Mixing BB and CCB in Afib with RVR

[mauricekenter]

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Sorry if this has been discussed before, but I couldn't find it anywhere on the forums.

Long story short, do you guys mix IV CCB and BB in an Afib with RVR patient who is unresponsive to CCBs alone? Lets pretend I have already made sure they aren't just in chronic afib and now simply tachycardic.

I have had a few cases where the patient doesn't respond very well to my 2 boluses of diltiazem (typically ~20mg IV each) and at our shop if you put them on a diltiazem drip they have to go to the ICU. In the past I have been taught you shouldn't mix IV CCB and BB because you can severely decrease the BP or put them into a heart block. Yet twice I have given metoprolol 5mg IV after my first 2 initial diltiazem boluses and it controls them beautifully without making them go to the ICU on a drip.

What do you guys think?

Also what do you do for those patients who have CHF... Just BB? Dig?

Thanks!

 

[RustedFox]

Sorry if this has been discussed before, but I couldn't find it anywhere on the forums.

Long story short, do you guys mix IV CCB and BB in an Afib with RVR patient who is unresponsive to CCBs alone? Lets pretend I have already made sure they aren't just in chronic afib and now simply tachycardic.

I have had a few cases where the patient doesn't respond very well to my 2 boluses of diltiazem (typically ~20mg IV each) and at our shop if you put them on a diltiazem drip they have to go to the ICU. In the past I have been taught you shouldn't mix IV CCB and BB because you can severely decrease the BP or put them into a heart block. Yet twice I have given metoprolol 5mg IV after my first 2 initial diltiazem boluses and it controls them beautifully without making them go to the ICU on a drip.

What do you guys think?

Also what do you do for those patients who have CHF... Just BB? Dig?

Thanks!

A lot of guys at my shop hit them with a loading dose of digoxin. Seems to bring the dissociation closer to normal.

 

[EM_Rebuilder]

I'll start with Dilit.... if it doesnt work, I stop it and give Esmolol. I dont think I have ever given them both at the same physical time.

 

[mauricekenter]

Not necessarily at the same time. Usually 30 mins or so after

 

[gutonc]

This is one of those scenarios where what you guys do in the ED and what we do on the floor or in the ICU differ dramatically.

For reasons I've never been able to figure out (and don't really care about), ED folks love them some dilt drips while the MICU folks get massive wood over esmolol drips or metop pushes...and forget the cards guys who will skewer you for mixing and matching your various blockers.

My personal approach is to go with BB first and then CCB if that doesn't work. But I've taken plenty of people from the ED on useless dilt drips, given them a slug of metop and called it a night (the converse is true as well...plenty of folks who responded to CCB drips and stayed that way). I think the key is to not get married to whatever you started with and be willing to switch gears if it's not working. Anybody getting IV cards meds will be on tele if not in the ICU/CCU so I worry less (I still worry...just less) about the theoretical issues with giving one after the other. If I'm piling drugs on in this setting I get cards involved just to get a neutral 3rd party view of the situation. It's helpful if you can talk to an attending rather than a fellow, not because cards fellows are bad, just because they don't have the experience of their attendings.

 

[dchristismi]

If I don't have a good response to cardizem, I switch to metoprolol. This never happens quickly - it's usually 20 minutes at least, but I don't know that there's a time to it. My cards guys don't seem to mind, either. I'm a fan of loading with dig as well, although it usually takes longer.

Now, if the BP drops, or they're anticoagulated already, I will just consult Tampa Energy. Works quite well once you get the patient past the initial, ahem, shock.

 

[mauricekenter]

Well that's good to hear no one is adamantly opposed to using IV BB if IV CCBs have failed to control adequately. dchristismi what is your dig load?

 

[combatwombat]

My personal approach is to go with BB first and then CCB if that doesn't work. But I've taken plenty of people from the ED on useless dilt drips, given them a slug of metop and called it a night

Am I wrong to be a little taken aback by all this talk of "personal approaches"? Aren't there evidence-based guidelines for this kind of thing? Or at least *some* research to light the way?

 

[Bostonredsox]

Well that's good to hear no one is adamantly opposed to using IV BB if IV CCBs have failed to control adequately. dchristismi what is your dig load?

If they are sedentary and thus vagal tone is low, dig is your friend. I load 0.5, 0.25, 0.25 in the first 24 hours then .125daily. If they are moving alot and getting out of bed and stuff the dig is less effective. Also, i would caution loading dig if you have already loaded a ton of dilt and theyre beta blocked at baseline, you can kill the AV node and then I end up having to trans-venous pace them upstairs.

As for BB and CCB, my shops ed docs love dilt. Up here we use esmolol more often than not if they need a drip and metoprolol if pushes are getting the job done enough on say the cardiac or Stepdown floor. The cards guys also have their own opinions. A few like dilt alot, a few prefer to BB. I agree with Dchris thouth, I generally pick one and if it is having no effect and it is not new onset, I give them juice.

