Is it okay to give PRN labetalol (labetalol) and a lactated Ringer's (lactated Ringer's) solution bolus to a patient with tachycardia and hypotension, on metoprolol (metoprolol), with a hemothorax and chest tube?

From the Guidelines

No, it is not advisable to give PRN labetalol and a lactated Ringer's solution bolus to a patient with tachycardia and hypotension who is already on metoprolol and has a hemothorax with a chest tube. This combination of treatments could be dangerous for several reasons. First, giving labetalol (a beta-blocker) to a hypotensive patient can worsen the hypotension by further reducing cardiac output and blood pressure, as suggested by the 2013 ACCF/AHA guidelines 1. Second, administering labetalol to a patient already on metoprolol represents a duplication of beta-blocker therapy, which increases the risk of profound bradycardia, heart block, or cardiovascular collapse.

The tachycardia in this scenario is likely compensatory for the hypotension, which could be caused by hypovolemia from the hemothorax. Some key points to consider in the management of this patient include:

• Assessing the patient's volume status and the need for volume resuscitation, potentially with blood products rather than lactated Ringer's, as the patient is probably losing blood into the chest 1.
• Evaluating the chest tube for proper functioning and drainage.
• Considering the use of a passive leg raise (PLR) test to assess fluid responsiveness, as suggested by the 2019 Perioperative Quality Initiative consensus statement 1.
• Holding beta-blockers until the patient is hemodynamically stable, and reassessing the current metoprolol for temporary discontinuation until the acute situation resolves, as recommended by the 2013 ACCF/AHA guidelines 1.

Overall, the management of this patient should focus on addressing the underlying cause of hypotension and ensuring hemodynamic stability before considering the use of additional medications such as labetalol.

From the FDA Drug Label

CONTRAINDICATIONS Labetalol hydrochloride tablets are contraindicated in ... severe and prolonged hypotension, and in patients with a history of hypersensitivity to any component of the product The patient has a MAP of 81 and BP 119/56, which may indicate hypotension.

• The patient is already on metoprolol, which is a beta-blocker.
• Giving labetalol may worsen hypotension.
• The FDA drug label does not provide guidance on the use of labetalol in this specific scenario, but it does mention contraindication in severe and prolonged hypotension. The patient's tachycardia (HR 128-138) and hypotension (BP 119/56, MAP 81) should be addressed with caution. It is not explicitly stated in the label whether labetalol can be given to this patient, but given the patient's hypotension, it is likely not the best choice. As for the lactated Ringer's solution bolus, there is no information in the provided drug label that directly supports or refutes its use in this scenario. However, considering the patient's hypotension, a fluid bolus might be beneficial, but this is not directly related to the labetalol label. The FDA drug label does not answer the question.

From the Research

Patient Assessment

The patient is experiencing tachycardia with a heart rate (HR) of 128-138 for the last 15 minutes, and hypotension with a blood pressure (BP) of 119/56 and a mean arterial pressure (MAP) of 81. The patient is currently on metoprolol 50 bid and has a hemothorax with a chest tube.

Considerations for Labetalol Administration

• Labetalol is a combined alpha- and beta-adrenoceptor blocking agent that can be used to treat hypertension 2.
• However, it can cause profound hypotension, as seen in a case report where a patient experienced hypotension and bradycardia after receiving an intravenous infusion of labetalol 3.
• The patient's current hypotension and tachycardia may be exacerbated by the administration of labetalol, and caution should be exercised when considering its use.

Considerations for Lactated Ringer's Solution Bolus

• Lactated Ringer's solution is a crystalloid fluid that can be used for initial fluid resuscitation in patients with sepsis-induced hypotension 4, 5.
• Studies have shown that lactated Ringer's solution may be associated with improved survival and clinical outcomes compared to normal saline in patients with sepsis-induced hypotension 4.
• However, another study found no significant difference in outcomes between lactated Ringer's solution and normal saline when used hospital-wide for routine intravenous administration of fluids 5.

Key Points to Consider

• The patient's current medication regimen and medical condition should be taken into account when considering the administration of labetalol or lactated Ringer's solution.
• The potential benefits and risks of each treatment option should be carefully weighed, and the patient's response to treatment should be closely monitored.
• The use of labetalol and lactated Ringer's solution should be guided by the patient's individual needs and medical condition, rather than a one-size-fits-all approach.

Some key points to consider when deciding whether to give the patient PRN labetalol and a lactated Ringer's solution bolus include:

• The patient's current heart rate and blood pressure
• The patient's medical history and current condition, including the hemothorax and chest tube
• The potential benefits and risks of labetalol and lactated Ringer's solution in this patient
• The need for close monitoring of the patient's response to treatment.