opposite Vasoactive meds??

bluesky, BSN, RN · Oct 3, 2004

Did this pt have crappy indexes? To me it sounds like she's trying to get better CO and maybe help dilate the possibly infarcting coronaries with the nitro while she's at it (though of course your IABP is supposed to be doing just that). Decreasing the SVR with the NTG and Milrinone, while improving contractility (and rate) with the EPI and Milrinone will help your CO.

heartICU · Oct 3, 2004

I agree with bluesky - the epi was probably to improve cardiac index. Epi at low infusion rates usually works more to improve myocardial contractility more than blood pressure, especially at the dose you said it was running at. Pressor doses are usually much higher. The nitro will help keep the coronaries open - did the patient also have a radial graft? If they did, radial grafts have a high likelihood of spasm when they have been grafted onto the heart, and nitro can help decrease this possibility. But most likely your MD wanted the ntg for coronary perfusion and epi and milrinone for contractility.

chaosRN, ASN, RN · Oct 3, 2004

Immediately post-op the CI was 2.4 and SvO2 was in the mid 60's. By the time doc was at the bedside, the CI was ~1.6 and the SvO2 had dropped into the low 50's.

The saphenous vein was used, no radials.

Someone mentioned the the NTG (I think it was nitro and not epi) was being used because of the ST elevation. What do you think? I read your post again -

"dilate the possibly infarcting coronaries".

Thanks again to all!! :)

zambezi, BSN, RN · Oct 3, 2004

I pretty much agree with bluesky's post, the epi was probably for the contractility while the nitro was used to dilate out the arteries...strange through since the primacor should also have helped to increase contractility while decreasing the svr (which the iabp should have also been doing as well...), hopefully imporving blood flow/sv/and svo2...

jewelcutt · Oct 3, 2004

If the patient was on an IABP and primacor and still had a CI of 1.6 I would definitely keep the epi on, sometimes we would keep it on at 2-3 mcg's for patients this sick. Of course we would always use ntg to prevent spasms of LIMA grafts, but if they had ST elevation and an RV infarct good idea to dilate the coronaries. NTG won't have that much of an effect on the BP, so if you have BP problems you may need to use some nipride also.

chaosRN, ASN, RN · Oct 4, 2004

Just FYI: the LIMA wasn't used, and the MD didn't want to use nipride.

Thanks! :)

versatile_kat · Oct 4, 2004

Careful of coronary steal with post-op CABG's/MI and SNP.

chaosRN, ASN, RN · Oct 4, 2004

I was thinking about this (I'm a nerd remember?) and...oh man. :eek: I feel so dumb :imbar . The pt was on norepi (levophed) - not epi @ set rate of 5-10 cc/hr. Gosh, please don't think I'm too stupid!! :chair:

Does this change a lot? Pharm is my weakness, but improving everyday!!

DSAC · Oct 4, 2004

Our CABG patients typically come out on all of these meds plus some. We have very sick patients that usually have several pre-existing complications or are very old. We typically will do surgery on patients that get refused other places.

Typical patient comes out on:

Epi ---0.03-0.05 mcg/kg----cardiac support---improve CO/CI--contractility and HR --at low does decreased afterload

Milrinone---0.5 mcg/kg---cardiac suport---improve CO/CI--contractility and decreased afterload

NTG---.25 mcg/kg---dilation of fresh grafts and dec. preload---decreased afterload at higher does, titrate for BP, but never titrate off unless BP bottoms, then back on ASAP

Nipride--if BP still high and NTG maxed at 2 mcg/kg--reduce afterload

Levo --- ??? mcg/kg-- vasc. tone and mild contract. ---titrate down for elevated BP

Dopamine---2 mcg/kg--improve renal perfusion and u/o--most pts. have renal insuff.

Precedex---.5 mcg/kg--sedation ( great drug for anesthetic and analgesic properties)

Insulin ---started after arrival in unit d/t increase in glycogen breakdown d/t Epi

Lidocaine---2 mg/min --d/t irritability of the heart s/p surg.

Cardizem---occasionally used with radial artery graft

Amiodarone---used with valve surgeries in place of lidocaine

Then again, occasionally, they will come out with a IABP also.

futuregasman · Oct 5, 2004

Levophed is a little nore selective than epi. Epinephrine is an agonist of all the receptors of the sampathetic nervous system, i.e. Alpha 1, Alpha 2, Dopinergic, Beta 1 and Beta 2. Levophed has a more significant effect on the alpha's and a little effect on the Beta 1. So there is a difference in what results you will get with contractility in the heart with epi vs levo.