Clonidine Use in the Chronic Unit

MizChelleRN · May 12, 2014

I've been in incenter hemo for 5 years and rarely give it as well. I remember a few ppl who would request it specifically. Or make sure tge patient has refills on their home meds.....not that we give clonidine in place of chronic meds but if someone can't afford their refills for awhile I might give them a dose.....got off track for a moment. Actually most cases fluid removal will bring the bp down.....many of my hypertensive patients are in an ok range by the time they leave. I would say you'll probably learn and "know" your patients and how they run before you dose them. Can't speak on the acute patients however.

SmilingBluEyes · May 12, 2014

We do not administer clonidine at all in the chronic unit. Nor do we administer any BP meds. We DO give SL nitro for chest pain. But the rest is treated/used outside the chronic clinic by the patient.

NurseRies, BSN, RN · May 14, 2014

I only ever gave it a few times, usually with non compliant patients and only POST dialysis. We had several ppl that just lived at BPs of 210/115. When their pressure dropped to 135/80, they would sometimes nearly pass out or throw up. They would be maxed out on BP meds at home, labatelol 800mg tid doesn't touch them, along with their norvasc, lisinopril, and prn clonidine at home. Prob how they ended up ESRD to begin with. Some people truly have uncontrolled hypertension, it is their baseline. If it was someone who never had systolic greater then 200, I may consider calling the doc to ask about clonidine, but still would only do so post HD.

Trauma Columnist · May 14, 2014

HTN can always be managed. Yes, it might take a combo if up to five meds, but if a pt is compliant with meds and fluid restriction, BP should be controlled.

Prn clonidine should not be used after dialysis, only before or in the first hr or two. This is due to rebound HTN. You give the clonidine, take off fluid and then there is much less or no rebound HTN. Giving it after HD is just asking for trouble.

NurseRies, BSN, RN · May 14, 2014

Interesting. I guess every nephrologist may be a little different. The MD at my clinic always wanted to give it post HD.

Trauma Columnist · May 15, 2014

But then their BP will rebound! Makes no sense and dangerous practice.

westieluv · May 16, 2014

Thanks so much for all of your replies. I still hesitate to give it and normally don't, regardless of what another nurse may do. I wish our clinic didn't automatically offer it as a PRN for everyone, but they do. It would obviously be much less of a gray area if the opportunity to give it was not there.

Guttercat, ASN, RN · May 28, 2014

As you know Westie, intradialytic htn can be a head-scratcher. I do not like to throw big guns (clonidine) at patients unless I have exhausted other means, because it's addressing a symptom instead of the problem. We've all had the patient who walks in normotensive, but their BP reaches critical values as dialysis and fluid removal progresses. This is especially counterituitive when we think that we have turned the patient into a raisin. The patient has no edema, and the lungs are clear, so what gives, right? Why is the BP post-tx hovering at 190/115? A lot comes into play here: Cardiac output changes as fluid removal progresses, PVR, autonomic reactions, and the list goes on.Fun, isn't it? :)As one study I read suggested (I tried to find it)--it can be due to the patient still having a couple or more kilo's to unload, even though they look like a shriveled peanut. This study suggested extra treatments for a week or two. However, this (hidden fluid) is only one piece of the puzzle, and each patient is different. That said, I have occasionally "pushed" fluid removal on a couple of patients with refractory intradialytic htn who I thought might still have extra fluid on even though clinically they presented "dry," with some success.Put your "big brain" on, and read this article. It sheds some light, and will give you greater insight into your patients with refractory BP issues. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830363/

Chisca, RN · May 28, 2014

. Intradialytic Hypertension: A Less-Recognized Cardiovascular Complication of Hemodialysis

Outstanding article. Another reminder of the complexity of hemodialysis.

westieluv · May 28, 2014

Thanks so much to both of you for posting those links. I am definitely going to read through both of them to gain knowledge on the subject.

I have one patient, a sweet, little 85 year old lady, who never comes in more than 2 kg above her EDW, always achieves her EDW, has no symptoms of fluid overload, and starts off with a SBP in the 140s. During her treatments lately, her BP has been climbing, sometimes as high as SBP in the 180s. She takes her Lisinopril pre-tx per doctor's order and the rest of her BP meds after she gets home from her treatment so she definitely does not get Clonidine while at the unit, but it is so frustrating trying to get to the bottom of why this is happening. I am still new enough to dialysis to not really "get it" at this point, so these articles will help immensely. I would read them now, except that I have to work at 5:30 tomorrow morning and I have a screaming migraine.

Thanks again, I'll read them and check back in. :)

Guttercat, ASN, RN · May 29, 2014

Westie,

They're one and the same article/study.

As to your particular patient mentioned above, with older folks (and those younger folks who are chronic fluid abusers) there are often cardiac output changes due to cadiomyopathy and valvular defects: too much fluid on board and the heart isn't strong enough to "push against" the pressure. However, lower that volume a bit, and the heart has enough oomph to pump out greater quantities of blood with each beat. Thus, the BP can rise during treatment.

This, of course (as outlined in the study), is only one small piece of the giant mechanical, nervous system, and chemical feedback system that regulates each individual's BP. Yours included.

Interestingly, in some folks with terrible ejection fractions one wants to keep a patient slightly fluid overloaded so that the diseased heart has something to work with. In these people (generally little old people), a couple hundred ml's too dry and the BP can crump in a hurry.

In your patient, I suspect there's a combination of factors including a weak heart, a changing true dry weight (she might have lost a pound or two of body weight), and BP meds dialyzing out during treatment. You might try gently increasing UF goal over the next few treatments. Discuss this with your peers and MD's, of course.