Pt hx: Lower GI bleed (associated with rectal tube/hemorrhoids), ESRD
Dialysis MWF
assess: AA0x2, temp 35.5, lungs slightly coorifice, 95% on 2LNC, HR 80's, B/p 60's/30's, +2pitting edema in arms/legs, good pulse arms, weak pulses feat, MAE, bowel sound present, abd nontender, anuric, large gel-like bowel movements with bloody clots.
access: triple lumen to R groin (old-maybe infected)-removed after blood products infused, new 3L to l groin placed
Pertinent labs:
Hgb: (4am)9.4, (8am) 8.4, (post transfusion 2 u PRBCs and 2 plts) 10.4
hct 28-30ish
na 135
k (am)3, (post-transf.) 3.1 (pt then got 20meq KCl IV)
bun/creat: 35, 5
alb 1.5 (?)
pt received liter and a half of NS, blood products, and continuous NS at 50/hr afterward, B/P still 70's/30's with MAPs in 40's. (temp now normal 36.9-37.2 with warming blanket) Started on Levo at 5mcg/min.... B/P came up a bit 80's-90/40, MAPs in 50's-60. Levo down to 2mcg/min. B/P dropped again after about hr to 70's/30's with MAP in 40's. HR up to 100's now. Levo turned up to 15mcg. MAP finally 65, diastolic pressures still low 30s. HR 120. NO access for a CVP.
pt still AAO, no other pasing of lg blood clots.
dr. finally agrees to give more fluids. bolus over an hour of NS.
Maybe hetastarch or albumin better? What other ideas do you guys have for the case?
As we can see the albumin is only 1.5, the reduction of oncotic pressure may further dry the patient intravascularly. The doctor should consider giving albumin to temporary bring up the level. However, the underlying cause should be pinned.
I would also ponder the following..
1. Septic workout
2. Coag profile to rule out DIC..
3. An ABG.. chances of acidosis?
4. HGT level?
5. Likely to be adrenal insufficiency.. secondary to infection.
6. Any echogram done?
7. How is the LFT?
As I can see that the levo was tirated from 5 to 2 then up to 15.. could it be too fast cutting it down? I hope we have CVP reading here.
How about Hetastarch vs. Hespan? I've not given either of these yet.
Should be the same thing unless my memory is failing me. I'm snooping in here tonight as I'm not an adult critical care nurse, but I used to give Hespan during apheresis procedures (granulocyte donations) at the blood donor center where I worked prior to becoming a nurse.
RN1982
3,362 Posts
eh, duh. Sorry, thinking something different.