IV nitro

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AMA3004

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IV nitro - what do you guys think about it ?


As far as i know most systems have it as SL and transdermal, but IV, I would think there would be a significant change in the affect as it would be concentrated, and it wouldnt be as long lasting.


would you guys think it would be a good thing to have ? and if so, why ?
 
We use it at my service and although we have pumps, I would feel comfortable eyeballing a drip. And just titrate to BP. It only takes about a minute to wear off and the effects aren't as durastist like the SL. I also enjoy it because since it can be ran consistently it works better with the fluid bolus we give most STEMI's. I have limited experience with the transdermal but I am skeptical using it on someone who's shocky due to decrease blood flow and sweaty skin.
 
We use sublingual GTN in the little red spray bottle. Standard dose is 0.8 mg repeated 3-5 minutely or 0.4 mg if the patient is small, frail or cardiovascularly less stable (i.e. BP a bit closer to 100 mmHg systolic or has inferior STEMI).

Intravenous GTN is not used and there are no plans to introduce it. It is more expensive and quite complex to administer, it could only be used by Paramedic or ICP level personnel, and I don't know of any studies which show it is better than standard sublingual GTN ... if it is, I'd presume it would only be in patients with heart failure and not angina or STEMI.

For that matter, I don't know of any studies showing GTN even improves outcomes for the patient in STEMI. It was originally intended for use in patients with angina pectoris and somehow wound up being used in patients with acute myocardial infarction, probably because the underlying pathophysiology is similar and therapeutic effect was presumed to be the same.

As the CPG for STEMI (myocardial ischaemia) is written, GTN is given initially and only repeated if it is associated with significant benefit. For example, if somebody is given a spray of GTN and their pain (or ST-changes on their ECG) markedly reduces then returns a returns a couple minutes later, give another spray. If it doesn't do much (or anything) it is not repeated and I think this seems sensible.
 
I use IV Nitro both prehospitally and for Ground/Flight Critical Care. It's quite useful in treating acute heart failure patients, though I still utilize s/l nitro while I obtain IV access and set up the infusion. I routinely transfer patients on IV Nitro titrated for chest pain. It's certainly a therapy which requires an educated Paramedic , but the same can be said of many infused medications (sedation, pressors etc). I'd much rather see systems develop appropriate protocols for the treatment of heart failure with IV Nitro and CPAP vs hastily intubating these patients after inadequate medical management (possibly without applying an appropriate pre oxygenation strategy). As for IV Nitro for chest pain prehospitally, I don't see this as offering any benefit vs SL Nitro.
 
We have standing orders for it, to be maintained on a pump only. As said, it's benefit is rather meager in the setting of MI but it is awesome with CHF exacerbations. So much better than having to remove the CPAP mask every five minutes to get SL and is much easier to manage. For AMI it is nice to be able to start with a low dose and see how things go from there instead of blasting them with 400mcg right off the bat.
 
thanks for the replies everyone, I really appreciate the feedback.

this has me thinking, why would it not be as effective for MI ? what would be the main differences between SL and IV nitro ?
 
AMA3004 said:
thanks for the replies everyone, I really appreciate the feedback.

this has me thinking, why would it not be as effective for MI ? what would be the main differences between SL and IV nitro ?
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Nitro isn't really shown to do much for MIs, regardless of route. If anything IV might be more effective as it's difficult to deliver enough NTG sublingually to achieve coronary artery dilation, and doing so IV is probably safer (more tapered dose). But even then, our medical directors seem pretty convinced that pain control also plays a key role in reducing MVO2, which is really where the benefits of nitroglycerine may lie.
 
We use it and use it regularly. Starting a drip a 5mcg/min is a much lower dose than SL, so it is easy to titrate for the BP. Using it at a higher dose for CHF along with BiPAP is perfect and has become the first line choice over lasix.
 
nater said:
We use it and use it regularly. Starting a drip a 5mcg/min is a much lower dose than SL, so it is easy to titrate for the BP. Using it at a higher dose for CHF along with BiPAP is perfect and has become the first line choice over lasix.
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Hopefully a much higher dose : )
 
I learned early; wrap the glass IV bottle of Nitro with a washcloth, doubled over and taped to the bottle; that way it doesn't swing against the metal IV pole on the cot and break. Get sprayed with NTG one time (normal BP is 90/50) and spend time in the ED cause you lose consciousness and it takes a long time to live that down
 
TXmed said:
We use it at my service and although we have pumps, I would feel comfortable eyeballing a drip. And just titrate to BP.
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I find it shocking that anyone would choose to eyeball a gravity drip set on a vasoactive medication when a pump is available. This situation is literally the most effective possible application of an IV pump on an adult patient on Earth! The differences in safety, reliability, and certainty are through the roof.

At minimum dosing standard Ntg is not even 1 gtt per minute on a 60 micro set, at max it is 1 per 10 seconds. An average dose of say 5mcg/min is 1 drip every 40 seconds. You just eyeball that?

You can have a pump set up and running in less than the 40 seconds it takes to time 2 drips at that rate.

Dopamine is a lot more reasonable to eyeball, but you'd still be nuts to gravity that or any other vasoactive when you have a pump.

