Low blood pressure great neurological status? - page 2

Have a kiddo right now whose a little bit of a mystery and wondering if anyone else has ever seen something like this. Kiddo has been pretty sick for a few months, is now s/p a heart transplant, was... Read More

  1. Visit  imaginations profile page
    0
    I encountered a similar, though not the same situation, last night.

    A bigger patient (14 year old, 60kg) 20+ days post BMT in renal + respiratory failure. Previous issues with hypertension (preceding transplant and renal failure). Intubated + ventilated for two days following surgical insertion of a permacath for haemo dialysis, pre-op was dependent on bi-level non-invasive. Nil issues with blood pressure in the two preceding days (one pre-op, one post-op - now day two post-op, weaning ventilation to extubate back to non-invasive). Patient 'sedated' with 4mcg/kg/hr Fentanyl (was prev on Fentanyl PCA + background for pain), Propofol (1.4-1.8mcg/kg/hr) & Precedex (0.3-0.6mcg/kg/hr) however awake, settled, communicative and neurologically intact.

    I noticed a downward trend in mean arterial and systolic pressure (via non-invasive cuff, no invasive monitoring) over about three hours and pulled back on my sedation (over 9 hours the Fentanly was halved, Precedex turned off and Propofol off for periods) however continued to lose blood pressure until both systolic and MAP were well below (as in 10mmgH +) his 10th centiles for age/weight. However, he remained alert, neurologically in tact, pink, warm, well perfused etc.

    No one (none of the senior nursing staff or the overnight medical staff) could target a reason for his blood pressure drop or explain why he remained so awake/in tact.

    Very disconcerting experience. Any pointers to help break down the situation? Things I could have/should have been looking for or doing? I'm a new ICU nurse and would appreciate the input
  2. Visit  marmstrong26 profile page
    0
    Quote from imaginations
    I encountered a similar, though not the same situation, last night.

    A bigger patient (14 year old, 60kg) 20+ days post BMT in renal + respiratory failure. Previous issues with hypertension (preceding transplant and renal failure). Intubated + ventilated for two days following surgical insertion of a permacath for haemo dialysis, pre-op was dependent on bi-level non-invasive. Nil issues with blood pressure in the two preceding days (one pre-op, one post-op - now day two post-op, weaning ventilation to extubate back to non-invasive). Patient 'sedated' with 4mcg/kg/hr Fentanyl (was prev on Fentanyl PCA + background for pain), Propofol (1.4-1.8mcg/kg/hr) & Precedex (0.3-0.6mcg/kg/hr) however awake, settled, communicative and neurologically intact.

    I noticed a downward trend in mean arterial and systolic pressure (via non-invasive cuff, no invasive monitoring) over about three hours and pulled back on my sedation (over 9 hours the Fentanly was halved, Precedex turned off and Propofol off for periods) however continued to lose blood pressure until both systolic and MAP were well below (as in 10mmgH +) his 10th centiles for age/weight. However, he remained alert, neurologically in tact, pink, warm, well perfused etc.

    No one (none of the senior nursing staff or the overnight medical staff) could target a reason for his blood pressure drop or explain why he remained so awake/in tact.

    Very disconcerting experience. Any pointers to help break down the situation? Things I could have/should have been looking for or doing? I'm a new ICU nurse and would appreciate the input
    Precedex can cause bradycardia/hypotension if used longer than 24 hours- the kids look well perfused but get pretty bradycardic and hypotensive. We usually drop our dose down when this happens and they usually perk back up. What did it turn out to be?
  3. Visit  BlueBabyNurse profile page
    0
    Gosh these cases sound crazy. Were thyroid levels checked? Cort stim? That's all I've got! 😳
  4. Visit  umcRN profile page
    0
    Quote from BlueBabyNurse
    Gosh these cases sound crazy. Were thyroid levels checked? Cort stim? That's all I've got! 
    We are actually looking into this now since we are still (a month later) having this issue. Cortisol level is "low normal" @ a whopping 2. Endocrine said they couldn't help a few weeks ago but now after trying to come off hydrocortisone multiple times always ending in failure we are consulting them again. Ugh. Kiddo doesn't care much though. Last night had a BP of 58/29(38) and was awake, alert, laughing, kicking the feet and throwing play-dough at us (annoyed that so many people were in the room trying to fix the BP and not playing instead).

