Treatment of Garden Hose Dissection

[Dr.Evil1]

So I was reading the garden hose dissection thread and was remembering my studying. It seems everywhere I read about the treatment of aortic dissection or hypertensive emergency in general (see Pg. 1317 Rosen's 6th edition) there is a biasis towards nitroprusside. It seems, though, that this drug is used RARELY if at all in the REAL practice of clinical EM. I asked some people (attendings at my institution) about this and everyone says that it is very hard to titrate and more often then not causes hypotension. Plus you have the potential for cyanide toxicity, the need to wrap the bag in foil, and the risk of local necrosis with extravasation. The one patient that I did put it on in my ICU rotation the attending immediately changed it during rounds the next day.

So I was wondering what the experience of the old dogs out there actually is in regards to the use of nitroprusside? Is is part of your clinical practice?

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[ERMudPhud]

My patient ended up on nipride and esmolol. Its quick. Its in our Pyxis. I'm used to it. Plus I've had frustrating experiences using just B blockers like esmolol or labetalol (I know its not pure B) with the HR coming down very low but the BP still being higher than I want. With nipride+esmolol you can titrate the two effects somewhat independently

My recent patient was transitioned to labetalol in the ICU since they hate nipride for the previously mentioned reasons

 

[docB]

I use nipride when indicated. I feel that in there is a kind of monday morning quarter back phenonema where the consultants, attendings, etc. who see the patient after the first few hours are presented with a slightly hypertensive pt instead of the 220/140 patient they had before. They then feel the negatives of the nipride outweigh the positives and they shut it off. This is probably how it should be but they never seem to want to acknowlege that it was necessary initially.