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

Specializes in CIC, CVICU, MSICU, NeuroICU.

Hello everyone, I love to offer my opinion on this topic. Previous information about myself: 4 years CVICU, 1 year of Neuro and 11 months left in anesthesia school. Personally I would probably would not give 2L of fluid upfront. I understand that rationale for fluid resuscitation for septic patient. This patient still maintain more than adequate blood pressure despite the state of tachycardia. If they are truly concerned for sepsis...blood cultures should be drawn, central line and A line placed. Serial laps and I would guide my fluid management from there.

In addition, I am concerned with desatuation. Crystallioid doesn't stay intravascularly more than 45 mins...so if they were to really want to fluid resuscitate this patient..they should be a bit more aggressive. Judging from the clinical presentation, I would do a bit more work up and not rush to give 2 L upfront....1 L..may be but not 2.

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

You are not wrong, it does have to do with dilation of blood vessels but not the cardiac output failure as is seen in late septic shock. In the bodies effort to attempt to compensate in early sepsis....fluid shifts occur within the body as well as vasoconstriction to try to maintain "normal" vital signs........as the body's stress continues, hormones are released that "depress" the hearts ability to function and pump effectively so the heart tries harder (hence the 140/100 and tachycardia) and uses the bodies fluids to compensate.....meandragonbrett stated "warm shock", vasoconstriction occurs early in the process, and urine output falls in the bodies effort to hang on to all fluid. When the body can no longer compensate, severe vasodilation occurs, you have the massive catecholamine release, the capillary beds turn to mush, the fluid leaks into the extra cellular space and the patient crumps. My instinct is that this particular patient was not in that category and like I said I would bolus with 1000cc (load the tank a bit), and then evaluate carefully my next step before just blindly giving 2 liters. But it is impossible to be sure not being there ourselves...:0

Sepsis-Associated Myocardial Dysfunction*

[/url]In patients with sepsis the heart often undergoes substantial functional changes due to the cytokine-mediated "sepsis-induced myocardial depression" resulting in ventricular dilatation and depression of ventricular function, which is detectable by echocardiography or radionuclide ventriculography. At the time of echocardiography our patients obviously did not suffer from overt sepsis-induced cardiac depression. However, minor changes in ventricular contractility may have escaped due to lowered systemic vascular resistance and left ventricular unloading respectively

In contrast to the lowered systemic vascular resistance, pulmonary vascular resistance in patients with sepsis often increases due to associated acute lung injury (ALI) or ARDS leading to right ventricular (RV) overload, possibly causing BNP release. Acute cor pulmonale develops in 25% of patients with ARDS even in those submitted to protective ventilatory support http://eurjhf.oxfordjournals.org/content/7/7/1164.full

Patients with severe sepsis and septic shock often have elevated BNP levels, which are significantly associated with organ and myocardial dysfunction, global tissue hypoxia, and mortality. Serial BNP levels may be a useful adjunct in the early detection, stratification, treatment, and prognostication of high-risk patients.

Clinical Utility of B-Type Natriuretic Peptide in Early Severe Sepsis and Septic Shock

Specializes in Critical Care & ENT.

Based on the information provided.....there could be various possibilities. Looking back, we can all say what we would have done or take a different course. In regards to the BP....if the O2 Sats were 60%, the patient could have been confused. Could they have been slightly combative or moving around and the cuff went off at the same time? What was the trend in BPs? Was the SaO2 verified on a different hand? Or what did the ABG state the numbers were? Metabolic acidosis? :::scratching head..thinking.....ARDS? SIRS?::::::

In the initial stages of sepsis, cardiac output can be well maintained or can be even higher than what we would expect to see. That could also be another reason why the BP was high. Tachycardia could be present to help increase cardiac output the patient. It's important to know WHY the tachycardia is present--- early shock? fluid volume deficit? anxiety? confusion? ---remember.....treat the cause! Tachycardia can still be present in shock, even though adequate fluid repletion.

Fluids---based on my knowledge, septic patients need lots of fluids. It's important because not having enough fluids can result in tissue hypoperfusion and worsen organ dysfunction. CVP should be monitored to help determine how much fluids you want to give the patient. A CVP of 8-12mm Hg should be suffice. If having other issues, then this range may be suggested to be higher.

Interesting patient overall...hopefully he is doing well. Please follow up with any additional information!

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

Yep, we all agree!!!

Thank you, Esme12. This was great information, and it was a great breakdown of what is happening in the body during sepsis.

Yep, we all agree!!!

Definitely that! We need more clinical discussion on this side of the board! It's been kind of bland lately.

@MattRNStudent23.......ask us more questions that you want clarification on anytime!

Specializes in Vents, Telemetry, Home Care, Home infusion.

I'd also like to know H+H as many advanced COPDer's are anemic which impacts O2 sat interpretation.

