IV bolus ordered because pt hypertensive

PacoUSA, BSN, RN · Mar 19, 2015

Too complicated to explain? Does that fool of a doctor think a nurse cant understand it or is it more likely that he couldn't understand it himself to explain it?

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Are Enn · Mar 19, 2015

this is one of the few doctors i know who is extremely nice and easy to talk to. I have had no problems in the past asking him several medical related questions. he, for the most part, has been able to answer all my questions to my liking. he completely blew me off with this question, however.

it is driving my crazy because I have absolutely no idea why he did what he did and I would love to know.

PacoUSA, BSN, RN · Mar 19, 2015

I'd like to know myself as I would not think to give a bolus to a hypertensive patient.

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icumufasa · Mar 19, 2015

Unless he was trying to thirdspace the fluids from the vessels. Did he order diuretics too?

SubSippi · Mar 19, 2015

We can't answer the question until we know what kind of fluids were given.

Are Enn · Mar 19, 2015

NS 500 cc bolus run at 999cc/hr. No laxis. Only meds administered were IV lopressor and hydralazine.

Momma1RN, MSN, RN, APRN · Mar 19, 2015

My first thought would be related to third spacing and attempting to prevent shock to support circulation. I'm curious though, too.

icuRNmaggie, BSN, RN · Mar 19, 2015

There isn't enough information in the original post to answer the question.

Did the blood cultures show gram negative rods, which cause a systemic inflammatory response, or gram positive cocci?

Were any other sources of infection identified?

Was the pt oliguric? If so a fluid challenge is appropriate.

Was he febrile and tachycardic as in the hyperdynamic warm phase of sepsis or going into a rapid afib or maybe just very dehydrated?

Was he tachypneic, and what did the ABG show?

Did the lactate level indicate anaerobic metabolism?

Did the labs indicate acute renal failure or hepatorenal failure?

Were there any other signs of poor perfusion such as a change in mentation, or an inability to obtain an Sp02 waveform ?

Are Enn · Mar 19, 2015

prelim BC = gram positive cocci

pt had foley - by the looks of it, appropriate output was in the bag; appeared to be clear, yellow urine

afrebrile; pulse ox was fine

no EKG ordered, so unsure of rhythm, but I was told it was regular based off coworkers assessment

rest of labs I am unsure of

the physician who took a look at the pt and ordered the bolus was not the attending. it was in the middle of the night and the attending ordered the hospitalist to take a look at the pt. besides the basic information, the only other information relayed to the hospitalist was the positive BC.

SubSippi · Mar 20, 2015

Since he mumbled something about bacteremia, he might have suspected the patient was going septic, and one of the ways sepsis is managed is with fluids.

As far as the fluid bolus being given despite hypertension, the hydralazine and lopressor will bring the BP down quickly, and 500cc really isn't that much anyway.

Also, the fact that the patient is both hypertensive and tachycardic makes me think that the HTN could have been the vessels clamping down due to a low circulating blood volume. If that were the case, NS would help with that, too.

This is just a guess, though, and from the brain of a CVICU nurse, not a MICU nurse. So I haven't dealt much with treating sepsis.

Lev, MSN, RN, NP · Mar 20, 2015

a coworker had a pt who had BP of 220s/120s and pulse of 120-130ish. prelim blood cultures also recently came back positive. when I asked the doctor, who was at the beside, the reasoning behind the bolus, despite the high BP, he mumbled something about bactermia and said, "it's too complicated to explain." IV Lopressor and hydralazine was also administered.
anybody have an insight into this?

I think the elevated pulse given the bacteremia is a sign of early sepsis. The elevated BP could also be a sign of early sepsis. When your BPs that high 500cc isn't going to matter matter so much. If the patient started third-spacing and became a little hypovolemic which could be partly why the HR is elevated they'll need the fluid. The BP could be higher than usual from vasoconstriction in early sepsis.