why bolus and bicarb?

[IvoryLena]

I had a very sweet little baby who was born with gastoschesis, unfortunately, surgery was unable to do anything, so we were doing just comfort measures. she had severe acidosis so I was ordered to give 20 ml bolus(no change), then bicarb(slight change), then bolus(no change), bicarb(slight change), and another bolus NS. My question is why would giving NS boluses change the metabolic acidosis? and why not give the bicarb first? Blood pressures were stable through this whole time even high as you can imagine why. I did ask the doc but she only gave me a vauge answer about blood pressure, am I missing something? This was the first time I had to give bicarb, was an admission, and post surg pt. I was so busy with this child and another child I had, and I was alone in the cluster! Can anyone please explain this to me.

[NICU_babyRN, BSN, RN]

Sounds like the infant was losing a lot of fluid (could be insensible loss) so they wanted to see if bolus would help the dehydration. Was infant tachy or low hear rate at all? What was your gas? and Lytes?

[ittybabyRN, RN]

I'm just curious why you were treating the acidosis in such an aggressive way if you were just doing comfort care at that point?

[prmenrs, RN]

I confess, I'm wondering the same thing.

[IvoryLena]

The Ph was changing from 7.0-7.1. She did have third spacing and she had no urine output. Her heart rate and blood pressure was fine. I just felt like, what is the point of filling this poor thing with more and more fluid. Not to mention she ordered it as a direct result of the bad gas, so I would assume she was attempting to treat the gas and not another issue. She is a fresh out of school nurse practioner so mabye that had something to do with it. I really cant remember what her electrolytes were.

[IvoryLena]

Also, We were treating her just so she could get through the night so the family could see her in the AM. Fortunatly, she lasted untill the family got to say their goodbyes and then passed.

[prmenrs, RN]

What a sad position to put YOU in! My condolences to all concerned.

[littleneoRN]

Maintaining good perfusion is helpful in maintaining a neutral pH or correcting an acidosis. With all that 3rd spacing and insensible loss, this makes sense as a contribution to your gas, so fluid bolus seems possibly appropriate. What doesn't seem appropriate is that you had a post-op, unstable baby you were trying to keep alive for parents til the next morning and you had another patient?

[prmenrs, RN]

It is sad, also, that you weren't better supported. I'm thinking you were right to question the NNP's order, I think she was hoping a little volume expansion would help the baby last til morning, and apparently that did happen. The NNP was not very clear as to what her goal was, and that might have helped you.

Hang in there, we all, even us old fogies, turn to a doc/nnp and say WHY do you want to do that again? Frequently, they give us unsatisfactory answers.

Keep learning and growing, you will be awesome!

[SteveNNP, MSN, NP]

I know I'm chiming in late... but here's my take on the situation (as a fresh-out-of-school NNP myself)

So metabolic acidosis is caused by the cells of the body switching from AERobic to ANaerobic metabolism, which produces little energy, and floods the body with byproducts such as lactate. Lack of perfusion and oxygen delivery often starts the vicious cycle. The latest research (especially in premature infants) shows that crystalloid volume expanders such as saline are more effective at correcting that than bicarb. Bicarb neutralizes the acids, but then forms more Co2 as a byproduct, and has been shown to potentially increase the risk of IVH.

All that aside, giving bicarb or saline in this instance seems to be contrary to a comfort measures plan of care.

[IvoryLena]

Thanks everybody, It makes more sense now.