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Which pressor to use???

Specializes in Cardiac.

Hey guys! I work in a MSICU, but we had a pt the other day who was actively infarcting. Had been cathed a few weeks prior, diffuse CV disease, med management only.

He went into resp distress on floor, hypotensive, low HR, transferred to unit. Was on 4 pressors in the night, but became stable by morning for me and was only on dobutamine at 5mcgs.

Fast forward to middle of the day when the pt suddenly became hypotensive and tachycardic. SBP of 60. All 4 of my pressors are still on the pumps (not attached to pt). SOooooo, my question is, how do you know which one to re-start, dc, or titrate up? Dobutamine, levo, dopamine, epi were all available to me. I'd like to hear some suggestions before I tell you what happened.

maolin

Specializes in IMC, ICU, Telemetry. Has 2 years experience.

I'm chiming in because I want to follow this thread closely and see what the experienced pros have to say. I'm a bit more than halfway through my ICU orientation and still trying to learn the ropes of making judgements like this. So my answer is just for practice. I'm anxious to hear other responses.

I think that my preceptor would suggest restarting the Levo first - it seems to be the one we like to use first. What does the ekg look like? CVP? Resp status? In what order were the pressors discontinued previously? Maybe the last one stopped should be the first one restarted?

cardiacRN2006, ADN, RN

Specializes in Cardiac.

No CVP, pt was vented AC 16, not overbreathing the vent. Also was on 4 of versed (which I cut down) and 50 of Fentanyl (also cut down). EKG was SR with lots of PVCs, then right to ST during this event. No st elevation, but troponin was 11.5! The whole situation lasted about 10 minutes, but I did have to through the pt in trendellenberg for a while.

So, anybody else???

Hey-

Were you running all these meds via a central line or swan? I know you said you had no cvp...Was it via a PICC or peripherals?Do you use neosynephrine at your place? I would probably used that first due to the preference at my hospital. Seems to cause less peripheral ischemia then others. We use NEO as a 1st line pressor for our "cardiac patients" and CABG's and then add a little NTG for coronary dilation even while patients are hypotensive. Then I would add Levo with the tachycardia I would stay away from dopamine and epi. As for the dobutamine I would hold as well being that it can cause hypotension although it is an inotrope.

Without a swan I think it would be very difficult to manage this patient. What were you using as parameters to titrate epi? Did you at least have an art line? What ended up happening to the patient?

LCRN

Assuming pt. is normovolemic. Levo would be my choice. I wouldn't go Epi and Dopa due to tachycardia. Would definately want more info like CVP and PAd.

It is also somewhat difficult to say Neo is a first line drug. It all depends on the SVR, CVP, HR, SBP, PAd, and overall assessment. Often times strictly tightening up the SVR isn't going to cut it. If they are hypovolemic or need ionotropic support then the alpha stimulation will either band-aid the problem or do nothing.

cardiacRN2006, ADN, RN

Specializes in Cardiac.

I had a triple lumen in one groin and an a-line in the other. I also had 2 18g PIVs.

I wanted to go up on the dobutamine-because it was already running. My preceptor told me to put back on the dopamine, but the doctor (who was on the unit) said to dc the dobutamine and put on the levo. We have Neo at our facility, but it wasn't hanging in the room. I forgot to mention that he was also on NTG, but was only on 5mcgs of that as well. Dr said keep that on even though his BP was so low.

I guess my problem is that although I thought I was familiar with these meds, when the time came, I just didn't know which one to choose. The Dr wanted me to wean off the levo when I could and go back on dobutamine, but as the shift went on, I ended up going up on the levo. When I left, the SBP was starting to fall below 90. I haven't been back to work since, so I don't know what happened.

I think as I am doing more on my own, I feel as if I know less!

CVICURN2003

Specializes in CVICU, MICU, CCRN-CSC. Has 9 years experience.

