Last night I saw an order I have never seen before and I was hoping someone (Pawpaw John?!), could enlighten me. s/p code pt was very hypotensive - on Levophed @ 80 mcg/min, Dopamine @ 20 mcg/kg/min, Epinephrine @ 1 mcg/min and still kept dropping to SBP 40-50. Doc wrote for NaHCO3 1 amp IVP if SBP drops below 60. I asked and someone said that NaHCO3 can support the pressors by "recruiting more catecholamines"? Pt was also on a HCO3 gtt (3 amps) @ 200 ml/hr. Code ABG showed pH = 6.89, CO2 = 8, pCO2 = 48 and lactate = 42! We got the ABG corrected pretty quickly, but surely those numbers are incompatible with life...he was (obviously) non-responsive and showing strong decorticate posturing! Family wanted everything done so when I left he was on CRRT!
Dinith88, I am not trying to argue, honestly. I am telling you what i have seen on several occassions. I deal with sepsis and acidosis often. I HAVE been maxed out on several pressors with severely acidotic patients with minimal response, and seen a response after bicarb is pushed-- plain and simple. There have been times i suspected acidosis just because the pressors weren't working, and have been proven correct. I am not saying the bicarb saved them. Usually when they are that far gone they don't make it anyway. And the fact that bicarb turns into Co2 is not good either. It is usally a transient increase in bp, as i mentioned. Also i have never heard of writing an order for bicarb according to bp iether. Bicarb is given for LACTIC ACIDOSIS, which can worsen hypotension and make the pressors not work well. I don't work with cardiac patients that much anymore. There are more studies and articles out there, i'm sure that could lean toward whatever point one wanted to make. However, I know what I see.
How does anyone have time to be on the net at work?? I can never figure that one out.
We're not supposed to be
And as far as your seeing a transient bump in blood pressure when administering bicarb bolus to really sick/acidotic patients, i'm not arguing with you about that...you're not wrong. In fact, the study i linked makes mention that this is not an uncommon observation. In their opinion though, it's a matter of temporarily increasing 'preload'...or something to that effect...which basically translates into a bp increase from the fluid bolus (bicab amp) rather than due to some bicarb med effect.
Alright Dinith, you should be a lawyer. These are people I'm already increasing preload with by wide open fluids with pressure bags (with no results). But we could go back and forth forever on it, so I'll refrain from furhter discussion:)
Last night I saw an order I have never seen before and I was hoping someone (Pawpaw John?!), could enlighten me. s/p code pt was very hypotensive - on Levophed @ 80 mcg/min, Dopamine @ 20 mcg/kg/min, Epinephrine @ 1 mcg/min and still kept dropping to SBP 40-50. Doc wrote for NaHCO3 1 amp IVP if SBP drops below 60. I asked and someone said that NaHCO3 can support the pressors by "recruiting more catecholamines"? Pt was also on a HCO3 gtt (3 amps) @ 200 ml/hr. Code ABG showed pH = 6.89, CO2 = 8, pCO2 = 48 and lactate = 42! We got the ABG corrected pretty quickly, but surely those numbers are incompatible with life...he was (obviously) non-responsive and showing strong decorticate posturing! Family wanted everything done so when I left he was on CRRT!
Thanks in advance for your input.
Terri Finney
in sunny NC!
:monkeydance: The patient is dead no matter whay you do. Everything appears to be futile.
I've done it and it works, not on a long term basis but I had a young patient who we were waiting for father to get in to say goodbye before letting her go and we were maxed on pressors with a continuous bicarb gtt running and I'd push an amp of bicarb her pressure would go up to 110 or so and hold for a short while her pressure would start dropping when it got too low I'd push another amp and she would respond and come up, vicious cycle, thankfully her father was in before too long and we stopped pushing amps and she was soon gone.
dorimar, BSN, RN
635 Posts
Dinith88, I am not trying to argue, honestly. I am telling you what i have seen on several occassions. I deal with sepsis and acidosis often. I HAVE been maxed out on several pressors with severely acidotic patients with minimal response, and seen a response after bicarb is pushed-- plain and simple. There have been times i suspected acidosis just because the pressors weren't working, and have been proven correct. I am not saying the bicarb saved them. Usually when they are that far gone they don't make it anyway. And the fact that bicarb turns into Co2 is not good either. It is usally a transient increase in bp, as i mentioned. Also i have never heard of writing an order for bicarb according to bp iether. Bicarb is given for LACTIC ACIDOSIS, which can worsen hypotension and make the pressors not work well. I don't work with cardiac patients that much anymore. There are more studies and articles out there, i'm sure that could lean toward whatever point one wanted to make. However, I know what I see.