MAP=60? Why wait to treat?
- 0Dec 1, '11 by sewnewI am currently working as a student nurse/tech on a SICU at a busy teaching hospital. Was told that patients on the unit should maintain a MAP of at least 60 or above in order to maintain optimal organ perfusion. Wondering why nurses have to wait until the MAP falls to 60 before treating the patient. Doesn't it make sense to start bolusing the patient with fluids as soon as the MAP starts trending down? Is this standard practice or unit specific?
- 3Dec 1, '11 by meandragonbrettJust because it's trending down doesn't mean it will continue. Why would you treat something that isn't necessarily a problem yet? Bolusing them prematurely could cause more problems that neither you want to deal with nor the patient needs going on.
- 4Dec 2, '11 by detroitdanoEvery case is different.
An anuric end stage renal patient doesn't get rid of any great amount of fluid (insensible losses aside), so anything you give them stays there; you may not necessarily want them to have that fluid.
Some neuro patients just run low no matter what you do; Florinef, fluids, whatever, they might just live with a MAP of 45. Seen it a billion times.
They tell you cerebral perfusion pressure should be 70-100 or so. If someone has an ICP of 10 and a MAP of 60, CPP is 50. Sounds like you should be doing something about it, but if they're not broken, don't fix 'em.
It takes some getting used, not treating a low MAP. In orientation you're taught to flip out over it. Look at the overall picture and then decide if you need to flip out. Are they making urine? Arousable and appropriate? Are they in a deep sleep? The list goes on.
- 3Dec 2, '11 by PetERNurseThere's no magic behind the number 60 either.
No magic, just physics. GFR drops significantly at MAP <60mmHg, and CPP is too low to meet O2 demands. They won't instantly go into anuric renal failure or have massive brain death, but you don't want them to stay this way long.
Remember, you want to treat a patient's physiology, not a number. Monitor trends. If the BP is trending down, maybe it is due to the addition of a new medication, or a dose needs to be adjusted. Is there excessive fluid loss (diarrhea, vomiting, sweating, hemorrhage, etc.). Maybe it is due to ventilator settings (what is the PCO2 trend?). Sometimes it is as simple as changing the patient's position.
Sounds like you should be doing something about it, but if they're not broken, don't fix 'em.
We also don't want to have to fix something that is broken. This is why monitoring trends is so important so you can treat a problem (ie: prevent it) before it becomes a problem.
Depending on the etiology you may be limited with what you can do, and as others said, marginal BP may be acceptable in some patients.
- 1Dec 4, '11 by fiveofpeepUrine Output is an early indicator of ineffective end organ perfusion.
I also wanted to add that bolusing a patient with a junky heart can cause CHF exacerbation --> respiratory distress.
When I first started working in ICU, I was bolus happy--especially coming from PACU, but over time you will learn what is really an emergency and in most cases there is often a wait and see approach.
It's important to look at the big picture (as others have voiced) and think about what is going on with this patient. Are they dry? Do they have a fever? Are they tachycardic? Have they been passing large amounts of dilute urine? Did you recheck the blood pressure?
Others have given great advice. Best of luck to you
- 3Dec 7, '11 by cdsgaMonitoring is what ICU is all about. But just treating numbers is a dangerous thing and can lead to more trouble and worse outcomes and more numbers to treat. So as my experience has taught me and other wise ICU mentors-treat the patient not the numbers. Report trends and start investigating the decline-get a game plan and ward off potential bad outcomes.