IV bolus ordered because pt hypertensive

[Are Enn]

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?

[SubSippi]

Same thought that I had. CVICU nurse here too, and unless its a cardiac patient, in any other kind of shock, dont you give fluids pretty immediately?

To the best of my knowledge that's how it happens. I'm just sitting here thinking, how do people get anything accomplished without a PA line?!

[Anna Flaxis, BSN, RN]

Sounds like maybe a patient with a cardiac history and sepsis. Without knowing more, it's really hard to say with certainty what was going on, but this is my best guess.

[psu_213, BSN, RN]

I am on a general medical floor, so things like lactic acd and ABGs are rarely ever drawn, unless they are initially drawn in the ER before admission. even if a lactic acid was drawn, I doubt the coworker had that value on the tip of his brain and was able to relay it to the physician.

If sepsis is suspected, lactate levels should be drawn early. Serial measurements help to indicate a pt's response to tx. I am certainly not trying to criticize the OP or the nurse who was caring for the patient, but I would be a good idea to have the lactate levels (and their trend) handy when caring for a septic patient.

[MunoRN, RN]

I think the reason the Doc couldn't really explain is that he didn't really know why he was ordering the bolus, it sounds as though he was misdirected by the positive prelim BC. While we do use fluids to treat septic shock, bacteremia itself is not septic shock, but it sounds as though the Doc is skipping the step of assessing for signs of shock and incorrectly treating the supposed bacteremia (it's important to keep in mind that blood cultures, particularly if only one BC is drawn can often be falsely positive).

What you'd be looking for is signs of poor perfusion, usually the most obvious being hypotension which clearly isn't this patient's problem. The tachycardia along with the severe hypertension might represent an unusual form of hypoperfusion; hypovolemic anemia or dilutional anemia. In this case the body, particularly the kidneys, will continue to drive up blood pressure despite more than adequate volume and BP due to anemia. In that case the worst thing to do would be to give extra fluids, what the patient would actually need would be lasix or blood.

[Anna Flaxis, BSN, RN]

The more I think about it, the more I am convinced that the patient might not have been septic at all, and that there was something else going on. As Muno pointed out, false positives are not uncommon, which is why we typically draw two BCs from two separate sites.

[superT RN]

He's septic people!

He needs lots of fluid!

[Anna Flaxis, BSN, RN]

We don't know that he's septic. A single positive preliminary blood culture does not confirm the diagnosis. There isn't enough information to come to the conclusion that he has sepsis.