Ejection fraction and bolus

Well, we don't have standing orders for such a thing, we have residents we call for orders. But definitely, I"ll look at their EF when I'm considering a bolus..as well as I&O, BUN/CR, trends with labs and VS and especially will review meds to look for any problems. But if I've got a pt crashing a BP and it looks like he's dry, I'm gonna give fluid. Your question is really a complex one, since there are so many things to consider. And do I try to consider them before bolusing? You bet. One thing to keep in mind is trying to remember what the dx is that they are there for....for example, some pt's even with low EF may need higher pre-load to optimize function...so they're gonna need some fluid if they are dry. Another thing to consider is do they need an afterload reducer? (Is their BP low cause their SVR may be too high? Hard for the heart to push against a wall if the SVR is too high?) I've given hydralazine to borderline CHF'ers to reduce afterload thereby allowing their BP to elevate. It's tricky and it helps to have swan data to go by as well before doing something like that.

I like to keep this in mind too...500 cc of saline is only two cups of water. If they develop flash edema or CHF I can hit them with some lasix or bumex to pull the fluid off. I'm not sure if your protocol allows it but you can always give half a bolus (250 cc) and see how someone responds.

This type of management is tricky and you've got to have a good understanding of what's going on with your patient. At least that is my humble opinon. Bottom line: am I comfortable giving a bolus to someone with a low EF? Yes, if the scenario fits it. And no, we don't have a cut off value for the EF. Hope I haven't confused things for you...I rambled a bit here. Great question.

Highland-- WOW, what a great reply! I appreciate you taking your time to answer my question.

It's little tidbits like this that will help me be a safe, prudent nurse. I appreciate your feedback.

For our sheath pulls we can give a 500ml bolus per protocol for symptomatic hypotension, irregardless of EF. But I agree with ~Highland that sometimes you need to "fill the tank" to maintain adequate pressures. You are going to consider the EF, but there are some other factors that really trump that. If there is nothing much to pump, your EF could be 70% and you still might have issues.

Cheers,

Tom