OK so I'm not a new nurse but I'm new at a certain hospital and maybe need a brush up on somethings or just would like to see what y'all think.
Last night I took care of a cirrhotic pt who came to us because apparently after they took 8 L off her abdomen last week, she started to "leak" from her umbilicus. Her WBC was elevated and the MD wrote "concerning for SBP." When I assessed her, she had no pain and palpating her abdomen she was soft and non-tender. Whenever I have taken care of SBP patients in the past, they've had lots of pain! Isn't that normally true?
She had a low BP and apparently that is normal for her but 80s SBP and I get worried. I waited to see if she would improve and she didn't and so I contacted hospitalist who ordered lactic acid level which came back elevated (2.6). They later ordered a dose of albumin and a 500ml bolus. Her BP never got better and actually decreased to mid 70s SBP. She looked OK, no s/s but how can I just leave her BP that way? Kept bugging the hospitalist and then she ordered ANOTHER lactic acid and bolus of NS.
I've seen liver pts before with low BPs but at what point can I say, oh I can accept a lower MAP because she's a liver patient....? Don't they still "deserve" a MAP of 60 to 65?
The charge had the look that I wasn't worried enough about the pressure (uh...I was bothering the hospitalist multiple times) and the dayshift nurse who knew the patient and thought I shouldn't have been worried at all.
Also, why did the MD order ANOTHER lactic acid so fast? I always thought lactic acid levels were to assess for sepsis, but it almost was as if the MD was using the level to check for improvement in fluid status/hypovolemia?? Or what am I missing?
I know there are a few things mentioned in this post. Thanks to all who respond!
A little confused about why you say high doses of Albumin are never ordered because it will kill the kidneys. I find quite the opposite to be true as a liver nurse. We give large doses of Albumin as part of our SBP protocol on day 1 & 3 for renal protection (1.5g/kg on day 1, 1g/kg on day 3), as well as to aide in pushing fluid where it belongs. NS boluses for hypotension in liver patients are ill advised because they'll just go right to the belly. Hoping you can explain what you mean.
It may be because albumin/proteins are larger molecules, like glucose. Hard on the kidneys. Some dialysis/renal patients have protein restricted diets.
As a liver nurse, you give the albumin for renal protection to increase vascular volume and thereby improve renal perfusion
Lactic acid levels aren't always very accurate in liver patients since they don't clear it as well. A lactic acid of 2.6 is not very concerning. As for the blood pressure. You do need to have the 'ideal' of a 65 map in mind (because it is supposedly, based on minimal research, the minimal pressure needed to support adequate organ perfusion), but you also can't just treat people as a number. They probably need to look at overall clinical picture, patient's historical pressures, if urine is being made, if their kidneys seem to be taking a hit in their labs, if they are dizzy or orthostatic, etc. It sounds like in this case the low bp was not suspected to be secondary to advanced sepsis so they probably weren't overly concerned about treating it with medications. I wouldn't think it would be acceptable to keep a patient with a MAP below 60 for more than 6-12 hours without good cause. Maybe they were just being a bit too conservative in their resuscitation efforts because the patient was at risk for fluid overload.
A little confused about why you say high doses of Albumin are never ordered because it will kill the kidneys. I find quite the opposite to be true as a liver nurse. We give large doses of Albumin as part of our SBP protocol on day 1 & 3 for renal protection (1.5g/kg on day 1, 1g/kg on day 3), as well as to aide in pushing fluid where it belongs. NS boluses for hypotension in liver patients are ill advised because they'll just go right to the belly. Hoping you can explain what you mean.
In order to elevate oncotic pressure you need to get albumine level close to normal, 3,5 to 5.5 g/dl. For prevention of postparacentesis circulatory disfunction (which is the case describes) dose is up to 8 g/liter removed fluid or 50 g once immediately after procedure.
One volume of 12.5% albumine (say, 50 cc) draws out approximately 3 times of water into intravascular space. So, if you need a liter of this space added up, you'll need 1000÷150= 7 bottles, or about 90 g if albumine, approximately 1.2 - 1.5 g/kg. And it gives only 1 liter of fluid in intravascular space - in case of hypovolemia, it can be a bare minimum.