I would have given a 250 ml NS bolus first unless direct contraindications (poor EF, rales). Then I would have started on the levo. Left on the nitro. Not used the epi or dopamine (HR). I would have also drawn some electrolyes to see what the pts K, Mg and CaI were. It would have been hard to manage this pt without a swan I agree. The dobutrex and nitro could have been so much more effective if you could get some good numbers. Why didn't you monitor the CVP? Especially when you had an art line and a transducer already At our facitlity we only use Quads, so I am unfamilar with triple lumens. Even on the power PICC's you can monitor the CVP. Maybe needed a little fluid bolus since he was tachy and hypotensive. What was his UOP? What was the patients EF? What did his lungs sound like (overloaded or not already)...HMMM so many questions....Cardiogenic shock setting in maybe? Then I would have hit the MD over the head with a swan kit....just kidding. sort of.

nurse4theplanet, RN

Specializes in Critical Care, Pediatrics, Geriatrics.

Wow...I just want to point out something I thought about. We are going over legal aspects in a seminar class I am taking. We recently discussed the whole malpractice/negiligence issues regarding expert testimony required to convey to the jury what a 'reasonable professional would do in the same situation.' I just wanted to point out how different everyone's answers, critical pathways of thinking, and questions about the situation are. Even with my primitive experience in ICU, I understand that 'there is more than one way to skin a cat.' I just wanted to point it out because I am sitting here thinking that if something were to go wrong and the family decided to take the nurse to court, an expert could come in a suggest that the situation be handled in a completely different way. I guess the full reality of the personal responsibility of the nurse just became a tad bit clearer reading through the various answers. Just thought I would share my thoughts.

nurse lucky

Specializes in Ortho, Neuro, Urology, Cardiac, CC. Has 18 years experience.

I agree about knowing the CVP.

I would have done a FF it his lungs were dry and he had a decent EF and then my first line of pressor would have been Neo as it doesn't increase the HR. Second would have been levophed.

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Well, I didn't have Neo ordered or hanging on my iv pole. EF was 25%, UP was good at around 75-100/hr. I can't get a CVP if I don't have one! K was 4.4 from an ABG done just an hour before. Crackles at bases, +1 edema (pretibial and pedal).

So it seems people are preferring levo, which is what the Dr told me to do as well. The other answers make sense as to why you wouldn't choose them first.

Thanks guys!

Probably would use Neo, Levo or Vasopressin and definately shut of the nitro, would probably turn down the Dobut (drop bp), check Ionized Ca and give some if low, maybe give blood if Hgb low. I guess Cards like it if less than 11 in a MI. Fluids as last resort or IABP and palliative care

I agree that it's very difficult to assess without a swan. If the patient was in heart failure, bad pump leading to hotn and compensatory tachycardia, then I would have wanted a positive inotrope. If you give a high alpha agent like levo or phenylephrine and the patient is already clamped down then you're just going to make the problem worse. I probably would have started a little neo first (or levo since it's what you had) and then added dobutamine if the problem didn't correct. It sounds like he had pump failure in which case you would need to keep him pumping and dilated. You mentioned the UO was okay however, so obviously his perfusion was alright, but he did have edema indicating inneffective pump function.

augigi, CNS

Specializes in Critical Care, Cardiothoracics, VADs. Has 10 years experience.

Agree it's difficult to choose without adequate information. However, you got to just treat what you see in the patient with what you have, and avoid making things worse. With evolving ischaemia, I'd definitely avoid using epi/dob/dop and increasing cardiac work, and just use the levo in the first instance.

ghmccart

Specializes in ICU/CVICU. Has 3 years experience.

study your meds, and research them, it is up to you

phiposurde

Specializes in critical care,flight nursing. Has 9 years experience.

Very interesting thread. I have more question then answer actually !! Here goes: what did the ecg shows?? I find it strange that the person in shock present with bradycardia as well. You aslo state that there was an active MI.. how come He didn't go back to the cath lab?? What was his po2 on the ABG? Was he intubated? If so, what was the trend of the capnograph? What kind of respiratory distress what he in?( laboured breathing, low sat, ect) If so, I believ he could have benefitiate from some bi-pap.

