Fluid bolus with BP 140s/100s?

Zaphod, BSN, RN · Dec 30, 2011

Low urine output tells you pt is dry. The BP is up because of tachycardia-compensatory to maintain cardiac output. CO=HRxSV. Fluid bolus should help, but pt may even need more-have seen up to 10L being given in sepsis.

Now I dont know what other comorbidities are present, with high BNP and crackles-maybe he is in CHF, cant speculate but that would mean a more conserative fluid therapy.

Creamsoda, ASN, RN · Dec 30, 2011

Hello wise nurses,
Perhaps you can help me understand this. Patient comes up to the unit with pneumonia, rules in for sepsis. Pressures in 140s/100s during time in the ED even higher in the unit but also tachycardic. Desaturated in upper 60s upon arrival to ED, on BiPAP saturating well now. Lactate under 2.5 but elevated, BNP over 5,500, BUN elevated (I realize in the ED they didn't have this info immediately). Patient given 2L fluid bolus wide open in ED. Urine output decreased.
I cannot for the life of me figure out why the fluid bolus and my resources didn't see anything obvious either. The best I can figure is that the almighty protocol was followed. Am I missing something?
Thanks for your input.
Mochamonster

Lactate was up, urine output low, tachycardic. Yes not obvious signs of impending doom yet as the BP was fine, but my thoughts are the pt has tightened up his vessels as a compensatory mechanism...for now. Likely had it been left too long, his BP may have started dropping. Thats my only thought Urine output is a good incidator that he was dry.

NCRNMDM, ASN, RN · Dec 30, 2011

[color=#1a1a1a]i'm only in nursing school, but i hope to be a critical care nurse after i graduate. some of what zaphod said makes sense to me, but some seems odd. i could be wrong, and, in fact, probably am. if i am wrong, and someone else has a definitive answer, i would love to hear it. as we all know, sepsis is an infection of the blood, and is quite severe. as we also all know, in response to infection (more specifically, the toxins released in the body due to the sepsis) the body produces cytokines which produce inflammation and aide in the immune response. cytokines, however, have some negative effects on the body, the most life-threatening, and most noticeable, of which is vasodilation. as the blood vessels dilate, the blood pressure drops, blood flow decreases to the vital organs, and the heart compensates by increasing the heart rate (causing tachycardia), and the cardiac output. eventually, the heart gets tired of compensating, and the volume of blood being pumped out (the cardiac output) drops. as the tissues receive less blood volume, they release lactic acid into the blood, and the ph begins to become acidic.

[color=#1a1a1a]i understand that, initially, the body may effectively compensate, and the co and bp may remain somewhat stable. i do not understand, however, how the patient's blood pressure could be in the 140s/100s upon presentation to the ed. this is where i am confused by the other poster who said that the elevated bp was due to the compensatory mechanism of the body. i suppose that the vessels could have constricted very tightly as the body tried to maintain its blood pressure, but i don't think the vasoconstriction would be enough to drive the pressure that high. someone correct me if i'm wrong in that assumption because i am here to learn.

[color=#1a1a1a]i agree with you that, perhaps, the fluid boluses shouldn't have been given. i did some work in the ed prior to beginning nursing school, and we usually had to bolus our sepsis patients because the pressures we saw were so ridiculously low. however, if we had a patient whose pressure was high, we did initiate several lines and prepare two or three bags of iv fluid in case we needed to rapidly bolus the patient. we tried not to bolus a patient who had a decent pressure because we didn't want to send anyone into chf or hypervolemia. we also considered getting dopamine or levophed out, labeling it, and keeping it at the bedisde just in case. also, with the bun and bnp being elevated, i am lead to believe that the patient has some degree of renal failure and chf, or some form of heart failure. the renal failure and heart failure could explain why the urine output was low, but sepsis could also explain that, as one previous poster alluded to.

