Fluids vs Pressors?

1) that NS can cause non anion gap acidosis 2) crystalloids only stay immune plasma for about 30 mins and then come back 3 days later to bite you in the ass. What exactly was the BP? This guy just had surgery which is probably an insult to his already crappy heart, so I would have gone with the albumin or pressors. UOP is going to be decreased by stress release of ADH

putting aside my misgivings for patient being treated. Patient needs appropriate investigation to identify reasons for low BP and urine output. That means ECG and cardiac echo to rule out intra-op infarction or perhaps another cause.

Agree that normal saline will lead to an acidosis, as someone said on another forum just the other day 'there isnt anything normal about normal saline'.

Agree absolutely that levophed is not to way to go. If the patient is hypovolaemic then flogging an empty CVS will increase cardiac workload unnecessarily. Adrenaline is a better way to go IF they need it.

So echo, ECG and proper haemodynamic monitoring, afterall if the patient wants everything then they need to have appropriate ongoing monitoring not half measures

I currently work in a SICU with three staff MDs that are general surgeons/intensivists that are academically very well respected/published/medical school educators, etc. Especially after abdominal surgery ICU prepared surgeons do not favor pressors due to decreased splanchnic blood flow. They drown them. These patients also 3rd space a ton so they are routinely on a lot of IVF as a maintainance plus PRN flushes, both crystalloids and colloids, often. Where I work, they often want their CVP >10-12. UOP is a concern, but they don't have to make a ton because the docs know they 3rd space. Pressors are added as a last resort at a low dose if nothing else works. Usually they don't get pressors unless they are septic on top of the surgery (which happens with perforations and such...) .... they just get drowned.

We get used to seeing a lot of water balloony patients where I work.

Sounds appropriate to start pressors in this patient. He sounds adequately volume resusitated. Continued use of NS can cause hyperchloremic non gap acidosis so just pounding the fluid is not an option. What was the patient's CVP? MAP? That would help guide the pressor choice and help clarify the type of shock the patient was in. Typically after 2-3 liters of saline its time to augment with pressors.

Sounds appropriate to start pressors in this patient. He sounds adequately volume resusitated. Continued use of NS can cause hyperchloremic non gap acidosis so just pounding the fluid is not an option. What was the patient's CVP? MAP? That would help guide the pressor choice and help clarify the type of shock the patient was in. Typically after 2-3 liters of saline its time to augment with pressors.

Our sepsis protocol has you give up to 5L of NS prior to considering pressors. I am not sure how much NS is too much (to cause acidosis) but 2-3L is not alot esp. on an adult volume depleted patient. I have seen up to 10-12-14L given over a few hours in the OR setting and the patients don't come out acidotic/hyperchloremic. How much NS are we talking about here? I can't say I've ever seen an acidosis pinned to fluid resuscitation or a hyperchloremia as a result of heavy duty crystalloid administration.

Sorry I haven't returned with updates. The patient received 2 doses of albumin after I left but ultimately ended up on levophed (was weaned the next day). I did not care for the patient the next day but was back on the case the 2nd day post op. Day 1 post op she received albumin and lasix. Day 2 post op she received 2 more units of blood and a total of 80mg of lasix. Her urine output was satisfactory and never needed to be placed back on levo.

I think she received 3 1L NS boluses within the first 12 hours post-op. Did not run a CVP reading. Patient only had a dual lumen PICC. We will run CVPs off of a triple lumen PICC using the distal (red) port. We do not run CVPs off dual lumen PICCS. Not sure if you can or not, does anyone know?

Sorry I haven't returned with updates. The patient received 2 doses of albumin after I left but ultimately ended up on levophed (was weaned the next day). I did not care for the patient the next day but was back on the case the 2nd day post op. Day 1 post op she received albumin and lasix. Day 2 post op she received 2 more units of blood and a total of 80mg of lasix. Her urine output was satisfactory and never needed to be placed back on levo.

I think she received 3 1L NS boluses within the first 12 hours post-op. Did not run a CVP reading. Patient only had a dual lumen PICC. We will run CVPs off of a triple lumen PICC using the distal (red) port. We do not run CVPs off dual lumen PICCS. Not sure if you can or not, does anyone know?

We run CVPs off any kind of PICC. One place I worked a while back had a policy that stated that we couldn't because they were concerned about catheter rupture with the pressure bag. Apparently they thought a PICC was not designed to withstand greater than 300mmHg -- don't know if they do now or not, or most facilities just don't realize this. Regardless, I have never seen catheter rupture due to a pressure bag happen.

