Criteria for Giving IV BP Meds?

[ChristineN]

So last night at work I was getting report on a pt from the ER and noticed their blood pressure was 200/100 when triaged. 6 hrs later when I was getting report on the floor the BP was 210/110 When I asked the nurse what she had given the pt to treat the BP her excuse was nothing, as due to the pt's vomiting the pt couldn't keep any PO meds down. I questioned why Hydralizine IV hadn't been given, the nurse seemed to not understand why you would give it if the systolic is less than 220. Pt ended up getting nothing for BP in the ER. The nurse taking care of the pt is a travel nurse new to my facility, so I'm curious, what is the criteria at other facilities are for giving IV BP meds?

[Thedreamer]

Yea, treating that underlying should paint a better picture to work with. Maybe some Zofran IV to help with the N+V, see if the BP comes down, check out what the CBC looks like, maybe get a BMP or CMP. Hopefully after that the BP comes down, VS get to a better norm and you can start replacing those lost fluids and electrolytes.

[Thedreamer]

We had a lady come in with persistent N+V, throwing Irregular rythyms, BP, the whole 9 yards. Once we got her to stop vomiting and got the stat labs back.. potassium was 2.5! Eek! Gave her some NS with K20meq and few days later had her outta there with all shiny and new!

[ChristineN, BSN, RN]

I agree renal failure = BP issues. But with continued vomiting, I'm not convinced that you wouldn't have been treating an artificially elevated number. My plan would be to get the vomiting under control & get the patient settled ... obtain some more realistic VS, then treat accordingly.

After 6hrs how long would you feel comfortable letting that BP go untreated? I was working a stroke unit and we treat our non-stroke pts for SBP of 180 or higher.

[MomRN0913]

Just wondering..... was the patient vomitting BECAUSE his BP was through the roof? maybe if we lowered the BP the patient would stop throwing up!

[Altra, BSN, RN]

My bigger question relates to the inability to get the active vomiting under control. In 6 hours time ... we would probably have tried Zofran, Compazine/Benadryl, Phenergan, and possibly low dose Ativan.

[ChristineN, BSN, RN]

Just wondering..... was the patient vomitting BECAUSE his BP was through the roof? maybe if we lowered the BP the patient would stop throwing up!

That's what we were thinking.

[Esme12, ASN, BSN, RN]

my question is why did they give nothing for nausea like some phenergan iv which will also lower the b/p. as will compazine.....what about zofran? until the vomiting is some what controlled any treatment for b/p with out an anti-emetic is a moot point. in emergency medicine we look at vital signs as a part of an acute symptom and total picture of what is going on.. if you come in writhing in pain from an open leg fracture......and your b/p is 210/100 i will not give you an anti-hypertensive, i will give you pain medicine. htn in a renal patient is not uncommon and the vomiting maybe due to built up toxins and fluid so the treatment is dialysis, anti-emetics and then b/p control that's reachable for a renal patient. so my question to the ed doc is "why have you allowed this poor patient to puke their guts out for 6 hours!!!":devil:

it is common for all types of chronic kidney disease to eventually cause hypertension (approx. 80% of chronic kidney disease patients develop hypertension at some point). the reason for this is two-fold. with reduced kidney function, there may be a certain amount of clinical and sub-clinical fluid retention in the body, due to poor elimination of fluids and poor control of sodium. perhaps more importantly, the kidneys are a major component in the body's regulation of blood pressure. as such, the kidneys have their own ability to raise blood pressure via release of a hormone called renin. release of renin triggers a cascade of events all over the body which eventually cause constriction of the blood vessels (vasoconstriction).

this cascade of events is called the renin-angiotensin-system, or ras for short. when the kidneys sense that the glomeruli (the actual filters in the kidneys) are not getting the blood perfusion that they need (this means good, adequate blood flow within the glomeruli), they cause release of more renin, and blood pressure is eventually raised throughout the body. since chronic kidney disease does affect blood perfusion within the glomeruli, chronic kidney disease is almost always accompanied by hypertension to some extent, even if there is no fluid retention. some high blood pressure medications work by inhibiting the renin-angiotensin-system specifically, and these are therefore most effective in the context of chronic kidney disease.

