Fluid bolus with BP 140s/100s?

Specialties MICU

Published

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

Thanks for the information. In the ED I worked in prior to nursing school, we saw a lot of SOB and respiratory distress, but they usually either turned out to be nothing or they were so bad that we had to intubate pretty rapidly. I don't have a lot of experience with BiPAP, but I'm glad that I learned something.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.

Bipap is less "invasive" than intubation and an O2 sat of 60% if real, must be treated regardless of the comorbidities. The caution with COPD patients is a "caution" but if they are not a DNR must have treatment to save their lives.

Medscape: Medscape Access A great reference/article for Non Invasive Ventilation.

The use of BIPAP in acute exacerbations of chronic obstructive pulmonary disease (COPD) has the most compelling clinical evidence, according to Gregory Schmidt, MD,of the University of Chicago, Chicago, Illinois. In this setting, the inspiratory pressure can assist overloaded ventilatory muscles, while the expiratory pressure can reduce the breath triggering load imposed by intrinsic positive end-expiratory pressure. The ideal patient is one in whom impending respiratory failure is present but in whom cooperation with a mask system is still possible (ie, not in extremis). Multiple controlled trials have shown that in this scenario, BIPAP reduces the need for endotracheal intubation and may impact subsequent mortality. More recent studies have also suggested that similar benefits may be obtained when using BIPAP in COPD patients with delayed deterioration Medscape: Medscape Access

I hope this helps:D

Bipap is less "invasive" than intubation and an O2 sat of 60% if real, must be treated regardless of the comorbidities. The caution with COPD patients is a "caution" but if they are not a DNR must have treatment to save their lives.

Medscape: Medscape Access A great reference/article for Non Invasive Ventilation.

The use of BIPAP in acute exacerbations of chronic obstructive pulmonary disease (COPD) has the most compelling clinical evidence, according to Gregory Schmidt, MD,of the University of Chicago, Chicago, Illinois. In this setting, the inspiratory pressure can assist overloaded ventilatory muscles, while the expiratory pressure can reduce the breath triggering load imposed by intrinsic positive end-expiratory pressure. The ideal patient is one in whom impending respiratory failure is present but in whom cooperation with a mask system is still possible (ie, not in extremis). Multiple controlled trials have shown that in this scenario, BIPAP reduces the need for endotracheal intubation and may impact subsequent mortality. More recent studies have also suggested that similar benefits may be obtained when using BIPAP in COPD patients with delayed deterioration Medscape: Medscape Access

I hope this helps:D

That was a great help. I am reading the article as we speak. Thank you for your information!

[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]

actually, the body is able to compensate pretty well for a fairly good amount of time. they will be tachycardic, hypertensive, and have a very impressive cardiac output. you will often hear nurses refer to this as the "warm" phase of sepsis. your patient is hyperdynamic. their catecholamines are being pumped out in massive quantities to keep compensating for everything that is going on. then all of a sudden they will tank on you and will have the "cold" phase of sepsis.....hypotension, cold, clammy, diaphoretic, low co, svr will be low, etc.

as far as the elevated bnp.....it can definitely be elevated in sepsis for patients who even aren't esrd/arf or chfers.

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.

One thing to please be aware of......Nursing professors often lure their students into a trap of believing that anything more than 2L BNC is not safe for a COPDer and will cause them not to breathe. When you have a COPDer who is in distress, is hypoxic, is anxious, etc. you need to give them the amount of oxygen to correct their hypoxia. Just keep that in mind for when you get out in the real world (not for testing purposes though!) If your pts sat is 65% on 2L....obviously the 2L is not cutting it and they NEED more oxygen.

Why does sepsis elevate BNP values? I'm assuming it has something to do with the dilation of blood vessels, the decreased blood flow and blood pressure, and the decreased cardiac output that eventually occurs with sepsis. Is this correct, or am I totally wrong in this thought process?

Also, to Meandragonbrett, thank you for all of your information. It's great to hear from experienced nurses who are willing to teach and provide insight to students. Since I want to be an ICU nurse after graduation, I am really fascinated by all the workings of the body, and the various diseases and injuries encountered in the ICU setting.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Interesting discussion. I was going to post but edited it out since I probably don't know what I'm talking about.

Interesting discussion. I was going to post but edited it out since I probably don't know what I'm talking about.

You should still post it! You never know.....Us ICU nurses can always learn new things too!

Specializes in Critical Care.

It sounds as though the sepsis was based on only a mildly elevated lactate. One thing to remember is that a mildly elevated lactate can be due to any one of the many causes of poor tissue perfusion, including pneumonia and COPD. Fluid boluses should not be based on a lactate level alone, particularly since another cause of an elevated lactate is CHF.

Ideally, fluid resuscitation in Sepsis is driven by primarily CVP, as well as MAP, SBP, other signs of perfusion. At least with the protocol I use, this patient would not have gotten any bolus at all. The thinking in Sepsis used to be "the more fluid the better", although the current data suggests we've been over doing it and that a 3-4 liter positive fluid balance at 12-24 hours is ideal (in truly septic patients).

An elevated BNP is primarily due to stretch of the ventricles. Pulmonary diseases such as pneumonia and COPD can back up pressure into the right ventricle and raise BNP levels, but with an BNP that high, there would seem to be at least some component of HF. Sepsis itself doesn't cause elevated BNP levels directly, although secondary effects such as ARF and aggressive fluid resuscitation will raise BNP levels.

why does sepsis elevate bnp values? i'm assuming it has something to do with the dilation of blood vessels, the decreased blood flow and blood pressure, and the decreased cardiac output that eventually occurs with sepsis. is this correct, or am i totally wrong in this thought process?
not exactly. bnp is typically secreted by the ventricles as a result of increased filling pressures (pre-load). we don't exactly know why bnp can be elevated in sepsis but a working theory is that patients who have sepsis tend to receive quite a bit of fluid bolusing (i.e. to increase ventricular filling pressures.....or pre-load) and they can also have an increased pvr (pulmonary vascular resistance) that is related to acute lung injury or ards which leads to rventricular congestion-->potential for release of bnp.

disclaimer:

*not saying this patient was or wasn't a chfer or was or wasn't a sepsis with the bnp values. just answering the question regarding bnp and how it could possibly be elevated*

Thank you, that makes more sense. I knew that BNP was elevated in CHF and other heart failures, but I wasn't sure about why it was elevated with sepsis. It does seem kind of odd to me that this patient's BNP was elevated given that they had only had two liters as a bolus, but maybe that's just erroneous thinking on my part. Thanks again for your explanations, they were great.

Actually, I edited this because I can sort of see how two liters of fluid would elevate the BNP. I do not know, however, if two liters would be enough to push it up to the number it was at in the original post. That's where my confusion lies. Would it be a reasonable assumption to think that this patient also had some sort of heart failure going on in addition to pneumonia and sepsis?

+ Add a Comment