We had a big wig come up from one of the local tertiar cares to lecture for a CME, was advising smaller doses of both classes tend to avoid the side effect profiles better than max dose of one class. This was mostly for maintance control of the rate though. IE, he likes 50 BID of lopressor and 90 of XR dilt instead of 360 of dilt or 200 BID of lopressor. An extra pill for pt but less side effects. In the acute RVR situation, not sure the side effect profile is as important as they will both make them hypotensive. Obv have to consider which BB ur using if they are asthmatic and such. But I like rapid onset/offset drugs in the MICU. fan of esmolol.

 

[gutonc]

Am I wrong to be a little taken aback by all this talk of "personal approaches"? Aren't there evidence-based guidelines for this kind of thing? Or at least *some* research to light the way?

Sure...in this case for example...

CCBs work (unless they don't)
BBs work (unless they don't)
Pick one and run with it (until it doesn't work)

 

[Bostonredsox]

Sure...in this case for example...

CCBs work (unless they don't)
BBs work (unless they don't)
Pick one and run with it (until it doesn't work)

/nod.

they all are indicated and none have superiority over the other. Use one, it it fails use the other.

Your HCAP pt with history of pseudomonas, cefepime/ceftaz/mero/imi/dori/pip-taz all indicated as first line agents. Pick the one you like unless there is some other complelling reason to not use one or the other. EBM doesn't exist to separate out choices quite frequently.

 

[mauricekenter]

My fear has always been sending these people into a complete heart block which no longer is responsive to typical medications for bradycardia if I give both IV CCB and IV BB. I have come up empty on numerous pubmed searches. Anyone out there have any articles which have looked into this?

 

[The White Coat Investor]

My fear has always been sending these people into a complete heart block which no longer is responsive to typical medications for bradycardia if I give both IV CCB and IV BB. I have come up empty on numerous pubmed searches. Anyone out there have any articles which have looked into this?

I don't know; I always worry about it too. I think I may have even done it a few months ago. Lady ended up dying, but was pretty ill to start with.

 

[Daiphon]

My fear has always been sending these people into a complete heart block which no longer is responsive to typical medications for bradycardia if I give both IV CCB and IV BB. I have come up empty on numerous pubmed searches. Anyone out there have any articles which have looked into this?

Not aware of any reports, but I've also never seen this happen.

If it did though, I'd probably tx like iatrogenic overdose & reverse the CCB with HIE and the BB with glucagon, then provide a transdermal loading dose of joules as they are then by definition unstable.

Purely theoretical however.

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[deleted109597]

Your HCAP pt with history of pseudomonas, cefepime/ceftaz/mero/imi/dori/pip-taz all indicated as first line agents. Pick the one you like unless there is some other complelling reason to not use one or the other. EBM doesn't exist to separate out choices quite frequently.

I would pick the two I like, to double cover pseudomonas.
And then something to cover MRSA if it isn't covered by the two you've already picked. But that's just me. And the PN-6 core measures.

 

[EM_Rebuilder]

My fear has always been sending these people into a complete heart block which no longer is responsive to typical medications for bradycardia if I give both IV CCB and IV BB. I have come up empty on numerous pubmed searches. Anyone out there have any articles which have looked into this?

I dont think any of these medications block electricity?..

 

[Boatswain2PA]

if it did though, i'd probably tx like iatrogenic overdose & reverse the ccb with hie and the bb with glucagon...

hie ??

 

[Arcan57]

hie ??

From context, I'm assuming a high dose insulin gtt using it as a pseudo pressor foc CCB OD. I wasn't aware it had acquired an acronym.

 

[Boatswain2PA]

From context, I'm assuming a high dose insulin gtt using it as a pseudo pressor foc CCB OD. I wasn't aware it had acquired an acronym.

Makes sense. But is insulin used as a pressor for CCB OD, or is it used because CCBs block insulin release? (although I guess that would affect BP as well) Or both??

 

[Arcan57]

Makes sense. But is insulin used as a pressor for CCB OD, or is it used because CCBs block insulin release? (although I guess that would affect BP as well) Or both??

Pressor. EM:RAP had a good discussion on it last year or I'm sure there are review articles on it by now.

 

[deleted109597]

Hyperinsulinemia/euglycemia, as Arcan said.
It works. Sometimes you have to have them on D25 though.

 

[Daiphon]

From context, I'm assuming a high dose insulin gtt using it as a pseudo pressor foc CCB OD. I wasn't aware it had acquired an acronym.

Sorry. And you're correct... much easier to type HIE instead of hyperinsulinemia-euglycemia on my phone. Damn autocorrect drives me up a wall.

d=)

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[Daiphon]

Makes sense. But is insulin used as a pressor for CCB OD, or is it used because CCBs block insulin release? (although I guess that would affect BP as well) Or both??

Pressor. Insulin release blockade w/ subsequent hyperglycemia is a sign of toxicity but it's the conduction problem & loss of vascular tone that'll kill ya.

-d

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[Zanegray]

Pressor. EM:RAP had a good discussion on it last year or I'm sure there are review articles on it by now.

Scott Weingart has a recent emcrit podcast on this as well - something like ODs of cardiotoxic drugs. a good listen

 

[Boatswain2PA]

Thank you everyone....I learn a lot from the anecdotal cases discussed here.