hypertension is very common with renal issues, especially when you get to about 50% kidney function or less. it can also sometimes be severe and difficult to control. with blood pressure medications, doctors have to balance how low they can get your blood pressure and what medications you can tolerate in order to achieve that level. as renal failure progresses, it's not uncommon to need 2 or 3 different blood pressure medications, or more, and sometimes, the best that can be achieved may not reach the target bp given in the guidelines.

also, one should realize that the most common blood pressure medications used for renal patients will not typically lower their bp very much on their own. a typical bp reduction from an ace inhibitor in this context is about 4 points for systolic, so, don't expect a huge drop in bp. the elevated bun and creatinine can also cause nausea and vomiting from the toxic build up of wastes in the body and makes the patient ill. especially in the presence of uremic frost. the exact incidence of uremic frost is largely unknown. this dermatological manifestation of severe azotemia is rarely seen because of early dialysis intervention.concentration of urea in sweat increases greatly when the blood urea nitrogen level is high. evaporation of sweat with high urea concentration causes urea to crystallize and deposit on the skin.

http://en.wikipedia.org/wiki/chronic_kidney_disease a simpler explanation of the above...

[LouisVRN, RN]

What we treat depends on what is ordered. We have two groups of hospitalists one writes for sbp =/ greater than 140 the other does sbp =/ greater than 160 or 180. I have an issue getting pts who have pressure equal or greater than parameters who still have not received treatment. Vonce parameters are written to me it no longer becomes a judgement call it is an order to give it if sbp is greater than the parameters yet I've seen so many times it is not given. I understand that a pt who has a hx of htn may not want treatment for a sbp of 142 but at least document that they refused. I will call to get an order for bp meds for anything over 160

[netglow, ASN, RN]

140?!?! sheesh that's a low threshold for meds.

Even just hospital anxiety is going to get a person 160+

[psu_213, BSN, RN]

In our ER, I can guarantee that, barring some very outstanding circustances, the doctor will not treat the triage BP. As for later BPs we (and I imagine most ERs) don't have a given threshold where the doctor absolutely will order IV meds and we don't have PRN orders. My initial thought is, yes, the ER docs at my facility would order something IV for pressures in the 200s, but that does not mean that is right for your patient in their circumstances.

I once was taking care of a pt who was very sensitive to all BP meds, had pretty bad orthostatic hypotension, and had a debilitating fall a couple of years prior as a result of the orthostatic hypotension. Long story short, when the ER doc talked to the pt's PCP, the PCP said that his target systolic BP is >180. He was not there for a BP related issue, but it felt strange sitting on a high BP and doing nothing for it. Then again, it shows the importance of having regular visits to one's PCP.

[NeoPediRN]

Labetolol IV is the drug of choice for asympomatic hypertension in my ER. We typically do treat profound hypertension. Sometimes it doesn't click in the provider's mind to order something, but if you ask they usually have no problem writing for a med.

[turnforthenurse, MSN, NP]

Did you call the doctor? What did they say?

I'm surprised they didn't try to treat the N&V downstairs in the ER...if the patient can't keep anything down, they still could have given something IV or even something IM if IV access couldn't be established. You can't really get an accurate result if the patient is vomiting all of the time.

It is common for renal patients to have elevated BP's, especially in patients with CRF. Also keep in mind that RF patients cannot tolerate extreme drops in their BP...a BP in the 160's may be normal for them and if it drops to 130 or 120, they might not be able to tolerate it.

As for BP parameters, typically the order I see for both hydralazine and labetolol is to only give if SBP >180 and/or DBP >100-110. Sometimes it's if SBP >160. We usually give 10mg of hydralazine Q6H...labetolol is 20mg Q10min. If the patient doesn't have any PRN BP meds and the SBP >160, I will call the doctor. Sometimes they will tell you to call them back when it reaches >180, or sometimes they will order a one-time dose of hydralazine or clonidine. It all just depends on the doctor.