[Sweetooth EMT-P, RN]

Hi all,

Just a quick question with regards to a patient I had pre-hospitally the other day.

66 Year old women has been on dialysis (heme) since last January. She was in the grocery store when she suffered two syncopal episodes related to hypotension prompting the employees to dial 911. Patient reports getting off of her treatment around 3 pm and we were assessing her in the store around 4 pm. Initially patietn BP was in the 90's systolic sitting in a chair. She denied any complaints sitting, but stated she felt dizzy standing, and she was refusing transport. She also added that her BP was fine when they took it before she left the dialysis center, but also hadn't told them that she had similar episodes after her last treatment, but it had resolved rather quickley on its own. So anywho the patient again was really refusing so I had her stand up while I got her information just to see how she did, and sure enough she became pale and diapheretic BP dropped to 75/50 and she only lasted about 3 minutes standing, if that. Well that obviously convinced her that she need to go to the hospital as I had hoped it would. In addition to the CRF she also had hx of hypertension and depression. She added that her BP was normally 110-120 post treatment. LS were clear, 12 lead was normal, she was in a normal sinus in the 60's (on Lopressor). No complaints of pain... reports her fluid limit for the day is 1500 and she had no reached that limit. She does still make urine.

So I chose to give her a smalll bolus of fluid (200 mL) which improved her BP up to the high 90's, but that was lying almost supine. So did I do the right thing?? Or should I have withheld any fluid?? I know they can have autonomic disfunction, but I was giving the bolus based on the fact that maybe they took off to much at dialysis....


Any thoughts would be helpful and thank you ini advance



Swtooth EMT-P, RN

[Sweetooth EMT-P, RN]

Anyone... Anyone..?

[kdhnursern]

If you only gave her 200c bolus, you did okay. I've seen the ER give 1000cc and up saying we got them too dry. But in the dialysis clinic, we give them fluid in 200cc increments if their BP is low post tx. At some point, we decide (looking at the overall picture, it's not always the same) to stop the fluids. If they no longer are hooked up to the machine, we give them a small container of juice, a couple graham crackers, lay them in trendelenberg position, anything that might help the non-dialysis patient.
I appreciate that you asked. Most of the time, we have an uphill battle trying to keep our patients out of fluid overload. Thank you.

[Sweetooth EMT-P, RN]

Hi Kdh,

Thank you very much for the post. If this is her second time having hypotension post dialysis does that lead you to beleive its more of a fluid issue than autonomic, or the opposite?

Swtooth

[kdhnursern]

I would guess fluids since both times happened post-tx. That's one reason I like chronic hemo, we see the same people all the time 3X/wk and know their history well. But when we have a new patient, we have to go through the learning process. Our newest came to us about 8kg over the target wt we got from the dr. We set 2.5-3.0kg goals for him, he had some hypotensive episodes toward end of txs, so we would back off the goal. But in 2 weeks, we have him down to target wt and functioning better.

[oMerMero]

I am assuming she was on other BP meds in addition to lopressor. Perhaps those need to be adjusted. Sounds like you did the right thing.

[Hellllllo Nurse]

Originally Posted by oMerMero

I am assuming she was on other BP meds in addition to lopressor. Perhaps those need to be adjusted. Sounds like you did the right thing.

That's what I was thinking- maybe lower or D/C bp meds.

Returning blood can make a pt's bp temporarily higher- just like giving an NS bolus can. Then, once they're finished w/ tx, and out and about (especially if they're on their feet, shopping) their BP can drop again.

[DeLana_RN]

My guess is that that dialysis clinic staff took off too much fluid, i.e., the patient's EDW (estimated dry weight) is too low and needs to be adjusted.

When I worked in a clinic, occasionally pts had an "acceptable" (100+) standing systolic BP immediately after dialysis and then pass out in the lobby waiting for transport. For some pts, 100 SBP is just too low and they were too dry. A fluid bolus of 200 cc (sometimes more) would usually be sufficient. Therefore, you did the right thing.

The pt's clinic staff need to adjust her EDW and contact the MD regarding her antihypertensives; most likely, the EDW (and therefore the amount of fluid removed per tx) is the problem.

DeLana