interdialytic hypotension and fluid gains

[Hellllllo Nurse, BSN, RN]

At my chronic unit, we have quite a few small, light weight pts who are in very poor health all around, and whom we have to struggle w/ to maintain decent B/P during tx.

I am just a couple weeks out of orientation. In my orientation, I was given literature and watched films, both of which stated that hypertonic Na+ is given for hypotension. So I expected to be using it.

In reality, only NS is used in my unit. We've had several pts who've left heavier than when they came in, due to us having to give so much saline to maintain B/P. I questioned this but was told "This is how we do it." No meds are used to increase B/P. We can only use niphedipine to lower B/P. No other B/P related meds are used.

When I mentioned that the training films and study guides recommended hypertonic saline, I was told "Those films are old. that's not done anymore."

Seems to me that using hypertonic or mannitol would make alot more sense than giving 1000-1200 plus cc of saline during tx!

What is done where you work?

[jnette, ASN, EMT-I]

Wow.

We sure DO use hypertonic.. but use it for cramping, not to lower the B/P. We use Mannitol if the pt. has real B/P problems. Standing orders for both of the above. Can be given x3 in 30 min. intervals. Mannitol up to 30 minutes before end of tx.

We try other measures first... I like to keep a close eye on my "problem pts.".. the ones I know usually drop their B/P. If I see them dropping down to a systolic of 100 or even before that, I turn down their goal by 500... (and later do this again, if necc'y.) Wait 20 min. or so and check B/P again... if still no better or worse, I will then give them a 200ml NS bolus. If you catch it EARLY enough and begin dialing down their goal, and an occas'l NS bolus, it works far better than trying to pull all that fluid off just to meet the target weight. At least that way they can MAINTAIN a relatively decent B/P. On the other hand, if you wait too long to intervene, and it's the last hour or halfhour of their tx., it's all that much harder for them to get their B/P back up there. Then when they come off the machine, they'll have to sit there for an hour sometimes trying to get a B/P while you pour the NS to them. That makes no sense. We don't like giving our pts. all that saline.. it's so contradictory. We don't use the mannitol that often, either. We just keep a real "preventive eye out" for what's going on with the pt. and attempt to nip it in the bud before it gets too low. If they're in the last halfhour of tx., we will sometimes just "goal them out" and let them run without the UF.. just clean the blood. We do have one nurse who is too eager to get that target weight and she always waits too long to intervene... then the patient gets sick, cramps, and has no B/P... and she ends up having to give him/her nearly a bag of saline to get the B/P up enough to let the pt. leave. It's so much easier to intervene early ! And it usually works.

Then.. perhaps the pt. needs to have his/her tgt. wt. raised a bit.

We do this as well, if it is a routine problem with the pt. Usually helps. What does your procedures/protocol say? What are your standing orders?

Anyway, Hellllo, this is how we do it... hate that you're having problems there. Bummers.