic effects, just watch K and supplement as necessary. I kinda feel I am at a disadvantage because I do work night and do not get to talk to many MD's and we do not have intensivists or residents at our hospitals. We do have house md's, but they get upset if you wake them up and ask questions. That is why I've put this case scenario here. I really want to understand. What both of you are saying is opposite of what I've been taught. Cardizem would make bp lower, but as Timothy said, not necessarily. I do like the Lasix/albumin gtt. Never seen one of these, but I do know albumin helps increase bp, they use it in dialysis all the time. Thanks and appreciate the input and learning experience. I'll look up the drugs mentioned. About the albumin/lasix- how does that work, are they mixed together and given in gtt form?

ZASHAGALKA, RN · Mar 25, 2006

No Swan's was done. He was in his 80's and a frequent flyer with CHF. No sepsis was involved because Blood cultures were neg, stool cult were neg, and sputum culture was wnl, along with ua nml. I understand the reason's for dopamine, dobutamine, Levapheed, not sure what neo is. We don't deal with these drips on our floor. I have had other patients who had similiar CHF problems. Ex: we had a 37 yoa male with cardiomegaly, frequently in for CHF with low bp. Usually they were put on a Bumex drip to diurese(spelling not right?) with a comb of lasix with BP parameters. THe only people I usually see on Natracor anymore, are not doing well at all or it is first time CHF. I've dealt with several Lasix drips and like them because of the diuretic effects, just watch K and supplement as necessary. I kinda feel I am at a disadvantage because I do work night and do not get to talk to many MD's and we do not have intensivists or residents at our hospitals. We do have house md's, but they get upset if you wake them up and ask questions. That is why I've put this case scenario here. I really want to understand. What both of you are saying is opposite of what I've been taught. Cardizem would make bp lower, but as Timothy said, not necessarily. I do like the Lasix/albumin gtt. Never seen one of these, but I do know albumin helps increase bp, they use it in dialysis all the time. Thanks and appreciate the input and learning experience. I'll look up the drugs mentioned. About the albumin/lasix- how does that work, are they mixed together and given in gtt form?

You're right in that cardizem has a tendency to lower BP. But the high HR does so EVEN MORE. If it corrects the HR, then the cardizem should improve BP.

So, let's say this pt, w/ a HR of 90 has a decent SBP, 110, and that cardizem drops the number 10 pts, to 100, under normal conditions. If your pt's SBP is 80 because his HR is 160 and you correct the HR w/ a gtt of Cardizem, then your SBP should IMPROVE to 100 (what his BP would be with cardizem on board if his HR was normal). Does that make sense?

If the cause of the low BP is a rapid HR, then correcting that HR more than offsets the problem caused by giving cardizem. Result: higher BP. Same is true for dig, cordarone, etc.

Now, if you are giving maintenance doses of those drugs, all you might see is the lowering effect. But, if you use them in an active conversion, they should yield better BP, assuming the drug actually works and converts the pt and assuming that other reasons (sepsis, etc.) aren't contributing to the low BP.

Think Starling's law. Heart fibers are rubber bands, the more filling time between beats, the better the stretch, the better the return. Lower HR = more filling time, and more stretch = higher BP.

~faith,

Timothy.

zacarias, ASN, RN · Mar 26, 2006

This is a complicated case. I think he needs to go to the unit. His potassium is elevated. This needs to be corrected. Also his Cre is high. Lasix should be carefully administered with the Cr elevated. The lasix could make it worse. He's sick and needs invasive monitoring or DNR.

ZASHAGALKA, RN · Mar 26, 2006

This is a complicated case. I think he needs to go to the unit. His potassium is elevated. This needs to be corrected. Also his Cre is high. Lasix should be carefully administered with the Cr elevated. The lasix could make it worse. He's sick and needs invasive monitoring or DNR.

The OP did mention that he was made DNR and sent home on hospice.

~faith,

Timothy.

ark-two · Mar 26, 2006

I got the Starling's law and now it makes more sense. It was a complicated case and it was hard to watch a patient you have taken care of several times before be made a DNR for a condition you have treated him for before. I've been watching several of our frequent flyers become worse within the past couple of months and some even die. I felt that he was not given an option of aggressive treatment, but then again, the aggressive treatment is probably only a short term treatment to a long term problem. I enjoy asking questions on this site, because the people a very knowledgeable and willing to teach. It is always sad to lose the patients you get to know so well. Our hospital is a community hospital.

Another one of my patients who was also complicated. I admitted her with CHF/ + triponins/pneumonia. She was started on heparin in er. She started bleeding on Heparin-HIT! Heparin d/c'd and 1 unit blood transfused and had a reaction. I believed it was pulmonary edema-I was not the nurse performing the transfusion. BP 210/110 and she desated to the 70's. She was placed on bipap and I had her the next night. The nurse on the shift before me called cardiology due to HR of 150 with breathing TX. Cardizem bolus of 20 mg with gtt of 10. When I was getting ready to start the bolus I called Cardiology because her HR was 65. I was uncomfortable. He told me to give it and watch her and gave parameters.-we don't tritrate. I made the suggestion that she probably has an adverse reaction to the albuterol and needed xopenex instead. The nurse who had her the next night said cardiology switched her from duonebs to xopenex and dc'd the gtt. Oh-with her, her urine output decreased also and she was given a fliud bolus on the earlier shift. I was wondering if the opposite wasn't happening with her. We decreased her HR to the low 60's and she was not perfusing. Her bp went down at first with the gtt, but by the end of my shift sbp was 165. She is getting her cath today- her EF via echo was 60% and she also had high bun and cr. On 80mg of po lasix bid.

TennRN2004 · Mar 27, 2006

About the albumin/lasix- how does that work, are they mixed together and given in gtt form?

We don't use an albumin/lasix gtt. Our common dose is 250 of albumisol with 20mg of lasix it's called a "cocktail" where I work. We just draw up the lasix and put it in the albumisol bottle and run free flowing through tubing at the desired rate. It's great for a patient like this who is fluid overloaded, but may be intravascularly dry. The high heart rate could be your dopamine, or it could be that the patient is dry in the vascular space from third spacing out. Did he have a lot of edema?

Also, your UOP could be caused from several different factors. He could be in renal failure from being dehydrated, or more likely from hypoperfusion related to the hypotension. Also, at 80 years old, his baseline renal function was probably not that great and he could have just taken a small hit to his kidneys for whatever reason (medications, infection, dehydration, low bp) and caused big time problems. With such a low EF, I would guess his cardiac output was just not strong enough to perfuse his vital organs, including his kidneys.

Also, I would not think Cardiazem is a good choice in treating this patient. He already has compromised cardiac function with such a poor pump and low EF. You don't want to give a calcium channel blocker and decrease his contractility any further. Try to figure out why the heart rate is high and address the cause- the tachycardia is a symptom of a bigger problem.

You could have tried Primacor (it helps the heart regulate calcium and causes a stronger contractility or pump), it will cause hypotension also (because it reduces your afterload, but this decreases the workload on the heart) so you'll definitely need your pressors. Dobutrex would also have been a good drug, in addition if you were really going to go all out treating, a balloon pump could have helped this patient.