As for the main question, I never really played with IABP but woudn't he be a very good canditate?( Non compensate shock, low EF, possible cardiogenic shock). I do agree that he would have been a good candidate for more invasive monitoring. As for the CVP assessment, even if there was no actual monitoring, his JVP could have help. Is it very important to know cause pressor are useless if you have nothing the press. You can't press and empty reservoir. I think I would have use:

dopamine at 5-10 for it's inotropic effect. Stop the epi cause it increase the o2 demand, SVR and present risk for ectopic beat. Having already PVC in such a fragile heart I woudn't want to add v-tach to that. I would keep him on the levophed for now but keep in mind of the multi organ shut down with all that constriction, the increase SVR and the risk again for v-tach. But it has a inotropic effect what we want here. I would stay away from the phenylephrine beacause it has all the bad effect of levophed with no inotropic effect. I would consider maybe a lidocaine drip related to the PVC and the risk with the other pressor. Amiodarone with be a poor choice beacuse of his effect on the av conduction( negative chronotrope) and negative inotrope. As for the NTG, am not sure. It depend of the result of the ECG. If the patient present with inferior MI or R side MI I think it is very bad idea. But if the patient do present with CHF and not improve with the inotrope effect of the pressor maybe Primacor could be use cause it increase the CO and decrease the SVR which would help reverse the side effect of the levo. As for dobutamine, not sure. This guy heart seem in a very bad place right now. but if his oxygenation is very good increasing the o2 demand with the inotrope effect could have less effect. Plus, the Bipap could help with oxygenation and help with some of the preload and afterload. anyway that was my 2 cents!!8)

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Ugh, I don't even remember this pt anymore, to be honest. This thread is more than 7 months old. But we didn't have any kind of hemodynamic monitoring, we had no cath lab available, and certainly no access to an IABP. I wasn't talking about what to do with all the info at hand, I was asking what to do for the IMMEDIATE situation. I was in the room when the hypotensive event happened, and had all the meds hanging up on my pump, but not attached. I had received some very good info from this thread, and I have appreciated it all. Thanks for your detailed answers guys!

study your meds, and research them, it is up to you

Umm, I was a brand new nurse still on orientation when this thread was first posted, and I just wanted opinions of what experienced nurses preferred and why. I'm aware that it was up to me...I didn't come over and post this thread on allnurses mid-shift. I took care of my patient and sought answers from other people later.

phiposurde

Specializes in critical care,flight nursing. Has 9 years experience.

No CVP, pt was vented AC 16, not overbreathing the vent. Also was on 4 of versed (which I cut down) and 50 of Fentanyl (also cut down). EKG was SR with lots of PVCs, then right to ST during this event. No st elevation, but troponin was 11.5! The whole situation lasted about 10 minutes, but I did have to through the pt in trendellenberg for a while.

It is not recommend anymore to have patient in tredelemburg

http://www.caep.ca/page.asp?id=DF61785B363D4460835A593243E70058

heartrn4duke

Specializes in cardiac intensive care. Has 8 years experience.

Sounds like an RV infarct in that case fluids and dobutamine for fill and squeeze. Intubate if needed. RV infarcts need fluid. Dopamine for quick response. Dopamine has some alpha effects too and is good for RV infarcts.

jen123321

Specializes in SICU; Just accepted to CRNA school!. Has 2 years experience.

Tranducing CVP's is a nursing judgement where I work...all you have to do is set up the pressure tubing and hook it up, you really don't need a dr's order to do that.

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Sounds like an RV infarct in that case fluids and dobutamine for fill and squeeze. Intubate if needed. RV infarcts need fluid. Dopamine for quick response. Dopamine has some alpha effects too and is good for RV infarcts.

The pt was intubated.

jen123321, we do need an order for the CVP, plus the pts c-line was in the groin.

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