CHF and low BP

Your thoughts are correct. Many CHF patients tolerate lower BP's. I really think your pt needs to be followed by cardio. Maybe have the doc change paramaters on BP meds as well.

I think the cardiology consults was requested but the pt wasn't seen yet. The nurse also had the patient in trendelenburg and I got her to take the patient out of that and they had her flat. I kept emphasizing that 85/50 in a asymptomatic patient is not necessarily something requiring trendelenberg and boluses. The patient was due for his coreg and the nurse got parameters to hold for sbp less than 100. Obviously things weren't working for the bnp to be both about the same two mornings in a row, especially the 2nd bnp being after getting a fluid bolus the night before.

asymptomatic is the key word here. why treat what isn't broke. looking at the patient is far better than treating a number!

I have had cardiology bolus a CHF patient in the past. They will start with 250 to see how pt tolerates the 250 bolus recheck BP's at that point check lungs sounds ask patient how they feel and check saturation. If all is well they may give a second bolus if its needed. The problem depends often on Ejection Fraction of the patient. What going on with them (ex septic or other problems) A lot of factors are looked at before they decide to bolus a CHF patient.

However while ProBNP is drawn on CHF patients I never heard the doctors mention they use that as criteria for making decision about medication or treatments for there patients. If they do would like to know what they are b/c as far as I know they are only used as clinical markers but never been told to change a medication or not to give a bolus b/c proBNP is this or that.

Angela

PS Question: How low will cardiology allow CHF patient BP to drop if EF is like 10% or 15% just curious that mays play into the decision making as well. Need a a BP to sustain heart going as well .They often look at the MAP as well in these circumstances as well.

We had a pt who two nights in a row had asymptomatic low blood pressure, bp in the 80's, found on regular vitals, the doctor was called and treated this patient with a 250cc saline bolus. The patient has chf and was on IV lasix, lisinopril, coreg. The patient's BNP two mornings in a row was in the 3000's. This wasn't my patient but I thought it was strange that we were bolusing this patient. He did not have a cardiologist on board. I have seen CHF patients on ace inhibitors tolerate bp's in the mid to high 80's as a matter of fact that is where the doctor wanted them to be. I was just concerned that her CHF was going to be exacerbated. What is your opionion?

you CAN become dehydrated while having CHF - so many people seem to forget this. Perhaps this person was diuresed quickly... it is quite common to bolus a CHF'er - particularly 250 ml bolus.

We had a pt who two nights in a row had asymptomatic low blood pressure, bp in the 80's, found on regular vitals, the doctor was called and treated this patient with a 250cc saline bolus. The patient has chf and was on IV lasix, lisinopril, coreg. The patient's BNP two mornings in a row was in the 3000's. This wasn't my patient but I thought it was strange that we were bolusing this patient.

Presumably this patient was admitted with a bit of decompensated CHF, judging by the BNP. So you're trying to balance getting rid of 3rd space fluid (Lasix), maintaining adequate intravascular volume (bolus), and adequate but not overstressed cardiac pump (Coreg).

I was taught to accept systolic pressures in the 80s. Hell, I've coasted ICU players in the 70s for a couple hours at a time without worrying about it, as long as they hadn't had a recent uptick in their urine output. The only thing that really gives me pause is when folks have baseline systolic pressures substantially higher.

The problem though, is that (in general) you need MAPs in the 60s to adequately perfuse the kidneys. If this patient had real low diastolic pressures, they might well be asymptomatic all the way into acute renal failure. I suspect this was the worry of your physician.

On the whole though, I'm inclined to think that a couple 250cc boluses, unless this is a very small/thin patient, really aren't doing much. With pressures that low in a CHF patient, they're probably carrying multiple liters of 3rd space fluid along with really leaky capillaries, that 2/3 of a can of soda every once in a while probably isn't doing a heck of a lot one way or another. Just my thoughts (Cards isn't anywhere near my specialty).

Out of curiousity, what kind of BP response did you get from the intermittent 250cc boluses? I can count on one hand the number of times I've given a volume that low, and usually don't see much of an improvement.

Hey, I'm interested in how this would be treated. If someone's BNP is high but their BP is low, what would be the next step (assuming they is not dehydrated)? Does the patient's po meds get switched out for IV natrecor? I'm just curious - I work ED so I'm used to stabalizing CHF exaccerbations but I don't work with managing it long-term.

Wow thanks for all the insight! I don't know what his BP did as they started the bolus around 9:30p and I got to go home early, yahoo! I didn't have a chance to look at EF. I just want to understand the situation better. Also I think as nurses as another poster said we have to look at the whole picture espec the asymptomatic part. I am not sure the other nurse was really looking past the low BP part as seen by the fact that she put the patient in trendelenberg.

It reminds me of the other night when I had a pt peeing grossly bloody urine, likely more blood than urine, and he was a dialysis patient(who did pee about 250cc/24hrs). The primary wanted me to put a foley in right away but we didn't yet know why he was bleeding. A urology consult was going to be needed at some point anyway and I told the primary I wasn't comfortable putting the foley in with the bleeding situation. He called a urologist who called me back and after talking to an MD where urination was the specialty I was okay putting it in and getting irrigation orders.

There are consequences to both reacting and treating and to not reacting and reacting isn't always the best way it can at times make things worse.

I've seen some pretty low pressures in CHF patients, and as others have mentioned, it depends upon whether the patient is asymptomatic and whether they are maintaining a MAP greater than 60. If yes to those, then it can be just a matter of letting them ride it out while the meds are adjusted.