bolus and GI bleed

[fiveofpeep]

The other day I had a situation that really frustrated me. Patient was in our unit overnight until endoscopy the next day with massive amounts of frank blood in stool with a whole lot of clots too. We were transfusing blood all night and the patient was maxed on a vasopressor at times throughout the night when she would bottom out. Urine was adequate but Cr was rising. Patient had crackles occasionally, but in general, despite old age and cardiac history was tolerating the blood.

I felt like we should have bolused the patient and verbalized this vehemently many times. Even 250 ccs would be something. I dont see how using a vasopressor to starve the end organs to vainly attempt to hide the problem of hypotension by clamping down tubes that have no volume in them will help this patient.

I wanted to call the primary because I couldnt get through to the GI doc but the charge nurse was very aggressive and confrontational when I proposed a bolus, and in calling the primary.

I know Im new, but we've bolused patients with a lot more respiratory compromise than that because they really needed it. We've bolused anuric patients without an airway for christssake. This patient had neither renal failure or pulmonary edema at the time.

It was just so frustrating to me because it makes no sense to me to continue on course with a severely widened pulse pressure with critically low diastolic maxed out on levo without bolusing the patient. Especially when her bp was dropping to the 40-60s on levo! I just cant wait till I am an old timer and people wont completely disrespect me when I propose a solution and I can call the mds without charge nurse approval. It really gets me going to know this patient suffered all night (and her kidney's too) because the gi doc didnt want to do an endoscopy at night.

What would you have done in this situation. Do you think I should have also avoided the use of bolus based on the info I gave? Thanks for the advice in advance :)

[aCRNAhopeful]

Yeah that sounds stupid to me as well. When the nature of your problem is so obvious and the risk of being wrong so small why would you initiate a treatment that merely changes a number on the screen while the underlying problem remains? I'm still new as well so maybe we don't see the whole picture here.. but i highly doubt that's the case. I've found myself disagreeing with how a patient has been managed several times over the course of my first year in nursing. I think that doc might as well have put his paycheck on a silver platter for that patient because if that was my or my family member's kidneys getting trashed I would sue the crap out of him.

[sunnycalifRN]

A trick you can do to prove that the patient is dry: With patient supine, note patient's BP, then lift both patient's legs to 45 degrees and maintain, note BP now . . . if there was a significant increase, the patient is dry and needs volume. You still might not have gotten an order for a bolus, but at least you could give "proof".

[tri-rn]

How much blood had she gotten? Keep in mind, you were already replacing volume. 250 cc of crystalloids is less volume than a unit of packed cells. How high was her creat? If her kidneys were producing adequate urine they weren't suffering, so maybe not worth the risk of volume overload if she already had a cardiac hx.

[grandmawrinkle]

A trick you can do to prove that the patient is dry: With patient supine, note patient's BP, then lift both patient's legs to 45 degrees and maintain, note BP now . . . if there was a significant increase, the patient is dry and needs volume. You still might not have gotten an order for a bolus, but at least you could give "proof".

This is old practice and not evidence based to my knowledge, and I don't think it is really accurate. What is a "significant" increase, and how is that "proof"? There are much more scientific ways to decide whether or not your patient is hypovolemic.

IMO, GI hemorrhage and hypotension coupled with low UO (and often, tachycardia) is enough to tell you that your patient is hypovolemic. I've always given at least a couple liters of fluid along with the blood in the beginning if a patient starts bleeding out, and usually they get a high rate MIVF (200-250/hour, at least 100/hour.) Only blood was probably not enough....I think you were correct in that.

[tri-rn]

How much urine WAS she making?

[Hoozdo, ADN]

Given the restrictions the charge nurse put on you - I would have run that

blood much faster than usual. Usually, I run it 150 cc/hr. I would have given

it at about 250 cc/hr if her IV would tolerate it that fast and watch much more

closely for any reactions.

It seems ridiculous to have to go through the charge nurse to call a doctor.

You are right about running levophed "when the pump is dry." A 1L bolus, at

least, would not harm this pt.

If I get a septic pt with CHF we don't let that stop us from bolusing at least

one liter. It's part of our sepsis protocol. The only thing that would stop me

is pulmonary edema or obvious third spacing, (I would use albumin in that

case.)

[tri-rn]

I guess my question is...other than bp what is your reasoning that she was dry? You say her Cr was rising...what was it? And how much urine was she making? BP 40-60....systolic or diastolic? What were her MAPs? Did she have a horribly low EF, where she would have been easy to tip into cardiogenic shock? Or was she possibly already IN cardiogenic shock? Was she tachy? I don't necessarily think a bolus would have been BAD, but maybe it wouldn't have helped. Levo is bad on a dry tank, but how sure are you that the tank was dry? Was there a question of sepsis in addition to the GI bleed? There just isn't enough info in your original post to say. I can't imagine having to go through my charge to call a doc, but we're a teaching hospital and someone is always in house. Waking them up isn't an issue.

Not trying to be argumentative at all, just trying to see the big picture.

[AprilRNurse]

Look at it this way...you're already replacing the blood. The patient needed blood. Was there any maintenance fluid running? Bolusing the patient just dilutes it- it doesn't actually help carry oxygen where the patient needs it.

I'm studying for my progressive care certification- and they teach against bolusing a GI bleed patient because of this. the blood is fluid volume. You're replacing what is being lost.

[fiveofpeep]

The reason I know the patient was hypovolemic was because she had been bleeding for more than 12 hours before she had her first unit of blood and it is a constant flow of blood.

The patient got 4U of blood only and hgb and hct was 6 something. The main was d/cd. The patient was cool, pale, clammy, nauseous and complained of dizziness. HR is inconsequential in this case because the pt was 100% paced with a permanent PM. SBP was 40-60 on levo at times despite titrating up. Diastolic was perpetually less than 30

I dont remember the exact Cr but it was elevated. UO was borderline initially and increased because we gave lasix for the crackles, which probably didnt help the whole volume situation

The amount of blood hemorrhaging from the rectum far exceeded the amount infusing especially since it took so long to start blood transfusion.

The patient was not in active CHF, CXR was negative. Only crackles were to be had.

I still think she could have taken the bolus. I think it was just a culture clash between me and the charge nurse. I was floating to another ICU and in my unit we are very bolus happy because it's surgical and we know about the need for replacing lost volume.

Thanks for so many great responses!

[AprilRNurse]

If doctor ordered lasix he/she must not have felt it was a fluid volume issue though. Thats definatley a low BP, but maybe something else was going on.

[sunnycalifRN]

This is old practice and not evidence based to my knowledge, and I don't think it is really accurate. What is a "significant" increase, and how is that "proof"? There are much more scientific ways to decide whether or not your patient is hypovolemic.

Old Ben Casey, MD used to show that to our baby docs in teaching rounds as a quick assessment tool for patients with no central line. Sure, there are lots better more scientific methods, but, if you don't have central access or a portable ultrasound, it's a handy trick.