Need advice on PostOP B/P

[JKSDRN]

Hi, I am a night nurse currently working in a private surgical hospital and would like some advice from experienced med/surg nurses. I still consider myself a novice with my initial training as a nurse in a highly respected hospital related to heart/lung transplants and cardiac surgeries. I was trained on the importance of MAPs being above 60 and now in my new job the term MAP is never used or monitored. Many of our patients have what i consider dangerously low b/p (low 80's over high 30's, low 40's) and MAPs below 60. This hospital only staffs ACLS certified nurses at night and has an on call hospitalist available if absolutely necessary. If the on call hospitalist is called during the night over a low b/p his response is: 1. Is the patient symptomatic? 2. Are the fluids still running? (100 ml/hr 0.9% NS is standard). Most post op patients are lying down in bed so it is difficult to determine if they are symptomatic so the answer is usually No, and Yes, the fluids are still running. His response is then he / she are fine, leave the fluids running and "why in the He** did you call me attitude.

So here is where I would like to hear from you: Night one my patient had pressures 88/40, MAP 56, NS @ 100 ml/hr, low urinary output. Day two: Hgb 8, urinary output 75ml in 12 hours with 350 in bladder, fluids discontinued. Order was for 2 units PRBCs with Lasix between units.

I cornered the hospitalist before my shift and discussed my patients condition and he explained that as long as a patient is talking and walking he is not concerned with the low pressures and would not give me a low number acceptable to wake him up at night. He said, anesthesia creates vasodilation and low pressures are fine following surgery unless they are symptomatic. Also, with a low Hgb, the body is holding onto the fluid so the low urinary output is "ok" and will correct itself with the transfusion and Lasix.

My patient did produce a lot of urine following the transfusion and her pressures came up, but it was 24 hours after post op night one. I am looking forward to any comments, advice and in site you all may have. Thank you!

[HeySis, BSN, RN]

I agree that anesthesia can lower BP's beyond hat is "normal" and the patient can still be stable. But one of the criteria of leaving PACU is a stable BP, and I would not discharge to the surgical care unit with a BP that low unless the patient pre-op BP was 90/60"s range and I had previously consult with their anesthesiologists. Even before I called the anesthesiologist, I would have held that patient a good long time to make sure the BP was stable.

I'm curious to the standards of your facility? In ours, the modified aldrete has to be 9 or above and in every category score at least a 1 in order to discharge. (exceptions made for discharge to ICU or with an MD consult) For that pt to be a category 1 in circulation the pre-op BP would not be able to be higher then 100/60.

Has this been just one patient? Is it a trend on your unit? what do the other nurses that work there say?

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

If there is no active bleeding, we didn't transfuse unless the hgb was 7 or below. Our facility initiated this protocol during a time when blood donations were at a record low nationwide. We never called a physician 'solely' about a SBP in the 80s. (But this would be an excellent time to break out the manual cuff in addition to the automatic machine for comparison of the readings).

We did call, however, with concerns of anuria or urinary retention after 8 hours has passed post catheter-removal, or general post-op if no catheter was inserted, (which also presented an opportunity to fully update the physician with vitals, pain, nausea/vomiting, etc.). Post-op patients are 'special' in that, a lot of times, we feel d***** if we do and d***** if we don't when it comes to physician notification.

Your best course of action in this case is to confer with your charge nurse, (who probably knows the surgeons' and hospitalists' temperaments inside and out), and who will most likely be very familiar with post-op conditions and the norms from the physician's standpoint.

Another course of action to take would be to let your colleagues know that 'if' someone has to page Dr. Sleeping Beauty, to let you know so that you can give a quick update while he's still on the phone.

Procedures vary by facility, as you are aware. When in Rome, do what the Romans do. But add a few extra rounds and vitals on your patients just to be on the safe side. Vitals that are trending to the extreme in either direction are worthy of a phone call, (but do inform your charge nurse to guidance), and you'd have several 'additional' sets to bring to the physician's attention in justifying the call when he asks why "in the h***" are you calling.

[Okami_CCRN, BSN, RN]

Are you working in the United States?

I work in a critical care unit, our standard is that all patients maintain a MAP of 65 and above, unless their baseline is otherwise. In regards to post operative patients, they tend to be on the lower end of normal in the immediate post op period, but they should return to baseline within a few hours. Open abdominal surgeries are notorious for insensible fluid loss and need large volumes of crystalloid fluid.

I would be concerned that a patient only had 75ml in urinary output over a 12 hour period and nothing was done; no IVF bolus or labs? Also the standard for when to transfuse patients has greatly changed in recent years. I believe we do not transfuse for anyone with a Hgb less than 7.5, unless they are actively hemorrhaging or are symptomatic.

[Rose_Queen, BSN, MSN, RN]

What is the comparison to baseline? In order to be able to leave the recovery area and transfer to the inpatient unit, the patient needs to be considered stable. Many facilities use the Aldrete score to help make that determination.