Low blood pressure great neurological status?

[umcRN]

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 few weeks ago but recently blood pressure bottomed out. Labs are all normal, no signs of infection, nothing growing in cultures however requiring high doses of epi, vaso and dopa to maintain barely acceptable blood pressure (have not been able to rule out rejection at this time as too unstable for cath). However despite being so labile with blood pressures kiddo seems to be feeling so much better. Is awake, alert, answers questions (still slightly sedated and vented), asks for toys (speaks some sign language), the other day I had him sitting up in a chair coloring! Then he wanted to play with my phone and was pushing buttons and "making calls".

We're all scratching our heads a little bit and now trying to get him towards extubating and hoping the BP issues resolve themselves...

Any thoughts or similar experiences?

[umcRN, BSN, RN]

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!

[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 :)

[marmstrong26]

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?

[SprightlySparrow, BSN, RN]

Gosh these cases sound crazy. Were thyroid levels checked? Cort stim? That's all I've got! ?

[umcRN, BSN, RN]

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.

[SprightlySparrow, BSN, RN]

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!

[meanmaryjean, DNP, RN]

Kick the dopamine habit

[umcRN, BSN, RN]

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)

[ghillbert, MSN, NP]

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?

[umcRN, BSN, RN]

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.

[umcRN, BSN, RN]

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.