Pt stable with a very low Bp?

[sugar12]

Hello everyone I put this in the general nursing because I wanted all types of specialities to give an input. Please advise if I should've placed it somewhere else.

Scenario: PT ESRD on dialysis whose BP was running 62/32 done with a manual and bp machine confirmed and verified but pt was stable other than general weakness. Pt was supine so I'm sure if the pt was to ambulate BP would've plummeted and possibly bottom out. No history of cardiac issues that we know of.

Dialysis was done earlier that day. Pt had an allergic reaction to a med intermediate in severity (itching, flushing) 2 hours prior and bp was being monitored. Pt states that they have been running a low BP 80/50 and even lower for some weeks

Anyone ever had a patient like this who wasn't unstable and was AAOx3?

Feel free to ask questions if I didn't paint the picture adequately. Thank you.

[blondy2061h, MSN, RN]

How much fluid was taken off in dialysis? I would say that a patient with that bp is inherently unstable, as you cannot have adequate perfusion with a systolic that low. Also wondering where the bp was taken and where her shunt is? Any bp meds?

[brownbook]

Yes, I recovered a basically healthy 50ish year old for routine hernia surgery. It was reported, "he gets vagal."

For an hour in recovery his BP was in the 60's systolic, his heart rate 30 to low 40's.

He just said, "Oh yeah I do this." Anesthesia was not concerned, "just monitor him, give him some fluids." His wife said..."oh yeah, he does this...he has been worked up by everyone."

He remained alert and oriented. I did not try to sit him up....finally he went back to base line, (I forget the numbers but "normal" numbers,) got dressed and went home. He just said, "I feel a little tired when it happens....Dr'.s said they think it has to do with the blood pooling in my legs."

My heart rate was in the 100's the whole time!

[RedInScrubs, ASN, RN]

I agree, patients with BPs that low aren't stable by definition, because clearly they are at risk for poor perfusion and shock, but if they remain AAOx3, their heart rate isn't going tachy, their output doesn't completely cease, and they generally are asymptomatic, then you don't want to do to much to them for the sake of maintaining numbers, as you could make them MORE unstable with too many interventions.

I had one patient who came back from surgery with a BP that was in the 80s/50s, but he was entirely asymptomatic, save for a lowered urinary output for about 24 hours. He picked up after about 48 hours without any interventions besides a fluid bolus, and even sat up just fine with his blood pressure like that.

Dialysis is a bit different, though, and I'm not sure how stability plays in with that in comparison to surgery patients.

[SierraBravo]

Like Blondy said, how much fluid was taken off during dialysis? Perhaps they took off too much fluid?

62/32 is pretty concerning despite the fact that the patient is A&Ox3. Like someone said, end organ perfusion is probably the biggest concern. Think about what drives blood pressure: systolic BP is driven by cardiac output while diastolic BP is driven by norepinephrine. The pulse pressure is OK. Obviously weakness and fatigue is common after dialysis. Interestingly enough, patients are also hypothermic for at least an hour after dialysis. Sorry, I digress. But in regards to the scenario, I would have been requesting the Rapid Response Team as well as the provider. That BP is just too low for a patient (that I assume to be full code) to be sitting on a med/surg unit.

[firstinfamily, RN]

I wouldn't feel comfortable with a pt's b/p that low, what about the CPP? I don't see how he could have remained very alert!!

I would be playing detective and seeing how much fluid was pulled off, what b/p meds he may have been on. Was any pain medication given at any time etc.? At least the pt and his wife seemed OK with it. What was his heartrate??

[Been there,done that, ASN, RN]

Depends on your definition of stable. If 80/50 IS the baseline and they are alert, oriented, with skin warm and dry... I would not consider them unstable.

With a bp that low a manual or a cuff pressure is unreliable . Only an art-line knows the true story.

[BSNbeauty, BSN, RN]

What was his MAP? I have seen patients with a low BP but MAP was 60 or greater. They were considered stable at the time. In the ICU we were to titrate according to the MAP not the BP

[Larry3373]

62+32+32=126/3=Map of 42. Pt is likely not symptomatic due to chronically low BP. Probably needed a fluid bolus if too much fluid removed with dialysis.

[SierraBravo]

MAP=((2*Diastolic)+Systolic))/3

Therefore the MAP with that BP is 42. That's well below the minimal MAP of 60 to maintain end organ perfusion.

[Here.I.Stand, BSN, RN]

How much was taken off during dialysis? When I worked in an LTACH we had a lot of pts on dialysis, and of them a fair amount were on Midodrine to keep their BPs up.

If he lives at 80/50, he's probably compensated for being chronically hypotensive, so I'm not too impressed that he was asymptomatic at 62/32. But 62/32 is not adequate for perfusion.

[Here.I.Stand, BSN, RN]

Oh, and yes I have had pts who had very low BPs who were still conscious. Actually once I had this little lady started bouncing back and forth between short periods of VT, NSR, SVT, and asystole--she weakly said "I feel fine." (We DID intervene--sent labs, gave her some electrolytes, and had the crash cart in her room, 12-lead etc.) I've had others who have been hypotensive before correcting volume deficits, anemia, after giving lots of pain meds, etc. who had some dizziness but not as many sx as you'd think. Personally, I had an epidural w/ one of my deliveries and my BP dropped to 60/30; I felt a little dizzy but definitely A&O...still bought myself some fluid boluses and a flat HOB though. :)

But in any case, symptomatic or not that is not enough BP.