Protect your certification, your personal liability, and most of all, your patient. Use the pump.
 
Summit said:
I find it shocking that anyone would choose to eyeball a gravity drip set on a vasoactive medication when a pump is available. This situation is literally the most effective possible application of an IV pump on an adult patient on Earth! The differences in safety, reliability, and certainty are through the roof.

At minimum dosing standard Ntg is not even 1 gtt per minute on a 60 micro set, at max it is 1 per 10 seconds. An average dose of say 5mcg/min is 1 drip every 40 seconds. You just eyeball that?

You can have a pump set up and running in less than the 40 seconds it takes to time 2 drips at that rate.

Dopamine is a lot more reasonable to eyeball, but you'd still be nuts to gravity that or any other vasoactive when you have a pump.

Protect your certification, your personal liability, and most of all, your patient. Use the pump.
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Calm your tits and let me clarify. At my service we have pumps that are easy to set up. If there was a situation where I DID NOT have the pump, I would still feel comfortable running the drip. Nitro has a wide drip range depending on the concentration and gtt set used.
 
Summit said:
Dopamine is a lot more reasonable to eyeball, but you'd still be nuts to gravity that or any other vasoactive when you have a pump.
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One "nice" thing about Dopamine is that at least you can eyeball it just a little bit while you're grabbing a pump. Any other vasoactive gtt and I'm going to use a pump all the time. No, it's not great practice to eyeball Dopamine, but at least it can be done.
 
Summit said:
I find it shocking that anyone would choose to eyeball a gravity drip set on a vasoactive medication when a pump is available. This situation is literally the most effective possible application of an IV pump on an adult patient on Earth! The differences in safety, reliability, and certainty are through the roof.

At minimum dosing standard Ntg is not even 1 gtt per minute on a 60 micro set, at max it is 1 per 10 seconds. An average dose of say 5mcg/min is 1 drip every 40 seconds. You just eyeball that?

You can have a pump set up and running in less than the 40 seconds it takes to time 2 drips at that rate.

Dopamine is a lot more reasonable to eyeball, but you'd still be nuts to gravity that or any other vasoactive when you have a pump.

Protect your certification, your personal liability, and most of all, your patient. Use the pump.
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As the saying goes, maybe you don't know what you don't know. Just because you do it your way doesn't mean it's the only way that's correct. I use a device called a Dial-a-Flow. It's a gravity flow device with a calibrated flow control. We use them in the OR all the time. If I NEED to know how much of a drug a patient is getting (maybe something like dopamine), I'll take the time and set up a pump. But for NTG or phenylephrine where I'm titrating to effect, it's quicker, easier, far less cumbersome, and cheaper to use a dial-a-flow. If it's still needed by the time I get to PACU or the ICU, the nurses will change it over to a pump.

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jwk said:
As the saying goes, maybe you don't know what you don't know. Just because you do it your way doesn't mean it's the only way that's correct.
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Actually, I do know that a manual flow regulator (eg your Dial-a-Flow) is much better than a roller clamp, but they are rarely seen outside of the OR or Infusion Clinic. I've never seen one in EMS, and the post I responded to was talking about "eyeballing drips" vs a pump (or as he clarified, he meant if there was no pump). There was no discussion of manual flow regulators vs pumps so I don't understand why you responded as if there was.
 
Yeah, we carry it as nitro drip and nitro spray. Primarily use the nitro spray if unable to get access or something else. I prefer the nitro drip better than the spray, I feel like I have a lot more control over BP than with the spray. Only ever used it for STEMI's, but reading some recent research I'm not really sure if it that useful in that setting. Have yet to use it for a severe CHF exacerbation.
 
Dial-a-flow devices are certainly a lot better than using a roller clamp, that's for sure. Hopefully the ones in use today are a LOT more rugged than the ones I used 15 years ago... all of the ones I used broke within 10-15 minutes of opening them.

As to using a pump, I think a lot of the concern around them comes from the amount of time required to set them up. While I'm not a great fan of the Baxter Sigma system, it can be set up pretty quickly. Some gtts are simply mcg/min or mg/min... so no weight is necessary. Those, if you know what's coming, you can pre-program the pump and put it to sleep. Revival of the pump and placing it into service pumping the med takes maybe 20 seconds. Since the pump does know the meds, titrating can be done pretty quickly too. Push a button, enter the new rate, then press OK and the rate changes that fast.
 
Pumps are nice and I use them whenever it is feasible, especially for pressors, NTG and Cardene. In some situations like a STEMI with short transport times, we just clamp the tubing and transport. The time spent to change the lines and pump isn't worth it when intervention is waiting and tissue is dying. The Plum pumps are not awful to set up, but the IVACs are touchy.
 
I never used IV nitro in 911, but did lots in HEMS/CCT interfacility transports. I know from my ED nursing days that is is the best think since sliced bread for pulmonary edema.

Can you "eyeball" it? Sure. You can eyeball anything, if you need to. Is that a good practice? No. For obvious reasons.

Using IV nitro without a pump is like intubating without Etc02 monitoring. Of course it can be done, the better question is should it be done?
 
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