The problem is the fact that 15 g of it is metabolizing daily, and as all proteins it is metabolized for elimination in liver. It is very large protein load and can bump up BUN. In addition, acute overload with relatively small filtrable proteins like albumin causes progressive nephron injury (same thing as microalbuminuria in all other cases, through macrophageal injury):
The both things caused albumin to fall out of fashion for chronic therapy. 30 years ago it was given for chronic wounds healing and regularly administered for CRF/CHF patients.
It may be because albumin/proteins are larger molecules, like glucose. Hard on the kidneys. Some dialysis/renal patients have protein restricted diets.
As a liver nurse, you give the albumin for renal protection to increase vascular volume and thereby improve renal perfusion
I understand what you stated re: albumin, kidney patients & protein restriction), but the piece about albumin for renal protection is why I wanted to see if I misinterpreted KatieMI's post. She mentions "Albumin could help, if ordered in larger amount (which would kill the kidneys so never ordered)." That's the statement I am confused about because as I mention, I see precisely that ordered all the time, and this is one of the top transplant centers in the northeast.
In order to elevate oncotic pressure you need to get albumine level close to normal, 3,5 to 5.5 g/dl. For prevention of postparacentesis circulatory disfunction (which is the case describes) dose is up to 8 g/liter removed fluid or 50 g once immediately after procedure.
One volume of 12.5% albumine (say, 50 cc) draws out approximately 3 times of water into intravascular space. So, if you need a liter of this space added up, you'll need 1000÷150= 7 bottles, or about 90 g if albumine, approximately 1.2 - 1.5 g/kg. And it gives only 1 liter of fluid in intravascular space - in case of hypovolemia, it can be a bare minimum.
The problem is the fact that 15 g of it is metabolizing daily, and as all proteins it is metabolized for elimination in liver. It is very large protein load and can bump up BUN. In addition, acute overload with relatively small filtrable proteins like albumin causes progressive nephron injury (same thing as microalbuminuria in all other cases, through macrophageal injury):
The both things caused albumin to fall out of fashion for chronic therapy. 30 years ago it was given for chronic wounds healing and regularly administered for CRF/CHF patients.
Thanks for all your comments!! This is definitely one of those threads on this website where everyone is learning.
FYI, I know liver disease makes lactate levels less useful.
My question mostly centered around the MAP. I know we treat the patient not the monitor but a liver patient can easily have a MAP of 50 and be talking and acting "normal"; this does not mean that everything is OK!
Also, do lactate levels meant to be checked so frequently? Also on SBP, a patient a&ox4 with absolutely no pain with an absolutely soft non-tender-non-rebound abdomen because lesser worrisome for SBP in my opinion.
Thanks again for all your contributions. I like this type of thread.
My question mostly centered around the MAP. I know we treat the patient not the monitor but a liver patient can easily have a MAP of 50 and be talking and acting "normal"; this does not mean that everything is OK!
Also, do lactate levels meant to be checked so frequently? Also on SBP, a patient a&ox4 with absolutely no pain with an absolutely soft non-tender-non-rebound abdomen because lesser worrisome for SBP in my opinion.
Thanks again for all your contributions. I like this type of thread.
Z
MAP of 50 CAN be OK, especially if it is mostly b/o low diastolic pressure (90/45 gives MAP 57). Of course, it doesn't mean that "everything is OK" - it means that the patient has advanced liver cyrrhosis and decreased tone of arteriolae - the main "pressure keeping" part of circulatory system. But it doesn't mean that you have to call everybody and demand to do something right away if there is no other symptoms, urinary output is stable, there is no new "sundowning" (common symptom of impending functionally significant hyperammoniemia, BTW), no nausea, dizziness, weakness, etc. - in short, nothing new. These patients just live like that for a while, and it can be complete "norm" for their individual situation.
The most common symptom of SBP is not pain and not tenderness. It is fever, which can be low-grade and so difficult to catch at first. That's why everybody is afraid of it - SBP not always (and, in fact, more often than not) has that dramatic textbook presentation, especially in patients who are taking any med that suppresses pain/fever/inflammation in general, and missing SBP, as you can imagine, is a pretty big deal. So, your doctors just wanted to exclude it (or simply practiced CYA medicine).