    Also since it's been a while, kid is off sildenafil w/no issues (except the BP of course), heart cath went great with good function and no rejection and peritoneal dialysis has been started instead of CVVH, kiddo is getting stronger and able to sit up in bed unassisted and as mentioned above, is working on one hell of an arm. Rehab stops there since pt is still intubated (yes, kiddo didn't last long extubated last time, another long story) but if doesn't extubate this week will get a trach, and in the three months this toddler has been intubated we've never once had an accidental extubation, we don't even use restraints anymore, kiddo never goes near the tube. Now if we could kick the dopamine habit the kid might actually get to go home before the next birthday.
    Last edit by umcRN on May 27, '13
  5. Visit  BlueBabyNurse profile page
    0
    Quote from umcRN

    We are actually looking into this now since we are still (a month later) having this issue. Cortisol level is "low normal" @ a whopping 2. Endocrine said they couldn't help a few weeks ago but now after trying to come off hydrocortisone multiple times always ending in failure we are consulting them again. Ugh. Kiddo doesn't care much though. Last night had a BP of 58/29(38) and was awake, alert, laughing, kicking the feet and throwing play-dough at us (annoyed that so many people were in the room trying to fix the BP and not playing instead).

    Also since it's been a while, kid is off sildenafil w/no issues (except the BP of course), heart cath went great with good function and no rejection and peritoneal dialysis has been started instead of CVVH, kiddo is getting stronger and able to sit up in bed unassisted and as mentioned above, is working on one hell of an arm. Rehab stops there since pt is still intubated (yes, kiddo didn't last long extubated last time, another long story) but if doesn't extubate this week will get a trach, and in the three months this toddler has been intubated we've never once had an accidental extubation, we don't even use restraints anymore, kiddo never goes near the tube. Now if we could kick the dopamine habit the kid might actually get to go home before the next birthday.
    Whoa!!! Keep us updated for sure!! I am so curious!
  6. Visit  marycarney profile page
    3
    Kick the dopamine habit <<<< I'm so stealing this!
    HyperSaurus, RN, Esme12, and umcRN like this.
  7. Visit  umcRN profile page
    0
    I guess another question could be, has anyone ever experienced a transplanted heart that didn't respond well to vasoactives? Like I said this kid can't get off his beloved dopamine and sometimes epi & vaso however kid can be having a great couple days, be down to 5 of the dopa and then out of the blue just crash and when you crank up the dopa it'll be 15 with still no response (obviously we're giving fluid at this point too) but it's just so strange. I wish this child could stop being such a mystery, everyone wants him to just get better and get out (this is one of those kiddos that just has the entire unit wrapped around his little finger)
  8. Visit  ghillbert profile page
    0
    The first kid, I thought of adrenal insufficiency? I'd be interested to hear what happened. Impossible to determine the cardiac function if you can't cath/biopsy him, although I'm not sure why you couldn't. If he's sitting up coloring, he sounds well enough to biopsy.

    Did the steroid get cranked up at all to see if he became more responsive to vasoactive meds?
  9. Visit  umcRN profile page
    1
    Sadly this little one ultimately passed away about three months after I started this thread. Multiple organ failure. Toughest kid I've ever met or had the pleasure of taking care of. I learned a lot from this patient, both in nursing, medicine and how to enjoy life even if it appears you have no reason to. This little one will forever be in my heart.
    Esme12 likes this.
  10. Visit  umcRN profile page
    0
    Quote from ghillbert
    The first kid, I thought of adrenal insufficiency? I'd be interested to hear what happened. Impossible to determine the cardiac function if you can't cath/biopsy him, although I'm not sure why you couldn't. If he's sitting up coloring, he sounds well enough to biopsy.

    Did the steroid get cranked up at all to see if he became more responsive to vasoactive meds?
    Kiddo did ultimately get a cath that showed no obvious issues. Yes he may have been sitting up coloring but looking at him funny could throw him off the deep end, he was tough but exceptionally fragile at the same time.

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