Hypotension and when to treat

[HappyNurse2005, RN]

Had a middle aged pt the other day. IN for chest pain-has a prior cardiac history including pacer for tachy/brady syndrome, mi, chf, htn, extreme obesity, etc.

Her BP was low. mid 80s, mid 70s, occ mid 60s. primary MD thought it was just from her meds, wasn't concerned. Said as long as she was oriented and "mentating" ok, then it was okay. thought maybe it wasn't accurate b/c she has such large arms. I did pressures in her upper arm/lower arm/calf-all the same results.

She was mentally okay. Said she felt light headed. I suggested a fluid bolus. He said not until he knew what her EF was (she'd had a stress test and we were waiting on the results). When we hear her EF was 40%, he thought that was too low.

Cardiologist thought too much fluid, such as in a bolus, would put her into CHF. He ordered fluids at 75cc/hr.

Talked to primary MD later, he thought maybe it was urosepsis. We straight cathed her and got some really smelly cloudy urine. FINALLY convinced him to give her a bolus of NS.

Of course, after the 250cc bolus, her systolic came up to 95 and she felt better. She did have some stuff in her UA, so we started abx, but culture was't back yet so i don't know exactly what was in it.

whole point of this story-for you/your docs/etc when does hypotension become a treatable issue?

[Super_RN, BSN, RN]

All depends on the patient.

:) Super

[leslie :-D]

i would think when they're symptomatic is when treatment would be pursued. as long as pt. is baseline ms and is perfusing adequately, w/o complaint, then they are good to go.............me thinks.:balloons:

leslie

[LCRN]

At my facility we usually use the mean arterial pressure as a guidline...if it's under ~55-60 we usually start treating with fluid/expanders/ prbc if appropriate or vasopressors. We do this even when the patient is mentating because although the brain is being perfused adequately are other major organs...

LCRN

[HappyNurse2005, RN]

Maybe I've not been a nurse long enough to know better, lol, but a BP of 66 systolic, even on a person w/ normal mental status just doesn't sit well with me

I guess when I go back to work tomorrow (this happened yesterday and I was off today) I'll find out what happened.

[leslie :-D]

Maybe I've not been a nurse long enough to know better, lol, but a BP of 66 systolic, even on a person w/ normal mental status just doesn't sit well with me

I guess when I go back to work tomorrow (this happened yesterday and I was off today) I'll find out what happened.

it doesn't sit well w/me either happynurse.

but this is the response i got when i approached my medical director about low systolics. no parameters whatsoever. can get very scary at times.

leslie

[kat911]

It does depend on the person, what type of B/P do they usually run. What else is going on, tachycardia associated witht the low pressure? What is urine output doing. If uop is low and hr elevated then patient is trying to compensate and needs something done. Small fluid boluses will not usually throw someone into CHF unless they are already wet. Use your judgement and determine how comfortable you are explaining to a jury why you sat on the low pressure for so long. The explaination from your doc should make you feel comfortable, if your not get another experienced nurse to assess the situation.

[Tweety, BSN, RN]

i would think when they're symptomatic is when treatment would be pursued. as long as pt. is baseline ms and is perfusing adequately, w/o complaint, then they are good to go.............me thinks.:balloons:

leslie

I agree.

I think lightedheadedness is symptomatic and perhaps should have some adjustments in medication if possible.

Sometimes you have to weigh the benefits of the meds causing the hypotension with the side effects though.

[Altra, BSN, RN]

Those pressures seem lower than I would be comfortable with.

Generally speaking, in our ER, fluids would be running wide open for systolic BP

If SBP continued to drop through the 80s, I'd be looking for a doc to put in a central line.

[snowfreeze, BSN, RN]

Mean arterial pressure is the usual standard, if below 60 you are not perfusing some major organs. Urine output drops, mental status might decrease also depending on the patient. Look at those indicators to determine if they are not tolerating the low pressure and mention that to the doc...might just get their attention.

[zacarias, ASN, RN]

Happy, you did excellent. A fluid bolus of 250cc is not that much and it is highly likely that this is patient was a little dry anyway. An SBP of 66 is too low for me too.