Nitro Drip for CHF

tpchristifulli

tpchristifulli

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I recently had a patient who was having an exacerbation of CHF. Pulse ox was 80%, hr 120, Bp 220/110, ventilation rate of 38.
I initiated CPAP, ran a 12 lead, and started a nitro infusion. Pt showed major improvement and was almost asymptomatic after our 30 minute transport to the hospital.
Upon arrival at the hospital I was questioned and scrutinized for starting a nitro drip. The physician said that is uncommon and saved for patients who are a lot more critical..
I reasoned that not only does a drip allow me more control over the dosing, it allows me to not have to keep removing the cpap to spray the nitro under his tongue.
Why not paste? During the initial events of chf the patient hyperventilates and blows off a lot of carbon dioxide. We all know c02 is a potent vasodilator, when we blow too much off we constrict vessels ( why our chf patients have cold hands) and prevent efficient absorption of nitro paste.
I stand behind my decision to start a drip and would love to hear experiences you have had starting a nitro infusion.
 
We cannot do drips but I don't see why your actions would've been questioned. Did you go straight to the drip or was any SL administered prior to placing the CPAP?

The only argument I see them having is trying SL dosing + CPAP and "giving it time to work" which I whole heartedly disagree with for the patient's sake of pure comfort. Is it difficult to "ween" patients such as this from a NTG drip?

What were you running it at if you don't mind me asking?
 
Started at 5 mcgs/ min... Pressures responded as expected and Bp was in the 140s at hospital.
 
Not sure why they'd have an issue with that...from your FB page I know you know you're stuff, always learn something from your posts, was it a physician you weren't familiar with?

I'll take 5 mcg/min over 400-800 mcg q5 any day of the week.
 
We do drips without SL all the time here. Maybe they get one in the house but aside from that it's on the pump they go. Much easier that trying to lift up the CPAP mask and jam a tab in every five.
 
Tigger said:
We do drips without SL all the time here. Maybe they get one in the house but aside from that it's on the pump they go. Much easier that trying to lift up the CPAP mask and jam a tab in every five.
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I learned the hard way not to remove a CPAP mask on an acute CHFer after it's been applied to give more SL NTG.

@tpchristifulli are you aware of any studies regarding the efficacy of transdermal NTG in CHF exacerbations? I did a quick search and couldn't find anything but I also don't have access to any databases. I 100% agree about the vasoconstriction and poor/inconsistent/nonexistent absorption in this patient population. Currently we cannot do NTG drips in the field, only ground CCPs can take them on transfers and they cannot initiate them the sending has to already have it in place. Our Flight Medics can initiate them in the field though.
 
I don't understand why everyone is so fearful of drips. If you have a pump (and we cannot start them without one), it seems far easier to control effects than with paste or SL.

I get that pumps are expensive, but if you have them already it seems logical. Refurbished MiniMed IIIs are fairly reasonable to my understanding.
 
We do NTG drips on a regular basis out here for CHF and ACS patients. Our local hospital hates it, but we also don't take them to our local hospital unless we don't have a choice.
 
There's no issue with it. And 5 mcg/min is only a sniff anyway. The problem with the ER is that they look at the patient as they present and don't appreciate how they were. Guarantee you that if the pt had been pushed in wheelchair into the ER as they presented to you they would have started a drip.
 
Merck said:
The problem with the ER is that they look at the patient as they present and don't appreciate how they were.
Click to expand...

This is probably the biggest reason docs freak out in cases like this. They see the patient alert, comfortable, breathing easily, and satting well and wonder why the heck you put them on CPAP and a nitro infusion. Considering that prehospital drips in general are uncommon in most areas and most paramedics have little experience with initiating vasoactive infusions, I can see why a doc might be taken back a little by it......but that certainly doesn't mean it was the wrong thing to do.

tpchristifulli said:
I recently had a patient who was having an exacerbation of CHF. Pulse ox was 80%, hr 120, Bp 220/110, ventilation rate of 38.
I initiated CPAP, ran a 12 lead, and started a nitro infusion. Pt showed major improvement and was almost asymptomatic after our 30 minute transport to the hospital.
Upon arrival at the hospital I was questioned and scrutinized for starting a nitro drip. The physician said that is uncommon and saved for patients who are a lot more critical..
I reasoned that not only does a drip allow me more control over the dosing, it allows me to not have to keep removing the cpap to spray the nitro under his tongue.
Why not paste? During the initial events of chf the patient hyperventilates and blows off a lot of carbon dioxide. We all know c02 is a potent vasodilator, when we blow too much off we constrict vessels ( why our chf patients have cold hands) and prevent efficient absorption of nitro paste.
I stand behind my decision to start a drip and would love to hear experiences you have had starting a nitro infusion.
Click to expand...

No question an infusion results in faster, more predictable and controllable serum drug levels and clinical effects than any other route of administration. But probably the biggest argument against NTP vs. IV is the fact that even in ideal conditions, NTP is slow. Something like 30 minutes to peak effect.

So I wouldn't belabor the point about respiratory alkalosis-induced vasoconstriction because there are many variables that can affect that cascade in a sick CHFer....in a really bad episode with a significant A-a gradient you could even have a respiratory acidosis despite a normal or lowish Etc02. And someone could always just say "then why not give a couple SL's to vasodilate them quickly and then place the paste?" Because transdermal is still the slowest and least predictable route of administration, not matter what.
 
That's not quite how I'd do it, I'd start a little slower and progress if needed..
Let's see I'm thinking outloud.... Head elevated, O2 per general guidelines, I'd consider PPV *if* the pt's distress was severe, and they would tolerate.. If the pt's ventilations were ineffective, and the pt had a GCS of about 9 or below, I'd intubate.

