Hemodialysis with low BP on pressors?

[IheartICUnursing]

Just wondering if anyone has ever seen hemodialysis performed on a patient who is already on a vasopressor for BP?

I had a patient not long ago who was on Levophed, MAP hanging around 60s, with only a BP cuff, no art line to monitor BP. (at the time there was no art line because it was a low dose that was just started the night before) I had already had to titrate up slightly within an hour of coming onto my shift.

MD came by and ordered hemodialysis for her. I explained that, as he could see on the monitor, the BP wasn't so great, HR had newly risen into the 130's and that I was already titrating up on the Levo and didn't think she could tolerate hemodialysis in that state. He disagreed with me though, and the response I got was "Well, I'm the nephrologist. Just give her 2 units of blood (already ordered anyway) during dialysis to keep her pressure up"

Dialysis nurses came, I explained to them I didn't feel that the patient should be dialyzed, especially since we had already started a 2nd and 3rd pressor in the meantime, and didnt even have an A line for accurate monitoring. They called their charge nurse, who agreed and shortly after they left the pt became very unstable and ended up de-satting and being intubated.

... Oh, and I forgot to mention that pt was on CRRT the day before which was stopped because she wasnt tolerating it well.

Am I missing something, or was I correct in stopping them from doing dialysis? I am a new grad, first week on the job so I know I still have a lot to learn, but I felt really strongly about it!

[core0]

Ok, so its very similar to CRRT then? We just do CRRT in our facility. We set it up, run it and troubleshoot it. Its not so bad when its running smoothly!

My understanding is that SLED is similar to CRRT but uses conventional HD machines. In an ICU which rarely does CRRT its cheaper to do SLED for the few times that you need dialysis. Basically you use a HD machine and run it slowly (run over 8-12 hours). That allows the same clearance and UF as CRRT. According to some its also cheaper than CRRT;

http://www.nature.com/ki/journal/v70/n5/abs/5001700a.html

Back to your patient they absolutely shouldn't have had HD. Even with CRRT I wouldn't have taken fluid off, just corrected acidosis and electrolyte derangements. I would be hard pressed to think of a situation where someone was on two or three pressors and you would take fluid off. Usually you are giving fluid in this situation. We generally won't take off fluid until we are on fairly minimal doses of pressors.

[meandragonbrett]

And let's not forget SCUF, CVVH, and CVVHD!

[Raquel8]

Obviously not ideal, but I have had patients on pressors for the purpose of dialysis, it allows you to create a pressure while dialysising, often you can use albumin to pull fluid from 3rd space into vascular. But this practice isnt unheard of and from my personal experience patients do well. I also fight for aline with all patients on pressors to more accurately monitor bp during the procedure and through out the night.

[hockeynpolo]

HD is never done on unstable patients in my MICU. We have pts on CRRT and if they can tolerate it, we will increase the fluid removal rate per hour on the CRRT machine to pull more fluid off. HD pulls too much fluid off too quickly. I was taught that a good rule of thumb is to titrate your medication off first before you pull fluid off. If you're pulling 100ml/h of fluid off, but having to go up on your levo or have to add vaso, the pt isn't benefiting much because you're having to give more meds that are tough on the blood vessels in order to keep your MAP in the 60s. Every nephrologist I've worked with was fine with me taking as low as 5 to 10 ml/h off due to the pt's unstable condition instead of going up on my vasoactive gtts to compensate. Remember, even if you're not able to pull much fluid off, the filter in the CRRT machine is still pulling out all the "bad" stuff floating around in the blood.