The Surviving Sepsis Campaign: Clinical Practice Guideline Revisions for Improving Outcomes in Sepsis

Trends in Sepsis Management[/url]

Webcast: New Perspectives in Sepsis for the Critical Care Nurse

[color=#363636]bipap or bilevel positive airway pressure, keeps the airways open by providing a flow of air delivered through a face mask. with bipap the pressures that the doc prescribes alternate, a higher pressure is used to breathe in, called ipap, and a lower pressure is used when breathing out, called epap. bipap is the preferred method for severe, obstructive sleep apnea and copd

medically necessary:

the use of non-invasive positive pressure respiratory assist devices (bipap) for the treatment of severe copd is considered medically necessary when all of the following are met:

  • an arterial blood gas paco2, done while awake and breathing the individual's usual fio2, is greater than or equal to 52 mm hg; and
  • sleep oximetry demonstrates oxygen saturation less than or equal to 88% for at least five continuous minutes, done while breathing oxygen at 2 l/min. or the individual's usual fio2(whichever is higher); and
  • prior to initiating therapy, obstructive sleep apnea and treatment with cpap has been considered and ruled out.

note: when the above medical necessity criteria for individuals with the indication of severe copd are met, a non-invasive positive pressure bi-level respiratory assist device, without back-up rate feature, will be considered medically necessary.

for central sleep apnea, (i.e., apnea not due to airway obstruction)

medically necessary:

the use of a non-invasive positive pressure respiratory assist device (bipap) for the treatment of central sleep apnea is considered medically necessary when, prior to initiating therapy, a complete, facility-based, attended polysomnography has been performed and the test results have revealed all of the following:

  • the diagnosis of central sleep apnea (csa) has been confirmed; and
  • the presence of obstructive sleep apnea (osa) has been excluded, as the predominant cause of the sleep-associated hypoventilation; and
  • if osa is a component of the sleep-associated hypoventilation, cpap has been ruled out as an effective therapy; and
  • oxygen saturation level is less than or equal to 88% for at least five continuous minutes, done while breathing the individual's usual fio2; and
  • significant clinical improvement of the sleep-associated hypoventilation has been demonstrated with the use of a bi-level positive pressure device, either with or without the back-up rate feature, adjusted to the settings that will be prescribed for initial home use, while breathing the individual's usual fio2.

note: when the above medical necessity criteria for individuals with the indication of csa are met, a non-invasive positive pressure bi-level device, either with or without the back-up rate feature, will be considered medically necessary.

basically yes copd and osa patients very often placed on bipap also when pt on this device and nebulizer treatments are order respiratory therapy can hook it up so nebs can be given while on machine which i find much more effective.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
[color=#363636]bipap or bilevel positive airway pressure, keeps the airways open by providing a flow of air delivered through a face mask. with bipap the pressures that the doc prescribes alternate, a higher pressure is used to breathe in, called ipap, and a lower pressure is used when breathing out, called epap. bipap is the preferred method for severe, obstructive sleep apnea and copd

medically necessary:

the use of non-invasive positive pressure respiratory assist devices (bipap) for the treatment of severe copd is considered medically necessary when all of the following are met:

  • an arterial blood gas paco2, done while awake and breathing the individual's usual fio2, is greater than or equal to 52 mm hg; and
  • sleep oximetry demonstrates oxygen saturation less than or equal to 88% for at least five continuous minutes, done while breathing oxygen at 2 l/min. or the individual's usual fio2(whichever is higher); and
  • prior to initiating therapy, obstructive sleep apnea and treatment with cpap has been considered and ruled out.

note: when the above medical necessity criteria for individuals with the indication of severe copd are met, a non-invasive positive pressure bi-level respiratory assist device, without back-up rate feature, will be considered medically necessary.

for central sleep apnea, (i.e., apnea not due to airway obstruction)

medically necessary:

the use of a non-invasive positive pressure respiratory assist device (bipap) for the treatment of central sleep apnea is considered medically necessary when, prior to initiating therapy, a complete, facility-based, attended polysomnography has been performed and the test results have revealed all of the following:

  • the diagnosis of central sleep apnea (csa) has been confirmed; and
  • the presence of obstructive sleep apnea (osa) has been excluded, as the predominant cause of the sleep-associated hypoventilation; and
  • if osa is a component of the sleep-associated hypoventilation, cpap has been ruled out as an effective therapy; and
  • oxygen saturation level is less than or equal to 88% for at least five continuous minutes, done while breathing the individual's usual fio2; and
  • significant clinical improvement of the sleep-associated hypoventilation has been demonstrated with the use of a bi-level positive pressure device, either with or without the back-up rate feature, adjusted to the settings that will be prescribed for initial home use, while breathing the individual's usual fio2.

note: when the above medical necessity criteria for individuals with the indication of csa are met, a non-invasive positive pressure bi-level device, either with or without the back-up rate feature, will be considered medically necessary.

basically yes copd and osa patients very often placed on bipap also when pt on this device and nebulizer treatments are order respiratory therapy can hook it up so nebs can be given while on machine which i find much more effective.

can you please reference your information so we can all look up what you found and learn. i find i like to follow the links and read the information in total to get the whole perspective about the information provided. thanks!!

Specializes in Critical Care.

The patients kidneys arent funtioning, he's septic, enough said

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