So I took my first 'early-heart' Thursday since I've been off orientation (only been on my own now about 3-4 weeks)...
She was a 74 y/o, hx. HTN (pre-op bp was 160's), MI in June, EF 50-60%. Had a CABGX3 with LIMA. She came back around 1:30 on a few mcgs of Levo and Epi. SR 85, not being paced. Pressure was about 140mmHg systolic, turned off the Levo. Pressure was creeping up, turned off the Epi and turned on the Nitro that was hanging there to 33.33 mcg/min. After about a 10 min or so, pressure is still creeping up, bump up the Nitro to 66.67 mcg/min and hang Nipride at 0.5mcg.
She's warm, core temp is 36.7. PA pressures ~34/12, CVP ~14. CO= ~4 CI= ~2.66 SVR= ~1400? SVRI= ~2650 (so a little tight..) Within an hour, I'm at 7.5mcg of Nipride! I give her 2mg of Morphine, as she starts to wake up (because this is shooting her pressure >165), then another 5mg of Morphine 10 minutes later. (I chose Morphine v. Versad - longer acting, would help the SVR). After I gave the Morphine within 2 hours, I'm able to wean the Nipride gradually and by the end of the shift (she's awake, calm, but sleepy- still intubated) - pressures 120's on 1.2mcg/min of Nipride.
(fyi, supp'd 40meq K, 3 gm Ca-early, and gave 2 plasmanates towards the end of the shift, when her filling pressures and cvp fell-at this pt she was on the 1.2mcg Nipride)
Hanging Nipride post-op isn't uncommon, but it was strange to require that much. Anyone else have similar experiences? Or any rationale to what happened? Could it have been a pain issue?
Let me know if you need any other clinical info, I tried to only include what I felt was pertinent.
didn't mean to offend either, just generally using antihypertensives not narcotics for pressure controll. We are very agressive with extubation, sometimes they comeout extubated and I can pull my hair out managing pain and varying bp's as well.
Don't worry sounds like we are shooting for the same target, just missing the others point do to the limitations of this type of communication. I'm cool with you. Atleast you care, there are lots who don't.
heartrn35
59 Posts
Don't worry sounds like we are shooting for the same target, just missing the others point do to the limitations of this type of communication. I'm cool with you. Atleast you care, there are lots who don't.