I have found that when pressors get turned on and off in less than 24 hours, patients probably didn't need them and it was some noob nurse or doctor that didn't like looking at a sB/P of 98 or a MAP of 59 and insisted on it. This is not always true, but I do think that often we pump up people's B/Ps to 120-130 systolic with no real reason to, and all that time you are giving them drugs that reduce organ perfusion. Pressors are not benign and should be used judiciously. Just my 2 .

5 liters is the suggested standard of early goal directed therapy. The intensivist I work with usually says if by 3 liters your not restoring perfusion to augment with vasopressors, so that is what I will now order (while continuing the bolus as well). Early goal directed therapy consists of a CVP 8-12 (we prefer 12 or greater), a MAP greater than 65, and a SVO2 greater than 70. If the CVP is not rising with fluids or the MAP remains below 65, then vasopressors are started (not because I am a noob APRN, but because MAP less than 65 suggest end organ damage, which is what we are trying to prevent with early goal directed therapy - sorry, too easy!!).

However, in a surgical patient, it is a different ballgame. Surgeons will blast fluid to level of 10-12 liters if no signs of pulmonary compromise as vasopressors in a surgical patient constricts wound beds, etc...

Finally, in early goal directed therapy, the hope is to turn pressors on quick, off quick. I do agree however, that if the patient's SBP is only 90, but their mean is 65, I would not start pressors quickly in that patient.

http://www.uptodate.com/online/content/abstract.do?topicKey=cc_medi%2F16828&refNum=7 Here's a link to the surviving sepsis campaign.. All about early goal directed therapy

Like the others have mentioned she did seem adequately replaced. However I wouldn't go with levo as my first choice when the elderly patient is already tachy,... if they were younger than go ahead. Depending on how hypotensive this patient was maybe the better choice would be to start them off with neo-synepherine which would increase their BP and sometimes lowers their HR.

One of the doctor's on my unit mentioned the other day that sometimes its better to go with pressors over fluids if possible because pressors you can just turn off if the patient is having a bad reaction, if its doing more harm than good or if it doesn't work. In seconds, the patient will be back to their baseline or close to it. Fluids on the other hand, especially when you're talking about the elderly who might already have CHF or some other type of cardiac diseases,... you can't just shut them off and everything goes back to "normal". Once you aggressively bolus them, you have to deal with the consequences for days. You might cause pulmonary edema thus compromising their airways and making them harder to wean from the vent...and that in itself leads to other issues.

I'm no expert but his theory seems to make sense.

Also, if a patient is hemorrhaging, the known cause is a GI bleed therefore abd surgery is likely to be in the picture, and they're nearing the 100yr mark... why doesn't this patient have a CVP?? I would be rallying for that.

I'm glad to hear that everything turned out well. :)

Like the others have mentioned she did seem adequately replaced. However I wouldn't go with levo as my first choice when the elderly patient is already tachy,... if they were younger than go ahead. Depending on how hypotensive this patient was maybe the better choice would be to start them off with neo-synepherine which would increase their BP and sometimes lowers their HR.

One of the doctor's on my unit mentioned the other day that sometimes its better to go with pressors over fluids if possible because pressors you can just turn off if the patient is having a bad reaction, if its doing more harm than good or if it doesn't work. In seconds, the patient will be back to their baseline or close to it. Fluids on the other hand, especially when you're talking about the elderly who might already have CHF or some other type of cardiac diseases,... you can't just shut them off and everything goes back to "normal". Once you aggressively bolus them, you have to deal with the consequences for days. You might cause pulmonary edema thus compromising their airways and making them harder to wean from the vent...and that in itself leads to other issues.

I'm no expert but his theory seems to make sense.

Also, if a patient is hemorrhaging, the known cause is a GI bleed therefore abd surgery is likely to be in the picture, and they're nearing the 100yr mark... why doesn't this patient have a CVP?? I would be rallying for that.

I'm glad to hear that everything turned out well. :)

The only problem with Neo is that its pure alpha, which can cause more problems in the end. Of course it depends on the type oh shock, but the heart rate variability with Levophed is usually minimal in our practice. We use Levophed as first line in most shocks, and add Vasopressin as our second. We have, however, mostly shelved Dopamine due to its heartrate effects. Great case and great conversation about it!!!