In response to Is IV Bolus Nitro Dangerous – Part I, there is this from usalsfyre,
I can certainly agree initial NTG infusion dosing is usually inadequate,
You know this, but you are hesitant to change. Try starting with a higher dose and see if that changes anything.
This is what titration means. Pumps are just a means of continuous titration – adjusting the dose to get the best response out of the patient. With NTG, pumps do not do much good initially – only after we have dramatically increased the dose, or if we start with a large dose.
One of my medical directors told me that he would run the NTG infusion at 999 ml/hour until the patient’s blood pressure started to respond. I do not remember what concentration he was using. 200 μg/ml and 400 μg/ml are the most common concentrations. Assuming 200 μg/ml, that would be 200 mg/hour (OK, it is really 199.8 mg/hour) or 3 1/3 mg/minute or 3,330 μg/minute. This is very aggressive, but he has a lot of experience and he is the doctor.
The worst case scenario just means that we need to turn the rate down, temporarily. When the patient’s blood pressure recovers, NTG can be resumed, although at less aggressive rates for this unusual complication.
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I tend to start at 50mcg/min at titrate up to the 100mcg/min range quickly. Like within 5 minutes.
If you are comfortable with that, then try starting a little higher, keep increasing what you start with, until you think that more would be too much. Stop short of whatever makes you uncomfortable.
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I haven’t, however, had the stones to try a bolus dose of NTG.
It isn’t about stones, but about continually assessing patients.
Stones suggests doing something on a dare. When we start doing that, we can ignore the patient, because what we are doing is not about the patient any more.
What is a bolus?
A bolus is just an infusion that is given over a relatively short time period.
Most boluses are not like adenosine, where we push the drug as quickly as we can without breaking the syringe or the patient.
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From Street Watch – The old 2 syringes in 1 port method for adenosine, which does not work without an adapter in needleless systems.
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Amiodarone is also a bolus, but it is given over 10 minutes. These patients often become hypotensive and most of the time the VT (Ventricular Tachycardia) does not respond to amiodarone, so the patient is cardiverted.
The difference between a bolus and an infusion is more in the documentation, than in the treatment.
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I get away with very aggressive treatment for a few reasons.
I have learned from some very smart doctors, PAs, nurses, medics, basic EMTs, and patients.
I have been fortunate to have some aggressive medical directors or some medical directors willing to listen to me explain why I did something aggressive.
I continually reassess my patients.
I sit on the bench seat, where I can see the patient. I don’t sit in the captain’s chair and watch the monitor, playing telemetry medic, then leave the monitor in the truck when I get to the hospital
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I can see where it’s been studied, the thought there…but it’s still a bias I’ve got to overcome.
We all have our biases. The most important part of overcoming them is to recognize them. (Not to go all 12 step.)
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I’m fairly fanatic about making sure my equipment gets charged so the battery issue only bit me once. They can be finicky, but knowing the tricks to get a good prime and keeping things plumbed so you don’t get an supply side occlusion helps. I’ve been stuck with something as clunky as a three channel Abbot Plum, so I’m fairly appreciative of the MiniMed.
Unfortunately, the batteries do not charge quickly and they have mo indicator of charge. I regularly find all of the pumps unplugged. The only way I can tell how much charge the battery has is if I turn the pumps on and the low battery alarm goes of, or if the pump will not even turn on.
There are many tricks for getting pumps to work without interruption.
Syringes are much more dependable and much more simple.
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Don’t really disagree with anything here, like I said, just a bias I’m working to overcome. The part that’s really odd is that I have no issue dumping a couple of milligrams under their tongue. I’ve acknowledged it, yet on my next CHF’er I will probably reach for the tabs. Maybe I need my partner to rap my knucles with a ruler :).
I like the bolus idea, but not infusions. The problem with one person in the back starting an infusion is that it takes concentration, which takes away from monitoring the patient. IFT’s are different, because the pump can be set up before moving.
Several ED have a “no infusion” policy for STEMI patients before going to the cath lab because they take so long. Bolus what needs to be bolused and start infusions later.
Maybe I’m missing something here, but shouldn’t infusions begin with a loading dose (bolus) anyways? After all, isn’t the primary purpose of an infusion to maintain a steady therapeutic concentration in the patient’s system instead of reaching a therapeutic concentration?