 

[Bostonredsox]

I would pick the two I like, to double cover pseudomonas.
And then something to cover MRSA if it isn't covered by the two you've already picked. But that's just me. And the PN-6 core measures.

none of the anti-pseduomonal agents that I listed cover MRSA. They all get vanc added at the start, peeled back later if MRSA ruled out.

And as for double coverage, that is not universal. Our ID guys do not double cover for all pseudomonal patients in this area. Theyre rationale is it depends on an areas particular pseudomonal patterns and antibiograms. They do give gent for synergy in a few pts I have seen. Plenty of them they treat with single agent pip/taz or merrem. We have enough of a cdiff problem here, I see adding a second big gun as just makinng that worse. And for 'picking 2 of those agents i listed', I would recommend against picking a beta lactam/BLI and a cephalosporin, as does the IDSA guidelines, unless you want your pt to seize. And i doubt you are putting all these pts on Merrem and Zosyn routinely to double cover. The majortiy of ed docs I see erroneously double covering for pseudomonas right off the bat are using something like vanc/zosyn/gent. Gents toxicisites far out-weigh its benefit in initial coverage to a pt who even if they do end up having pseudomonas, ais unlikely to have beta lactam resistance. And their is no atypical coverage in that regimen.

The IDSA guidelines for a pt with HCAP and a history of pseduomonas are actually Vancomycin + respiratory FQ + anti-pseudomonal agent. The 'triple therapy, does not consist of 2 anti-pseudomonals. And the few pts that come up with say Zosyn and aztrenoam, the first thing we or ID do is stop the aztreonam. If you are adding cipro in place of levaquin as your FG agent, than you are actually double covering for Pseudomonas. However, cipro does not have a routine use in HCAP given its ineffectiveness against S. pneumo, the #1 pathogen. The only pt we routinely double cover for pseudomonas right off the bat is a pt with a history of pseudomonal VAP who is in fact going on the ventilator again.

Just a different perspective. If your shop has a lot of piperacillin resistant pseudomonas perhaps your strat is better.

 

[deleted109597]

none of the anti-pseduomonal agents that I listed cover MRSA. They all get vanc added at the start, peeled back later if MRSA ruled out.

And as for double coverage, that is not universal. Our ID guys do not double cover for all pseudomonal patients in this area. Theyre rationale is it depends on an areas particular pseudomonal patterns and antibiograms. They do give gent for synergy in a few pts I have seen. Plenty of them they treat with single agent pip/taz or merrem. We have enough of a cdiff problem here, I see adding a second big gun as just makinng that worse. And for 'picking 2 of those agents i listed', I would recommend against picking a beta lactam/BLI and a cephalosporin, as does the IDSA guidelines, unless you want your pt to seize. And i doubt you are putting all these pts on Merrem and Zosyn routinely to double cover. The majortiy of ed docs I see erroneously double covering for pseudomonas right off the bat are using something like vanc/zosyn/gent. Gents toxicisites far out-weigh its benefit in initial coverage to a pt who even if they do end up having pseudomonas, ais unlikely to have beta lactam resistance. And their is no atypical coverage in that regimen.

The IDSA guidelines for a pt with HCAP and a history of pseduomonas are actually Vancomycin + respiratory FQ + anti-pseudomonal agent. The 'triple therapy, does not consist of 2 anti-pseudomonals. And the few pts that come up with say Zosyn and aztrenoam, the first thing we or ID do is stop the aztreonam. If you are adding cipro in place of levaquin as your FG agent, than you are actually double covering for Pseudomonas. However, cipro does not have a routine use in HCAP given its ineffectiveness against S. pneumo, the #1 pathogen. The only pt we routinely double cover for pseudomonas right off the bat is a pt with a history of pseudomonal VAP who is in fact going on the ventilator again.

Just a different perspective. If your shop has a lot of piperacillin resistant pseudomonas perhaps your strat is better.

We use Cipro. Levaquin isn't on formulary. CMS does recommend double coverage of pseudomonas for those at risk, and most HCAP are. While IDSA is reasonable, CMS determines core measure compliance. Guess which one I'm going to follow.

Only use gent for open fractures, and that's an ortho request, not my personal decision.

 

[Bostonredsox]

We use Cipro. Levaquin isn't on formulary. CMS does recommend double coverage of pseudomonas for those at risk, and most HCAP are. While IDSA is reasonable, CMS determines core measure compliance. Guess which one I'm going to follow.

Only use gent for open fractures, and that's an ortho request, not my personal decision.

Yeah i know that table, i was just using the IDSA guidelines as they are truly physician derived by the ID people. Not sure about CMS. But I see your arguement, it is good to be compliant with the people who pay you. And we have the alternative, levaquin is on formulary since it went generic, cipro is not. So unless its pseudomonas in the urine, RX interchanges it.

 

[Rendar5]

Speaking of gent, I learned a second use aside from open fx's. We had a rash of sick endometritis patients in the past few months. Apparently, 1st line agent seems to be gent+clinda per uptodate