WolfpackRed · Dec 30, 2011

just a thought - if the BP was in the 140s/100s, the high diastolic could imply two things. first, the pt could be chronic hypertensive, thus a SBP in the 140s may appear "normal", but may be low for this patient, as the OP reports the lactate is on the high side of normal, a trend in the lactate would be good to know.

second the narrow pulse pressure would also suggest, as with the decreased urine output, that the preload is down.

either of these could justify the fluid need. even if the pt had CHF, the fluid can come off later

Esme12, ASN, BSN, RN · Dec 30, 2011

Hello wise nurses,
Perhaps you can help me understand this. Patient comes up to the unit with pneumonia, rules in for sepsis. Pressures in 140s/100s during time in the ED even higher in the unit but also tachycardic. Desaturated in upper 60s upon arrival to ED, on BiPAP saturating well now. Lactate under 2.5 but elevated, BNP over 5,500, BUN elevated (I realize in the ED they didn't have this info immediately). Patient given 2L fluid bolus wide open in ED. Urine output decreased.
I cannot for the life of me figure out why the fluid bolus and my resources didn't see anything obvious either. The best I can figure is that the almighty protocol was followed. Am I missing something?
Thanks for your input.
Mochamonster

Well as a critical care nurse and an ED nurse....I gotta tell you I am not sure why the fluid. The patient arrived hypertensive and tachycardic. I would not think sepsis. My first thought would be anxiety, hypoxia and fever to explain the tachycardia. The decreased urine output can be just from stress and slight dehydration. I can see the liter which is pretty standard stuff in the ED....when not in obvious failure give fluid. But I would not slam them with 2 liters in view of the tachycardia and hypertension, The desaturation can be from either the PNA or CHF/Pulm edema from the fluid bolus. There can be some argument for and vasoconstriction pre-ceeding septic shock and vasodilatation....but after a liter I would use a less aggressive approach to re-hydration and if the patient continued with HTN and tachycardia I'd give a gentle wiff of lasix (before knowing the BNP). Not know the patient history makes it difficult, but giving fluid would NOT have been my first thought. :twocents:

mochamonster · Dec 30, 2011

Thanks for your responses everyone. Patient was not a good historian. All the patient could tell was that they had a "lung disease" (suspect COPD, but ABGs were good on BiPAP) and history of heart fibrillation from the patient's adult child (a-fib perhaps?). Docs think CHF likely. Patient was afebrile and blood cultures were not back yet. I'm sure the patient will turn out to have positive cultures. ED was unaware of low urine output at the time. Pressures went up to 160s/110s and back down to 140s/90s-100s. Luckily lung sounds remained clear and patient seemed to be okay with the fluid, but I sure was trying to figure out why they would run in so much fluid. Usually our docs are a little more conservative with fluid, but I was not in the ED, so I'm not going to judge. Just trying to make sense of it. Thanks for your insights! I'm a new nurse and I try to learn as much as I can. :-)

Altra, BSN, RN · Dec 30, 2011

2L ispretty conservative fluid resuscitation for suspected sepsis.

mochamonster · Dec 30, 2011

Point taken Altra. It is.

Esme12, ASN, BSN, RN · Dec 30, 2011

I just do no think sepsis would have been my first thought with that presentation and those vitals when admitted to the ED. I would correct the hypoxia and wait for labs and give "gentle" boluses of 500cc's to begin to "fill the tank". I agree that 2 liters while not alot in the presence of sepsis, with a 140/100 B/P ....I don't think I'd quickly dump 2 liters of fluid and hope for the best. I'd correct the hypoxia/tachypnea and tachycardia with O2 and give a gentle bolus and wait for labs (and the BNP was 5500) as long as the B/P held. But I wasn't there so it's tough to judge when I haven't seen the patient.

NCRNMDM, ASN, RN · Dec 30, 2011

Also, you said the patient desatted to the 60s upon arrival to the ED, but then said that he had suspected COPD. Don't COPD patients normally hang out at a lower baseline saturation when compared to healthy individuals? I don't think that anyone's saturation should be that low, and it needed to be corrected, but I am curious to know what the patient's baseline is. Also, is BiPAP a safe method of ventilation for a patient with COPD (just for my own information)? I know you have to be careful with how much oxygen you give a COPD patient as you can depress the respiratory drive if you give too much.

mochamonster · Dec 30, 2011

I'm with ESME12, but like you say we weren't there and who knows what they saw. Mattmrn2013, COPD is not a confirmed diagnosis, just my suspicion from looking at the patient. They just "looked" like a COPDer to me along their decades long smoking history. Also, in any emergency you have to save the patient first. I'm sure they tried other oxygen therapies first and weren't successful with those. Many COPDers end up on BiPAP if needed to maintain their sats, you just have to titrate based on their response to it.