low urine output high bnp

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    ok heres the situation a pt arrives in the ED at 0300 labs are drawn but pt is in respriatory failure and intubated. No history is known. She is sent to the unit at 0700. She recieve a bolus of 250ml NS in the ED why I'm still not sure. labs drawn on arrive to the ED show nothing outstandingly abnormal but she dose have a BNP of 420. The orders are for NS at 100ml/h which day shift starts. at 1400, 7 hrs after arriving on the unit, I/O's are done pt had 125ml of urine but had 950ml of input. Day shift hangs a 1000ml bolus. At 2200 pt had 150 of urine out another 1800ml of input, she is now +2475. I call the doctor start to go over the pt diag. and labs and was rudely cutoff being told yeah yeah.. I know all that. just give her another 1000ml bolus and give 200ml free water via NG q6h. before I had a chance to speak ealse wise the doctor hangs up. I once again check lung sounds still course but no crackles that I can make out, the pt was very obese. Pt never recieved any diuretics only fluid boluses anyone know why and why no concern over the BNP of 420 on a pt with no known history? My first thought when I placed my call was I would get an order for diuretics but I never got any they just kept feeding fluids to a pt was possible CHF. I just wonder why.
    by 0600, the next set of I/O's, she was now +4035 and had gained 3.4kg acording to weight.
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  4. 1
    Quote from boz2841
    ok heres the situation a pt arrives in the ED at 0300 labs are drawn but pt is in respriatory failure and intubated. No history is known. She is sent to the unit at 0700. She recieve a bolus of 250ml NS in the ED why I'm still not sure. labs drawn on arrive to the ED show nothing outstandingly abnormal but she dose have a BNP of 420. The orders are for NS at 100ml/h which day shift starts. at 1400, 7 hrs after arriving on the unit, I/O's are done pt had 125ml of urine but had 950ml of input. Day shift hangs a 1000ml bolus. At 2200 pt had 150 of urine out another 1800ml of input, she is now +2475. I call the doctor start to go over the pt diag. and labs and was rudely cutoff being told yeah yeah.. I know all that. just give her another 1000ml bolus and give 200ml free water via NG q6h. before I had a chance to speak ealse wise the doctor hangs up. I once again check lung sounds still course but no crackles that I can make out, the pt was very obese. Pt never recieved any diuretics only fluid boluses anyone know why and why no concern over the BNP of 420 on a pt with no known history? My first thought when I placed my call was I would get an order for diuretics but I never got any they just kept feeding fluids to a pt was possible CHF. I just wonder why.
    by 0600, the next set of I/O's, she was now +4035 and had gained 3.4kg acording to weight.

    Somebody is not listening to the labs. What is her albumin? What is the BUN Cr? Why all the focus of hydration What's the BNP now????? She's now +4000 intake and up 3.4kg? What's the bicarb and H/H? Serum osmo? Are they ignoring her because she's very obese? What's the etiol of respiratory failure if she has no history? Just that she's big??? I wouldn't give anymore fluids sounds to me like she needs a MD who cares and some lasix. If she has no history and is in resp failure. Has she had an echo? What's her EF? Does she need a PA line? Does she have an adequate MAP to perfuse the kidney's? Is she in ATN?

    I vote for lasix! and a renal consult....
    MunoRN likes this.
  5. 1
    Definitely need the whole picture with all the labs. I agree with Esme give the lasix and get renal involved. Also get cardiology on board.

    In doing a little research it seems that a higher BNP in an obese patients can have worse symptoms.
    http://www.ncbi.nlm.nih.gov/pubmed/16386669
    Last edit by ckh23 on Jun 4, '11
    Esme12 likes this.
  6. 1
    Based on the info provided, the smart money would be on acute renal failure, making the repeated fluid boluses a really bad idea and just push her closer to needing CRRT, there may not be sufficient renal function for lasix to work. If the patient was only dehydrated, their UO should have improved to more than 20cc an hour after 4 liters of fluid. The patient should have had a CXR, what did that show? Other than an echo, a good way of confirming the fluid overload suggested by the BNP would be a CVP reading. Even if you don't need a continuous CVP reading, a spot check would be very helpful in this situation, plus a CVP set up with a Vamp is handy for drawing labs and IV pushes. The BUN/Creatinine would be helpful, although the Doc might argue that an elevated creatinine is due to dehydration, even though the BUN will help determine dehydration vs ARF.

    I'm not sure what you mean by saying the patient has Coarse lung sounds but no crackles. Maybe it's a regional terminology thing, but I usually refer to "coarse" as coarse crackles (vs. fine crackles). Although I have heard people use 'coarse' for a pleural rub and then use 'rales' instead of coarse crackles.

    While an elevated BNP doesn't always mean fluid overload, it usually does. Pulmonary hypertension can cause RV dilation which will release BNP due to the stretch, although it's not really safe to assume that's what is and give a never ending supply of fluid until you've confirmed that with either an echo or at least a Swan. If it is pulm HTN then the patient might benefit from an enhanced preload by being a little 'tanked up', but everything in this situation so far points to fluid overload.

    If her PA pressure is 80/40 and her CVP is 2 with a BP of 80/50 and a clear CXR, then fluid might be useful, but if her BP is 180/100 with a CVP of 20 and a wet CXR, I wouldn't give the boluses as ordered and I'd stop the IVF. I'd ask for a renal consult and if the Doc declined I'd go over his head for one.
    Last edit by MunoRN on Jun 4, '11
    Esme12 likes this.
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    I think the renal consult is the way to go, but also try to get some kind of history from a family member or friend. What was the thoughts on why she was in respiratory failure to the point of being intubated? Surely an MI was ruled out. Pneumonia or P.E.? Did you get a glance at a CXR? Was the heart enlarged? Lungs look clear? I would guess the next step would be an echo to determine %EF. Renal consult for some gentile diuresis. You don't want to hammer the kidneys with diuretics either.
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    Thanks everyone for the input. xray showed pnuemonia bilat. all labs except the BNP were either wnl or within a few points of the normal range BUN Creatine were good, sorry I can't remember the exact numbers. I like the idea of CVP monitoring and getting renal involved and all of those but the intensivist refused to listen to anything I had to say. I'm fairly new at this hospital and unit, one month, so I don't have any pull with any doctors here. At my old unit it wouldn't be a problem they gave us leadway but not here. We could get any history due to her being intubated and she had no family info on her person, we even called the other local hospital to see if they had a history of her but no one did. This is a high trainsient area so she could be passing through like many do. Once again Thanks to all.
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    She's intubated, but is she awake? Can she write?
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    Sad that you work for a place where nothing you say matters and you have to perform without rationale. Really sad.
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    Could be a crappy RV too - sometimes adding pneumonia and increasing PVR is enough to crap out the RV and lead to elevated BNP even without signs of LVF. Eventually the kidneys etc will go because you're just not getting the fluid from the right to the left side of the heart.

    Impossible to say what should have been done, apart from obviously more data collection and if the doc had the info to decide, it would be nice if he wasn't a jacka*@ about it and just told you what his decision was based on.
  12. 0
    good questions I like the way you think


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