I feel like it’s my fault

[PGHNurse412, ASN]

I need reassurance I didn’t cause this patient to be in acute renal failure. Patient was admitted with pancreatitis. CT showed it was extensive. There was a large gallstone causing it. On admission lactate was 3.3 (0.4-2.0), lipase was >3000 (73-393), WBC 15.9, BUN/Cr WNL. MD started LR at 250 to help bring down lactate. When I started my shift I noticed the fluids were high. The patients BP was elevated 190/144. I wasn’t sure if there was concern for fluid overload or why the rate was high. So I paged the MD covering. Asked about decreasing fluids and they agreed and decreased it from 250 to 100. Well that morning the patients eGFR went from 67 to 20, lactate went to 5.7, BUN 34, cr 3.31. She needed stat HD and was transferred to ICU.  I feel like because I decrease the fluids all these problems happened. Is it possible to go into acute kidney failure that quickly? 

[Nurse SMS, MSN, RN]

Is it possible? Yes. 

Was it because of the fluids? No.

Plus, you didn't do this. You followed a proper protocol. You had a physician's order. 

Time to move on friend. This wasn't on you. If their BP was that high good chance this was already in the works.

[Been there,done that, ASN, RN]

There are many causes of AKI. Infection is one of them. Sounds like the patient was unstable from the get go. You reported a finding to the physician, and received further orders. It's that simple. Any patient's condition can change drastically throughout your shift.

Stop overanalyzing  any actions you take. You are making yourself feel responsible for the normal course of the patient's condition. I hope you have a colleague/ mentor  you can discuss this with.

[Guest219794]

First off, you did everything right.  You questioned a questionable order, and it was changed.  That is what heads up nurses do.

Second- Sick patients often get sicker.

Last, and not by a long shot, least.  Whatever doctor was managing a hypertensive patient with lactic acidosis with 6 liters a day of LR was probably not an expert in managing this type of patient.  Without knowing all the details, this sounds flat out bad, or lazy medical management.

Luckily this patient had a good nurse who used critical thinking and advocated for the patient.

 

[PGHNurse412, ASN]

13 hours ago, Been there,done that said:

There are many causes of AKI. Infection is one of them. Sounds like the patient was unstable from the get go. You reported a finding to the physician, and received further orders. It's that simple. Any patient's condition can change drastically throughout your shift.

Stop overanalyzing  any actions you take. You are making yourself feel responsible for the normal course of the patient's condition. I hope you have a colleague/ mentor  you can discuss this with.

That was a good way of explaining it! Yes I did but she didn’t text me back until the next day so my mind started to race. 

[PGHNurse412, ASN]

Update- patient was transferred to different hospital due to severe biliary pancreatitis, metabolic acidosis and respiratory distress. She was labeled as “ recovered covid” during her time here. I asked PCP even though she has been quarantined for 10 days, when do we re test? PCP said as long as no fever we are not retesting. Due to respiratory distress, they had to intubate her. She tested positive for covid 12 days post infection. I covered on covid units and before patients could leave for SNF they had to test negative 2x. The patients on the covid floor would be positive, on the unit for 8-10 days then test negative. I read the note and they said “ we are still going to keep this patient labeled recovered as she has no fever”.  I don’t understand (and I’m sure no one does) how on the covid floor they can test negative but this patient tested positive and is labeled “ recovered”. She is clearly very sick. Also I had to wear PAPR on covid unit, she was on the floor and we only wear masks but my unit manager said they are not going to test me or quarantine me because I didn’t give her any aerosolizing treatments. 

[CDoogle6, BSN]

Not on you. Period! You did the right thing, and outcome could have been worse.

[turtlesRcool]

On 11/3/2020 at 4:28 AM, PGHNurse412 said:

She tested positive for covid 12 days post infection. I covered on covid units and before patients could leave for SNF they had to test negative 2x. The patients on the covid floor would be positive, on the unit for 8-10 days then test negative. I read the note and they said “ we are still going to keep this patient labeled recovered as she has no fever”.  I don’t understand (and I’m sure no one does) how on the covid floor they can test negative but this patient tested positive and is labeled “ recovered”. She is clearly very sick. Also I had to wear PAPR on covid unit, she was on the floor and we only wear masks but my unit manager said they are not going to test me or quarantine me because I didn’t give her any aerosolizing treatments. 

What kinds of COVID tests are we talking about here?  The PCR test is incredibly sensitive and sometimes detects virus fragments weeks or months after a patient is recovered. These patients aren't symptomatic and they aren't infectious, but they will continue to test positive.

Rapid antigen tests are less sensitive. They will usually (though not always) detect a current infection, and usually won't continue to be positive after recovery the way the PCR tests do.  Those might be the tests being used for discharge purposes.  

Many COIVID units have PUI or PUM patients, who have never tested positive, but because of increased suspicion about their status must test negative twice before being discharged to a facility.  It's possible the double negative testing required on the COVID unit where you covered were for PUI/PUM patients, not those previously known to have active COVID.  I also suspect that any known COVID patients who require negative tests prior to discharge are getting the antigen test, not PCR.

Now, back to your original question.  Yes, it is possible to go into ARF that quickly with that kind of blockage.  Lots of people think of of COVID as a respiratory disease, but it's also an inflammatory disease and a clotting disease.  People have absolutely needed hemodialysis as a direct result of COVID and have even had strokes.  Last Spring when we went through the surge at our hospital, we still didn't have good, rapid testing.  We nurses got good at predicting which patients would come back positive based on their D-dimer levels.

I think it's reasonable you wouldn't feel comfortable with fever alone as the determining factor if a patient has active, transmissible disease. I have no idea if your patient was still infectious when you took care of her, though it's possible she was past the active phase but still dealing with the sequelae.  For your own peace of mind, get yourself tested.  Most urgent care places and clinics have COVID testing available, and generally with no out of pocket costs. You don't have to wait for your employer to do it.

 

[LibraNurse27, BSN, RN]

I think this patient already had a lot going on, and if she had active covid19 or had recovered from covid but her body was affected by the systemic inflammation that covid causes, I don't think any specific rate of fluids would cure her or prevent what happened. The renal failure could have been related to the pancreatitis, I've seen that happen a lot and didn't understand the pathophysiology, so here is what I found in a quick search of the medical journals:

"The pathophysiology of AKI in acute pancreatitis is not well studied. However, a key pathophysiologic process involves premature activation of pancreatic enzymes within the acinar cells. This leads to autodigestion of the pancreas and surrounding tissues, triggering a cascade of events that contribute to AKI (Figure 1) (10). Release into the systemic circulation of activated enzymes and proteases may cause endothelial damage leading to extravasation of fluids from the vascular space, hypovolemia, hypotension, increased abdominal pressure, intense kidney vasoconstriction, hypercoagulability, and fibrin deposition in the glomeruli. Moreover, acinar injury from autodigestion stimulates cytokine release and production of oxygen free radicals"

So I guess even the experts aren't sure why it happens, but they are sure it does happen. Don't blame yourself at all, and go get your covid test for peace of mind ?