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.
Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.
I've personally been A&O with a BP of "56 over I'm not sure.... ????" (taken in my doctor's office when I was being checked out for syncope). Not sure how low it actually was to cause the syncope.
When my weight is down, I routinely have a SBP in the 70s or 80s, with occasional bouts of orthostatic hypotension that require me to intervene to prevent syncope.
Even now, morbidly obese, I have episodes when my SBP is only in the 90s.
Typically when I think of "end organ perfusion", I'm thinking primarily about the brain, heart, and kidneys. Since this patient has ESRD, I'm not going to be too worried about putting them into ARF. Their kidneys are already shot, so I'm not concerned with that. ;-)
One of the first signs of poor brain perfusion is change in LOC. If the patient is at baseline mentation, I'm not too worried about that.
If they're not tachycardic or tachypneic, then I'm not too worried about heart/lung perfusion.
It's not unusual for patients to feel fatigued/wiped out on dialysis days.
In the absence of any s/s of distress, I'd notify the physician of the low BP, but I wouldn't freak out. I'd let it ride and keep monitoring for any changes in condition.
Typically when I think of "end organ perfusion", I'm thinking primarily about the brain, heart, and kidneys. Since this patient has ESRD, I'm not going to be too worried about putting them into ARF. Their kidneys are already shot, so I'm not concerned with that. ;-)
But we certainly don't want to compromise what kidney function they have left. Just because the patient is on dialysis doesn't mean they have no kidney function.
This calculation is just an estimate. I would like to see the art line reading of the MAP
Well, unless the patient goes to an ICU or a step down you're unlikely to see him/her have an art line. So on a med/surg unit the manual calculation is about all you're going to get. And that's not an estimate, it's the value you get from manually calculating the MAP.
And that's not an estimate, it's the value you get from manually calculating the MAP.
The MAP equation gives you an approximation. MAP is an average of the arterial pressure during cardiac cycle. Very technically speaking is the area underneath the BP curve on a measurement using an art line. While the equation gives you a good idea of the MAP, it is not exact.
Wow! So many insightful responses! Thanks everyone for your wonderful input!!
To answer everyone's questions: (let me know if I missed any)
Yes the patient was on a med/surg floor so I'm not able to get a map other than doing the calculations manually or from the monitor roughly 42. Pt was an admit around 9pm coming from dialysis. Pt had a dialysis catheter to right chest. Bp was being taken on born right and left arm. Approximately 1 L had been removed I believe. Pt is on miodrine. Pt reported bp running low for 1 month now. Baseline vitals when we tracked it back to the ER was 80/62 pulse around 77.
I think this case had so many factors and I plan to read some more as I am still new and have so much to learn.
First pt vitals after dialysis 1 hr later was about 101/68 even higher than the ER baseline. After the allergic reaction to dilaudid. Bp dropped to about 90/50. Gave pt Benadryl which dropped BP some more about 85/70.
Interventions: MD was called gave a bolus 500 ml of fluids. 12 lead EKG performed. No abnormalities Sinus rhythm. Pt was also on the basic tele monitor because we are med/surg unit but we also have tele. Bp was being monitored frequently. Strange thing after giving the bolus BP dropped and started running 60's systolic and 30/40's diastolic. Lowest was verified manually 62/32. Crash cart was in the room. Charge nurse notified. Pt still AA0x2. Non symptomatic. No tachycardia
Rapid response was then called: this is night shift so the ICU doc showed up and said because pt had been having this problem for some time it's not a true rapid. Pt asymptomatic. He said he has seen this with dialysis pt. Gave no orders and was back on his way. We watched the pt frequently all night
Next night: during day shift heard doc ordered albumin raised BP back up to 80/50 fluids were then d/c by doc. Last set of vs on day shift was 67/42. We called doc got fluids back on board. Pt maintained throughout night at 85/63 close to her baseline. Pulse was between 92-106 when awake and 87 when pt was resting. Pt ambulated fine and we of course continued to monitor.
1L is not much to take off during dialysis- especially then going and replacing 500ml. I've had patients have 3 and 4 liters taken off at a time. That's bizarre to me that the rapid team didn't mind keeping an ESRD patient with a bp of 62/32 on med surg. That would buy any patient I can think off (except comfort only) a pressor. My thoughts are that this man's prognosis is quite poor.
1L is not much to take off during dialysis- especially then going and replacing 500ml. I've had patients have 3 and 4 liters taken off at a time. That's bizarre to me that the rapid team didn't mind keeping an ESRD patient with a bp of 62/32 on med surg. That would buy any patient I can think off (except comfort only) a pressor. My thoughts are that this man's prognosis is quite poor.
Yeah 1 L is not a lot at all. It is strange but I'm new to the hospital and getting use to their policies. Our med/surg floor has a step down side but that BP was very low to be on the unit I agree. Pt is fairly young and I hope things turn around.
But we certainly don't want to compromise what kidney function they have left. Just because the patient is on dialysis doesn't mean they have no kidney function.
The person with ESRD has 10-15% of their kidney function at most, otherwise they wouldn't be on dialysis, and the damage is irreversible. Allowing asymptomatic hypotension is not going to put them into ARF. Most likely this was dialysis induced hypotension which is poorly understood. I just want people to think about it when they throw around terms like "end organ perfusion". Since the kidneys are already irreversibly damaged beyond the ability to function, we're primarily concerned with the heart and brain.
The person with ESRD has 10-15% of their kidney function at most, otherwise they wouldn't be on dialysis, and the damage is irreversible. Allowing asymptomatic hypotension is not going to put them into ARF. Most likely this was dialysis induced hypotension which is poorly understood. I just want people to think about it when they throw around terms like "end organ perfusion". Since the kidneys are already irreversibly damaged beyond the ability to function, we're primarily concerned with the heart and brain.
The National Kidney Foundation recommends dialysis for patients that have 15% or less of their kidney function left. Clearly the team isn't acutely worried about ARF but, again, you don't want to compromise what little kidney function they have left. As I'm sure you're aware, the kidneys are extremely susceptible to poor perfusion. I have no idea what you mean by throwing around the term "end organ perfusion". Just because the kidneys are damaged doesn't mean you disregard them and figure, "oh well, they're pretty much shot anyways so who cares if we cause them to shut down completely". Take a minute and think about the physiology of the kidneys... Some function is always better than no function. Period. Yes, of course we're concerned with the heart and brain, in fact we're concerned with all of the organs, thus the term "end organ perfusion" which you feel I am so capriciously "throwing around". Additionally, 62/32 was below the patient's baseline of 80/50. It doesn't matter if the patient was asymptomatic or not, the MAP was guaranteed below the minimum of 60 to ensure "end organ perfusion".
brillohead, ADN, RN
1,781 Posts
I've personally been A&O with a BP of "56 over I'm not sure.... ????" (taken in my doctor's office when I was being checked out for syncope). Not sure how low it actually was to cause the syncope.
When my weight is down, I routinely have a SBP in the 70s or 80s, with occasional bouts of orthostatic hypotension that require me to intervene to prevent syncope.
Even now, morbidly obese, I have episodes when my SBP is only in the 90s.
Some of us just run low....