[Amberlynn1181]

I'm a nurse of 3 months in NICU. I had a patient w/ no apparent defecits and a SAH. Her clipping is tomorrow, and her parameters were to keep SBP 100-140. Once, in the morning, it was at 155. 30 min later same. Manual cuff gave around 145. 30 min later back in the 130s. (NBP, no Art line). Stayed within limits for four hours, then back at 150. Was chewed out by another nurse for not starting a gtt. Another nurse disagreed, and said that as long as the trend was good, a gtt wasn't necessary. 30 min before my shift ended, I was in the pt's room, and no change in neuro status. I called work after I left and the oncoming RN told me that BP was back in the 130s (I called a doc and gave 10 of lasix for + fluid balance), but patient was unresponsive. Pt. has been on Nimotop. Possible vasospasm, but it scares me to think that it could have been caused by the BP. One nurse thought I was ignorant, another told me it was fine. Any opinions?

[Elenaster]

Okay, I'm a little confused, because I would think they wanted her SBP<140 to prevent rupture or re-bleed of her aneurysm pre-operatively. From my understanding, the bleeding is what significantly increases the chances of developing post-clipping vasospasm. Secondly, post-clipping, you want the patient hypertensive to help keep the vessel open and the brain perfused (as part of your triple-H therapy) unless they have an underlying cardiac condition that could not tolerate the HTN.

If that patient were mine, I would be far more concerned about rupture or re-bleed than vasospasm. Did she get a stat head CT when she became unresponsive? Also, did she have cardiac issues?

[Amberlynn1181]

Originally Posted by Elenaster

Okay, I'm a little confused, because I would think they wanted her SBP<140 to prevent rupture or re-bleed of her aneurysm pre-operatively. From my understanding, the bleeding is what significantly increases the chances of developing post-clipping vasospasm. Secondly, post-clipping, you want the patient hypertensive to help keep the vessel open and the brain perfused (as part of your triple-H therapy) unless they have an underlying cardiac condition that could not tolerate the HTN.

If that patient were mine, I would be far more concerned about rupture or re-bleed than vasospasm. Did she get a stat head CT when she became unresponsive? Also, did she have cardiac issues?

My mistake, she did have a rebleed. Her clipping was moved to a day early b/c of her neuro change. Docs did not have her on triple H therapy. I took care of her again the next night, and she had had a frontal bleed and clipping, which turned her into a swearing sailor . 4point restraints, posey, mittens, with only codeine and vicodin ordered. Kept calling neuro for sedation, and the orders were ineffective. I called the consulting doc and he gave me haldol, which seemed to work. Whole night was frustrating, b/c I told neuro that she was bound to rebleed again as long as she was yelling, agitated, combative, and she managed to rub her art line out, and the cuff pressures weren't accurate with her tensing all the time. I called early in the morning for a stat head CT and sure enough, infarct and herniation. It took all night for the doctor to finally agree to intubate and sedate her, since we couldn't control her activity well enough without it. What a night! I was so glad that I had extra support from all the nurses there.
She had no remarkable history for cardiac.

[Good_Queen_Bess]

One of my concerns is that your patient hasn´t got an arterial line. Surely it is of importance that her BP is monitored constantly as she is obviously unstable.
(Sorry can´t go on for too long as I´m on holiday in Algarve in Portugal and have only come onto the internet for a couple of minutes in the hotel lobby! I am NOT missing work, but was checking my emails etc)

[Elenaster]

Originally Posted by Amberlynn1181

she had had a frontal bleed and clipping, which turned her into a swearing sailor . 4point restraints, posey, mittens,

Gotta love those frontal lobe insults!

Aneurysms are tricky to manage and if you don't see them everyday, it's easy to confuse pre-op and post-op treatment. The key to remembering vasospasm management is thinking about keeping the vessel open so the brain remains perfused, and thats where your triple H therapy and Nimodipine are essential. You pt. should also be getting trans-crainial dopplers (TCDs) daily.

[Amberlynn1181]

That's what I told the doc, but there was no way to keep her still for another art line insertion, and he wasn't willing to sedate her. We all thought that we could have caught her neuro status earlier if she was sedated, because even though her glascow would drop, she wouldn't be hyperventilating so much and masking her ICP increase. And after her infarct, I called the neuro doc and told him about the BP problems, and he increased my parameters! It was just quite a night overall. I was back at work the last couple nights, and she's to be extubated today and they'll see how she does. She was down to 11mcg of propofol and trying to pull out her ETT, but not nearly as bad as she was before. The family through it all has been very supportive of keeping her calmer to support healing.

[kten03]

Originally Posted by Amberlynn1181

I'm a nurse of 3 months in NICU. I had a patient w/ no apparent defecits and a SAH. Her clipping is tomorrow, and her parameters were to keep SBP 100-140. Once, in the morning, it was at 155. 30 min later same. Manual cuff gave around 145. 30 min later back in the 130s. (NBP, no Art line). Stayed within limits for four hours, then back at 150. Was chewed out by another nurse for not starting a gtt. Another nurse disagreed, and said that as long as the trend was good, a gtt wasn't necessary. 30 min before my shift ended, I was in the pt's room, and no change in neuro status. I called work after I left and the oncoming RN told me that BP was back in the 130s (I called a doc and gave 10 of lasix for + fluid balance), but patient was unresponsive. Pt. has been on Nimotop. Possible vasospasm, but it scares me to think that it could have been caused by the BP. One nurse thought I was ignorant, another told me it was fine. Any opinions?

I haven't read all the following posts. however, any aneurysm in my opinion should have invasive arterial line and or PA line later in treatment.....regardless of her ability to hold still. I believe you did the best you could with what you were given to work with.

[neurogeek]

Rule of thumb: first 3 days keep pressure low to prevent rebleed, after that it's time to "pump of the volume" with BP and fluids to prevent vasospasm. You didn't say what day your patient was when this occurred so it would all hinge on that factor. BP changes by even 10mm/Hg can be the difference between live brain and dead brain. If u have orders to keep it <140 then keep it there. Don't let it trend up at all. Same for the opposite. If you have orders to keep it >160 then don't let it go below for more than a matter of minutes without treating. I've seen patients literally spasm in front of nurses eyes while they were sitting on BP's to "see what happens." Also, if u only have an NBP u shouldn't be waiting 30 minutes between pressures on a SAH patient. Q 15 at the most, preferably Q 5 until u can convince the doc to put in an a-line.

[kvsherry]

Did the nurse tell you what she thought you were ignorant of? I would have felt funny starting a gtt on a patient with such labile BP without an A-line. In the future I would call every doc I could to get the order for the A-line if the primary will not give it. Also, if you have residents...use them too, they are usually the most willing to listen.