Hemodialysis with low BP on pressors?

Specialties MICU

Published

Specializes in Critical Care- Medical ICU.

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!

:confused:

Up Vote Up Vote ×
Specializes in NICU.

I guess it depends on why they were wanting to do dialysis. Was it for fluid removal or clearance? We have done CRRT on patients who are on 1 pressor before. If you are on 2 or 3 pressors I wouldn't feel comfortable either.

Up Vote Up Vote ×
Specializes in ER/ICU/STICU.

Like the PP said it depends on why they are getting the HD. I have had patients on pressors getting HD or CRRT, however I don't think you were wrong here. If they are on MULTIPLE pressors they probably wouldn't have tolerated HD, especially if they couldn't tolerate CRRT the day prior.

Up Vote Up Vote ×
Specializes in Critical Care- Medical ICU.

The pt needed the HD because she was fluid overloaded. She definitely needed it, I just felt like CRRT would have been a better choice for her in her condition. Which is what we ended up doing instead later in the evening when she was stabilized :) We just gradually inc the rate we were running at, as tolerated.

Up Vote Up Vote ×
Specializes in cardiology/oncology/MICU.

Or maybe aqupheresis?

Up Vote Up Vote ×

SLED with citrate. It's designed for these patients.

Up Vote Up Vote ×
SLED with citrate. It's designed for these patients.

Yeah, that!

Up Vote Up Vote ×
Specializes in Critical Care- Medical ICU.

Hmmm SLED.... Interesting, somehow I have never heard of or seen it at my hospital. I googled it though, sounds perfect for those situations! How often have any of you seen this used? And is it something that is run by the ICU nurse or by dialysis nurse?

Up Vote Up Vote ×
Specializes in ICU.
Hmmm SLED.... Interesting, somehow I have never heard of or seen it at my hospital. I googled it though, sounds perfect for those situations! How often have any of you seen this used? And is it something that is run by the ICU nurse or by dialysis nurse?

SLED commonly used interchangeably with CRRT by some, altho I think they are technically different .. CRRT slower than SLED iirc. gets confusing when you hear a pt got a SLED from one RN And then CRRT from another..

at my ICUs, dialysis nurse sets up the CRRT, but the ICU nurse will monitor it and be taught how to respond to alarms from the machine etc by the dialysis nurse

they'd do the same for SLED probably, since it'd seem inefficient to have a dialysis nurse sitting around for prolonged periods of time

Up Vote Up Vote ×
Hmmm SLED.... Interesting, somehow I have never heard of or seen it at my hospital. I googled it though, sounds perfect for those situations! How often have any of you seen this used? And is it something that is run by the ICU nurse or by dialysis nurse?

We are often running 5-6 people on SLED at any given point. We run the SLED.

Up Vote Up Vote ×
Hmmm SLED.... Interesting, somehow I have never heard of or seen it at my hospital. I googled it though, sounds perfect for those situations! How often have any of you seen this used? And is it something that is run by the ICU nurse or by dialysis nurse?

SLED, you can be paired.

SLED with citrate, 1:1. If one pump runs dry or the SLED stops running and they're being pumped full of both solutions...it's just not good. It's a wonderful way to remove fluid off someone who cannot tolerate the massive fluid shifts associated with traditional dialysis. It's silly to watch only 7 ml/hr come off with UF when they're figuring out how they can tolerate it, but eventually you can ramp up the UF rate.

We get some quality training on running SLED with citrate. Most alarms can be reset, or we can flush tubing, adjust chamber levels, but like any other dialysis if the machine keeps beeping or clots off we need the dialysis tech/nurse to come up.

Up Vote Up Vote ×
Specializes in Critical Care- Medical ICU.

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!

Up Vote Up Vote ×
+ Add a Comment