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.
I would have used levophed and fluid bolus around 200-250range and tried to get the pt out of trendelenburg if I could. I think I'd titrate that levophed as far as I could granted it did'nt tickle the heart rate and I had adequate volume on board. What ever happened?
I found this to be a very interesting topic. More often than not these situations arrive especially witht the sicker patients. What works for some patients make not work for others. I agree a swan would have been helpful. we have also been getting introduced to EDM esophageal doppler monitors. Although more familiar with Swans--these do tend to be less invasive from an infection/arrythmic point of view.. What does everyone think of EDMS
I agree with most everyone here who said that Levo would be there drug of choice for this pt. What type of infarct was it? If it was right sided volume would be the only thing that would truly help this patient.
Specializes in ICU,CCU, MICU, SICU, CVICU, CTSICU,ER.
In the future it woundn't hurt to set up a CVP. In this pt it could have gone on the triple lumen. Use a stopcock gang for multiple infusions, and set up a stopcock on the CVP sideport for intermittent infusions. But at least you'd be able to monitor anyway. Of course, SG is ideal. Someone said hit the doc on the head with the SG kit--good advice!
Specializes in SICU, EMS, Home Health, School Nursing.
I agree with everyone on here... I would have started the levo first. My hospital really doesn't use epi drips, we just use it in code situations. Levophed would be your best bet because it wouldn't increase the HR like dopamine and dobutamine do.
Was this patient septic by any chance? What was the WBC count?
BULLYDAWGRN, RN
218 Posts
I would have used levophed and fluid bolus around 200-250range and tried to get the pt out of trendelenburg if I could. I think I'd titrate that levophed as far as I could granted it did'nt tickle the heart rate and I had adequate volume on board. What ever happened?