Low blood pressure great neurological status? - page 2

by umcRN

4,984 Views | 22 Comments

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 finally on an upward curve a... Read More


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    Sadly I don't think my hospital is quite there yet with the berlins. We've only been doing them for about a year or so and only as bridge to transplant. Haven't taken anyone off yet. As it is the kid is already going back on the list for a kidney.
    We're grasping at a new straw now. Sildenafil toxicity. Anyone heard of it? It's not dialyzed off and it's renally cleared. He's been on it for months, now wondering if that's causing the continued hypotension. Like I said, grasping for straws but would be an "easy" fix.
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    I suppose sildenafil could be the culprit, but it's actually mostly metabolized by the liver and largely excreted in feces. Severe renal dysfunction on its own wouldn't necessarily cause toxicity. Is his pulmonary hypertension so severe that he needs high doses? (Side note: The FDA has issued a black-box warning for using sildenafil for pediatric patients with pulmonary hypertension but the increased risk of mortality is related to the PAH itself. http://www.fda.gov/Drugs/DrugSafety/ucm317123.htm One of our attendings is a world-class expert in pediatric PAH and he's disputing their findings. He's a firm believer and has used the IV form in select patients.)

    Back to Berlins... we've been implanting them for 8 years (24 in total) and explanted 3 of them over the years. If I recall correctly we've only had 2 or 3 fatalities. The biggest cause of morbidity is coagulopathy.
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    Yeah I was reading about sildenafil being metabolized by the liver...I don't know. I'm off work now for a week so I won't really know how this theory is panning out. His PH is not bad, actually wasn't even noticible on a cath but after a bout of sepsis a few months ago he couldn't come off his nitric so they started sildenafil. The new heart initially struggled with the higher lung pressures but has since settled out.
    I've heard all about the black box warning. We have a big PAH program at my hospital and our units medical director is also a big PH guru and he was marching all up and down the unit fuming the day that decision came out. Ultimately he had to contact every patient of his who is on sildenafil and have their parents sign a waiver that they were aware their child was taking a medicine the FDA had not approved - just about all our PH patients are taking sildenafil PO at home and in hospital. I've never given it IV.
    In any case as far as the berlin/re-transplanting I just don't know if his parents would go through with all that, they're at their wits end as it is and I don't blame them!
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    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
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    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?
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    Gosh these cases sound crazy. Were thyroid levels checked? Cort stim? That's all I've got! 😳
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    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
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    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!
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    Kick the dopamine habit <<<< I'm so stealing this!
    HyperSaurus, RN, Esme12, and umcRN like this.
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    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)


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