Critical care question re:PA pressures

Brownms46 · Oct 18, 2003

Here is a great tutorial, and it might be useful in helping you to understand this problem.

http://www.ccmtutorials.com/renal/oliguria/

Check out this page also, as it gives some scenarios and solutions

http://www.ccmtutorials.com/scenarios/renal/index.htm

Maximus · Oct 18, 2003

Lasix would not make sense in chronic renal failure unless they are trying to use it as a venodilator to allow the large veins to store more fluid and take the workload of the heart. But nitro is much better at that. If the pt is in oliguric acute renal failure then lasix can help to jump start the kidneys. The difference is that CRF is irreversible damage to the kidneys.

The pulmonary and arterial pressures don't help determine much with this patient unless you also look at the filling pressures (CVP & PCWP or wedge), cardiac ouput, SVO2, and SVR. In order to determine why your pulmonary and systemic pressures are so high you have know whether the problem is with preload or afterload. Preload is represented by the filling pressures and they help to determine if this pt is fluid overloaded which is very possible in this pt.

My guess from the info you provided is that the pt is fluid overloaded and may need dialysis soon. In the meantime, nipride and/or esmolol would help control his BP and decrease the chances of any surgical bleeding from occuring.

EastCoast · Oct 18, 2003

Ditto all of the above. Isolated Pa/ and art line readings shouldn't replace how the patient presents clinically. First off I would never take the PACU readings as law because you aren't sure where the transducer was and if they were balanced and calibrated. So first step I'd get my own readings.

More than likely his AAA probably contributed to his renal failure long before surgery.

I think the ICU nurse didn't really think about what she/he was asking. Most all know that CRF=CRF=CRF and lasix isn't helpful and dialysis is optimal. Are you sure that the patient didn't have Chronic renal insufficiency? The treatment options might be more open in that case. Also, without wedge pressure it's a crap shoot. The patient may have underlying pulmonary htn so there are a lot of other factors that need to be considered.

Brownms46 · Oct 18, 2003

Originally posted by EastCoast
Most all know that CRF=CRF=CRF and lasix isn't helpful and dialysis is optimal.

You know some how I missed the CRF info until I read your post EastCoast! And I have to agree totally, and good way to put it!

EastCoast · Oct 18, 2003

hey brownie, you never know in these cases if it's one of those thing where one nurse (icu) asks another nurse (pacu) a question to make her / him feel like they missed something. anyhow, very cute baby in avatar.

Brownms46 · Oct 18, 2003

Yep I know exactly how that goes, and some people LUV to do it too! Awww thanks EastCoast...can't wait to get a new one, as he is such a butterball now:chuckle!

mattsmom81 · Oct 18, 2003

Agree with everyone's input! Triple A's are notorious for sky high BP postop and we frequently use Nipride...and probably fluid overload was also a culprit (frequent problem in renals during surgery) CVP better represents that.

Our surgeons are getting smarter now with our renals and getting renal consults prior to surgery and some specific guidelines for the patient. ...so they don't have to answer to the nephrologists when they're called in emergently...LOL!

Surgical Hrt RN · Oct 18, 2003

This patient probably needed Primacor to lower his SVR and PA pressures. He has what seems to be pulmonary hypertension. When we recover these AAA patients, they almost always are on Primacor to decrease the SVR and PA pressures. They want these patients vasodialated.

However, this patient is a chronic renal failure patient. He probably needed dialysis. Did this patient pee on his own at all. Was he oliguric BEFORE the surgery? If he wasn't then Lasix may have helped.

Most of all open-heart patients experience some ATN or slight renal failure from being on the bypass machine. If this guy had a preexisting renal condition than the surgery could hav emade it worse. Hope this helps!!!!

sharann, BSN, RN · Oct 18, 2003

Thanks you guys(gals)!!!! You all have really contributed alot to help me here. The patient was a chronic oliguric, Dialysis patient(had dialysis just prior to surgery). I believe that the CHF is not new as well. The guy was a wreck already. I'm surprised he survived. Of course he waz being ventellated in PACU. His ABG's were the most normal numbers! The ICU nurses frequently ask us these types of thing to "show us up". To make sure we know we are "only" PACU nurses, not ICU nurses. (Of course we stabilize the ICU surgical patients for them and recover them!).

Thanks again :)

poppy07 · May 10, 2009

How is the management of high PA pressures (ex: Pulmonary HTN or CHF) with Nitro, Nipride, and Primacor different? Nitro will dilate, create venous pulling, and decrease preload, decreasing the PA pressures. Why use Primacor if there EF is good vs. Nitro, etc? Thanks