orthostatic hypotension

[chadash]

Just wondering:

Had a patient who just had spinal surgery, and her BP drops dramatically when we stand her. Nurses say meds are not the issue, they just have ruled out everything.

Made a silly suggestion: compression stockings.

Could venous pooling in her lower extremities be an issue here? I once cared for a high paraplegic patient, and it was essential for us to put compression stockings on her before putting her in a standing frame...something with the sympathetic nervous system. The patient I am asking about is not paraplegic, but I wondered if the trauma of surgery could have a temporary impact this way. So, could it be a neurogenic vascular thingey?

Thanks!

[TazziRN, RN]

It could be a vasovagal thing, I 've seen it with back surgery pts before and have even seen it happen the one time I was stupid enough to do wound care on a back wound while the pt was upright. He nearly passed out on me, and it wasn't pain related.

[nightmare, RN]

Have you tried sitting her up for a minute then standing her?

[nrsang97, BSN, RN]

I always tell my patients to change position slowly. This helps a ton. Also why dosen't she have teds on? Everyone after back surgery has them on when they come back to the floor/ICU.

[HonestRN]

So, could it be a neurogenic vascular thingey?

Thanks!

Just how dramatically does it drop? Could it be neurocardiogenic syncope? Neurocardiogenic syncope is an autonomic condition originating in the nerves of the heart where upon standing the blood vessels expand, blood pools in the lower extremities, blood pressure drops dramatically and heart rate decreases leading to syncope. Just my thoughts

[chadash]

Yeah, it is pretty significant. Her BP will be pretty normal or even a bit high...we have her sit awhile, but when she stands it migh be as low as 60/40.

She is only a few days postop, but whatever the cause, if there is any problem with the blood rushing to the lower extremities, do compression hose have any impact in your experience? the goal, of course, is to get her moving until this resolves...

[HonestRN]

That kind BP drop sounds awfully like neurocardiogenic syncope. A tilt table test would confirm the diagnosis. Might want to suggest it to the Dr. or her nurse. What is her heart rate doing while the BP is dropping?

I would think compression hose would help but even more would be to dangle at the side of the bed before standing the patient up then stand the patient very slowly. Make sure she is well hydrated and sometimes florinef is ordered to maintain adequate BP. I wouldn't let her get out of bed without assistance or stand by. I would like to hear what is finally diagnosed as the issue here.

[lorilou22RN]

It is a Neurogenic issue. I started my career in rehab, and dealt with spinal injuries, we used to have TEDs, AND ace wraps on legs during all activity (especially while the patient was somewhat fresh in getting up). I truly do not remember the pathophys on it, but it is an autonomic dysfunction due to the injury/surgery. It will eventually resolve over time, but the compression to the lower extremities DOES help in returning blood flow to the heart for recirc, thus improving BP during movement.

[chadash]

Thank you all so much, this is so helpful!

[Dinith88]

Thank you all so much, this is so helpful!

Hey Chadash,

Your idea is a good one...but teds wont help a patient with such severe orthostatic bp. May help with venous congestion and edema of the lower extremeties but wont prevent big drops in blood pressure.

Sounds like you're confusing orthostatic syncope with the condition fighter-pilots experience at "high g's". When turning in jets (etc), the intensified gravity('g's') causes the blood to rush to the lower extremeties and the pilot blacks out. They wear special 'g-suits' that squeeze the pilots legs and abdomen to keep blood in the pilots brain to help prevent black outs.

So...i see where you are coming from...but teds and orthostatic bps versus g-suits and fighter-pilots are not the same. Very different animals.

Are you a closet aviation enthusiast? :wink2:

[chadash]

Hey! you read my mind...I was actually thinking, wouldn't it be nice if we could put compression trousers of some sort on them, that squeezed them intermittently...

Is that anything like a G suit? Without the intermittent squeezing?

Yeah, think I have this all confused.

Is this just something that improves with time for the patient? Would like to get her walking.

Aviation does sound like a great thing (watch all history channel shows on the subject) but driving a car is enough of a challenge for me.

[Altra, BSN, RN]

Has MD considered a blood patch?