Drug Titration

NICOM: Empower Drug Selection, Monitor and Fine-Tune the Effect

In most cases fluids alone are not enough to support the acutely failing cardiovascular system.

Adding Inotropes and/or vasopressors requires continuous meticulous assessment of the patient’s status. With NICOM, ongoing monitoring coupled with repetitive fluid challenges or Passive Leg Raising (PLR) maneuvers enables objective, tailored management of the patient.

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Case Study

In the following clinical example the ability of the NICOM to assist in drug selection and titration is demonstrated.

Background

A dyspneic patient with known COPD and CHF presented a differential diagnosis of acute decompensated heart failure (ADHF) or Pulmonary disease.

The Pulmonologist felt that the root cause of the patient’s shortness of breath was ADHF while the Cardiologist felt it was due to the patient’s pulmonary disease and stopped her diuretics. The patient was on 100 % non-rebreather with O2 saturation of 90-91%, at times diving below 90%. Urine output was low.

A NICOM test was ordered. NICOM test and Actions The monitor suggested a cardiac problem as evidenced by poor cardiac function with CI 1.6-1.8 and increased TPRI The passive leg raising challenge (PLR) indicated that the patient cannot increase her cardiac output in response to fluids, or in other words that she is in heart failure.

Low dose diuretics and inotropic support were started. Dobutrex, a powerful agonist, was started, however with little effect, perhaps due to the high afterload evidenced by high TPRI: It increased her BP as well as her TPRI and did not improve her CI much.

After the monitor indicated continued marginal response to Dobutrex, it was stopped and Primacor (Milrinone) was started, which also acts as a potent afterload reducer (reduces TPRI). As a result, BP decreased, TPRI decreased and CI increased markedly. Patient Outcome: The patient’s dyspnea resolved, her arterial O2 saturation improved markedly while her urine output increased, Intubation (with possible code) was avoided.

Discussion:

This case demonstrates two important of attributes of Hemodynamic monitoring with NICOM

1. Differential diagnosis in a clinical setting where two clinicians are debating what would be the correct management in a critically ill patient.
2. Drug titration – the ability to change dosing and regimens based on objective clinical data and obtain real-time feedback on the drug’s impact