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.

[kool-aide, RN]

The the pts norm was 80s and say maybe 2L taken off in HD for ESRD, this could be normal for the pt. Maybe could have asked to draw a lactate?

[sugar12]

The the pts norm was 80s and say maybe 2L taken off in HD for ESRD, this could be normal for the pt. Maybe could have asked to draw a lactate?

Possibility exists about 1 L was taken off in HD but patient is still at the hospital I believe so I'm sure they are doing a full work up. Lactate is definitely a lab that should've been drawn

[Lev, MSN, RN, NP]

A blood culture from the dialysis catheter site would be a good idea.

[NurseRies, BSN, RN]

I am an acute care nephrology nurse. I see chronically hypotension patients that are on dialysis quite often. I get concerned depending on the situation. But I've had chronic ESRD patients who are joking around, watching the price is right, talking on their cell phone, all with a BP of 70/35. Of course at first, I freak out. The best thing to do is to call that patient's nephrologist and ask about his history. The nephrologist may say something like, "oh yes, mr so and so is always hypotensive. We have done a full work up several times. Keep systolic above 75, as long as asymptotic, and give albumin if less then that."

In the acute care setting, I would def be concerned with 60 systolic. I would probably bolus with 250cc NS and re-assess. Give another 250cc, if patient's BP responds, then they are indeed depleted of volume at the vascular level. If there is no change in BP after 500cc NS bolus, they often try albumin or midodrine for dialysis patients. But I would want systolic above 80 at least! Even if the patient is not at their "dry weight" (the prescribed weight the dialysis patients try to achieve when they have very little extra volume on board)....

I did have one lady I took care of for several years in the outpatient setting who had a BP always in the 70's systolic and we removed 4L of fluid every single session. That took some getting used to. But she had been on Hd for 13 years and that is just how it was. If we didn't remove the fluid, she would be in the hospital with fluid overload, and she never passed out on me or had any trouble at all. She can't be on pressors the rest of her life. Our doc at the time said that years of fluid overload had stretched out her heart so badly, that she could not maintain an adequate blood pressure. He said really nothing could be done and it was a wonder she was still around. She is still alive to this day. Think about extreme fluid shifts with dialysis patients. They are 6L up every other day, and then may get sucked so dry that they crash, then do it all over again. These people's hearts are in terrible shape. Most ESRD patients die of cardiac complications. Some patients are very compliant and only gain 1-2L between sessions, but many are chronically volume up.

The preservation of residual renal function is definitely important. If the patient pees at all, then they have some residual function. Another situation where this comes up, is when you send a patient for a contrast procedure, do you give them dialysis immediately after? (To preserve renal function). Some nephrologists routinely schedule STAT dialysis after contrast procedure, but others feel that it can wait until the morning and aren't concerned. But other organs are at risk with such a low BP, as many have said.

Systolic above 80 would help me sleep at night.

day.

[nurse4ever08]

It could be fluid shifting. Also the kidneys have a lot to do with blood pressure so may be time for renal to do a good work up.

[sugar12]

@NurseRies Thank you for writing such a detailed post. It definitely helped me to connect the dots appropriately and put things into more perspective.

Thanks again everyone I wasn't expecting so many replies and everyone brought something new into perspective!

[jj224]

Well, unstable really depends on the patient's baseline. Always treat the patient first, not the numbers. Hypotension and fatigue are generally common after dialysis. Like everyone else stated, how much fluid was taken off? Were the pressures low during dialysis? What are pressures normally like during dialysis. What setting is the patient in - med surf? ICU? What co morbidities are there that could contribute? Either way, notify the physician and go from there.

[CardiacKittyRN]

It sounds to me like he's dry.. Too much off in dialysis. I would think he would need some fluids.. You said he had to no cardiac issue, but we generally see some low BP's with CHF.. However I would be really concerned with a BP that low because he could turn bad real quick! Just curious what was his MAP? It should be greater than 60 or organs are probably not getting adequate perfusion. Also, how was urine output? I'm kinda surprised the doctors weren't more concerned as well..