The use of intravenous nitroglycerine and morphine practices by specialized nurses in heart failure patients with respiratory complications; a cross-sectional study

Acute heart failure (AHF) with respiratory insufficiency is associated with an increased risk of readmission and elevated mortality and morbidity. The use of intravenous nitroglycerin is widely recognized as a cornerstone therapy. Although dosing recommendations for intravenous nitroglycerin in acute heart failure vary widely, actual clinical administration practices remain poorly documented, with no standardized data available for routine use. The role of specialized acute care nurses in administering nitroglycerin is pivotal; they are responsible for the precise administration and titration of IV nitroglycerin to achieve hemodynamic goals. Morphine is no longer recommended in the management of AHF. There is very scarce data about the use of nitroglycerin and morphine in the treatment of AHF by specialized acute care nurses in different settings.

This study aims to investigate the administration of intravenous nitroglycerin and morphine by specialized acute care nurses in the treatment of AHF with respiratory failure, focusing on patterns and variations in practice.

This cross-sectional study utilized an open, voluntary response survey to collect data from specialized nurses working in Emergency Rooms (ERs), Cardiac Care Units (CCUs), and Intensive Care Units (ICUs), across all 36 Dutch hospitals (ranging from general to academic) between May and November 2022. Participants were recruited via an open, voluntary survey without prior selection, and data was gathered using a 37-item anonymous survey. All frequency-based items were scored on a 5-point Likert scale (1 = Strongly agree, 5 = Strongly disagree); reported values represent mean scores ± standard deviation.

A total of 242 specialized nurses participated in this voluntary survey, with the majority (62%) working in CCUs, followed by 25% in ICUs and 13% in ERs. The administration of intravenous nitroglycerin was titrated to higher (above 5 mg/hour) rates more frequently by ER nurses (2.42 ± 1.06) and CCU nurses (2.68 ± 1.1) than by ICU nurses (3.00 ± 0.88) (p = 0.019). Furthermore, CCU and ER nurses most often administered higher NTG doses (3.0–6.9 mg/h; 63% and 61%, respectively) compared with ICU nurses (36%) (p < 0.001). In contrast, the administration of morphine was significantly more common among ICU nurses (2.31 ± 0.89) than among ER (3.10 ± 1.11) and CCU nurses (2.92 ± 1.20) (p < 0.001). (Table 1)

This study highlights significant differences in nitroglycerin and morphine administration practices in patients with AHF with respiratory failure among acute care nurses across CCU, ICU, and ER settings. Further research is warranted to explore the clinical implications of these practice variations for patient outcomes.