Let's monitor ECG for dysrthymais secondary to hypoxia. Then 325 ASA po.. Flush a cath and a lock to have ready.

.04mgSL x2 if SBP >140.... I'd wait two minutes to see if improved.. If no change, I'd do one more spray, and wait 5, recheck BP.

If transport time is greater than 15, THEN I'd do an infusion if the blood pressure was still high.

I would need them to meet the criteria for CPAP--- retractions, rate> 25/min, and o2< about 90%
 
This patient pretty much screams CPAP...
 
Household6 said:
That's not quite how I'd do it, I'd start a little slower and progress if needed..
Let's see I'm thinking outloud.... Head elevated, O2 per general guidelines, I'd consider PPV *if* the pt's distress was severe, and they would tolerate.. If the pt's ventilations were ineffective, and the pt had a GCS of about 9 or below, I'd intubate.

Let's monitor ECG for dysrthymais secondary to hypoxia. Then 325 ASA po.. Flush a cath and a lock to have ready.

.04mgSL x2 if SBP >140.... I'd wait two minutes to see if improved.. If no change, I'd do one more spray, and wait 5, recheck BP.

If transport time is greater than 15, THEN I'd do an infusion if the blood pressure was still high.

I would need them to meet the criteria for CPAP--- retractions, rate> 25/min, and o2< about 90%
Click to expand...
Aspirin? May I ask why?

After seeing how fast a CHF patient can crash, that seems like a very tepid treatment progression. A little NTG here or there; maybe, possibly CPAP; NTG drip if they are about to crash... It also sounds like you wouldn't even start the IV initially, unless I'm incorrectly reading "Flush a cath and a lock to have ready."

I would much rather stay ahead of the curve. CHF exacerbation is almost certainly getting CPAP, and an NTG SL loading dose while I get an IV. Moderate CHF will likely get an infusion in hopes of preventing a severe exacerbation.

TP, I've only had to start an infusion twice (I'll start them at 10mcg/min), both with positive results. I never had a physician question the treatment, though. In fact, they both seemed grateful to already have it hung. Has that happened to you more than once? I'd imagine it was just that physician's preference.
 
I believe the a Doc was just caught off guard and didn't know how to continue my treatments, so he discontinued everything. They took the CPAP off and discontinued the NTG and said immediately after .. " look he is fine"... They reversed everything I accomplished in 30 minutes and asked why I didn't try a nasal cannula or NRB first. I replied that I didn't wanna waste time with trying to blow oxygen on alveoli covered in fluid.
 
tpchristifulli said:
I believe the a Doc was just caught off guard and didn't know how to continue my treatments, so he discontinued everything. They took the CPAP off and discontinued the NTG and said immediately after .. " look he is fine"... They reversed everything I accomplished in 30 minutes and asked why I didn't try a nasal cannula or NRB first. I replied that I didn't wanna waste time with trying to blow oxygen on alveoli covered in fluid.
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We had a doc and nurse do something similar to a patient we were pacing a couple weeks ago. She was initially unresponsive with a rate in the 20s and hypotensive. Paced her, got her pressure up, but mental status stayed poor. Nurse took off the pads when we got there, and refused to put the patient on their machine. She was no longer in the 20s, but asystolic. Doc came in and pronounced her, despite our arguments of the effectiveness of pacing. This hospital is notorious for their apathetic ineptitude, though. I could definitely see that hospital getting upset with us starting a nitro infusion.
 
Household6 said:
That's not quite how I'd do it, I'd start a little slower and progress if needed..
Let's see I'm thinking outloud.... Head elevated, O2 per general guidelines, I'd consider PPV *if* the pt's distress was severe, and they would tolerate.. If the pt's ventilations were ineffective, and the pt had a GCS of about 9 or below, I'd intubate.

Let's monitor ECG for dysrthymais secondary to hypoxia. Then 325 ASA po.. Flush a cath and a lock to have ready.

.04mgSL x2 if SBP >140.... I'd wait two minutes to see if improved.. If no change, I'd do one more spray, and wait 5, recheck BP.

If transport time is greater than 15, THEN I'd do an infusion if the blood pressure was still high.

I would need them to meet the criteria for CPAP--- retractions, rate> 25/min, and o2< about 90%
Click to expand...

I hate to be a **** but I absolutely agree with STX.

Your response screams lack of experience with sick CHFers.

They crash, hard and fast. 'Breathers' in general are ones we need to stay ahead of. Otherwise you'll end up chasing your tail and playing catchup.

Why the aspirin?

I guess a by the book BLS/ILS approach vs critical thinking. You don't know what you don't know, aren't taught or haven't learned individually.
 
STXmedic said:
It also sounds like you wouldn't even start the IV initially, unless I'm incorrectly reading "Flush a cath and a lock to have ready."
Click to expand...
I would start it, dropped and flushed..

STXmedic said:
Aspirin? May I ask why?.
Click to expand...

I've asked that many times of STPs, FTOs and cardiac NP, it's just how our MD wants it done.
Handsome Robb said:
I hate to be a **** but I absolutely agree with STX.

Your response screams lack of experience with sick CHFers.
Click to expand...

Well it undeniably should, I'll gladly admit I'm not experienced. I've had two so far, both pick ups from nursing homes. That's why I'm on here reading and getting feedback from the grisled old guys.

MrJones said:
Might want to move that decimal point a little to the right.... ;)
Click to expand...
Should read .8 actually.
 
STXmedic said:
Aspirin? May I ask why?
Click to expand...

Household6 said:
I've asked that many times of STPs, FTOs and cardiac NP, it's just how our MD wants it done.
Click to expand...

I'm not sure if this is the case for the typical "nursing home pt with significant history of CHF having an exacerbation" type of patient, but a number of sources state that "the most common cause of CHF is ischemic heart disease". Probably something to do with this?
 
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