Re. lactate, it can be checked even every hour in acute situations like real septic shock. Counting that the situation was not that dramatic, the second doc probably just practiced CYA medicine - but please, remember that doctors count on your assessment and your impression of the patient more often than their own, especially when they are not actually there. If you call and with concerned voice tell them about some thing you perceive as worrisome, they feel compelled to do something, and so you get more results with which to call and ask for something else, and so the avalanche gets moving on. We played a game of this in my MSN program by making orders over the phone when the information about the same mock "patients" was presented differently, the results were amazing in terms of wheedling more drugs from prescriber just by "the nurse" playing good 'ol status dramaticus.
In short, know your patients' baselines, do not overthink things, trust your guts and your assessments. Numbers can lie and patients can lie too, but your hands and your brains can't :)
Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
MAP of 50 CAN be OK, especially if it is mostly b/o low diastolic pressure (90/45 gives MAP 57). Of course, it doesn't mean that "everything is OK" - it means that the patient has advanced liver cyrrhosis and decreased tone of arteriolae - the main "pressure keeping" part of circulatory system. But it doesn't mean that you have to call everybody and demand to do something right away if there is no other symptoms, urinary output is stable, there is no new "sundowning" (common symptom of impending functionally significant hyperammoniemia, BTW), no nausea, dizziness, weakness, etc. - in short, nothing new. These patients just live like that for a while, and it can be complete "norm" for their individual situation.
The most common symptom of SBP is not pain and not tenderness. It is fever, which can be low-grade and so difficult to catch at first. That's why everybody is afraid of it - SBP not always (and, in fact, more often than not) has that dramatic textbook presentation, especially in patients who are taking any med that suppresses pain/fever/inflammation in general, and missing SBP, as you can imagine, is a pretty big deal. So, your doctors just wanted to exclude it (or simply practiced CYA medicine).
Re. lactate, it can be checked even every hour in acute situations like real septic shock. Counting that the situation was not that dramatic, the second doc probably just practiced CYA medicine - but please, remember that doctors count on your assessment and your impression of the patient more often than their own, especially when they are not actually there. If you call and with concerned voice tell them about some thing you perceive as worrisome, they feel compelled to do something, and so you get more results with which to call and ask for something else, and so the avalanche gets moving on. We played a game of this in my MSN program by making orders over the phone when the information about the same mock "patients" was presented differently, the results were amazing in terms of wheedling more drugs from prescriber just by "the nurse" playing good 'ol status dramaticus.
In short, know your patients' baselines, do not overthink things, trust your guts and your assessments. Numbers can lie and patients can lie too, but your hands and your brains can't :)
Love reading these and other comments. Even though I'm retired (:-((), i still read my JEN and appreciate the pearls here. I suspect others who are still practicing will benefit from what is said here.
Thanks for all your comments!! This is definitely one of those threads on this website where everyone is learning.
FYI, I know liver disease makes lactate levels less useful.
My question mostly centered around the MAP. I know we treat the patient not the monitor but a liver patient can easily have a MAP of 50 and be talking and acting "normal"; this does not mean that everything is OK!
Also, do lactate levels meant to be checked so frequently? Also on SBP, a patient a&ox4 with absolutely no pain with an absolutely soft non-tender-non-rebound abdomen because lesser worrisome for SBP in my opinion.
Thanks again for all your contributions. I like this type of thread.
Z
Our standard for septic patients is a lactate drawn every 2 hours. Presumed source of infection + 2+ SIRS criteria = sepsis.
Re: the liver disease - even if a patient has liver disease and presents with an elevated LA, more likely the lactate is elevated for a primary reason other than liver disease. Yes there may be less clearance of the LA but most likely it got high for a reason.
Re: the liver disease - even if a patient has liver disease and presents with an elevated LA, more likely the lactate is elevated for a primary reason other than liver disease. Yes there may be less clearance of the LA but most likely it got high for a reason.
Lev, MSN, RN, NP
4 Articles; 2,805 Posts
It may be because albumin/proteins are larger molecules, like glucose. Hard on the kidneys. Some dialysis/renal patients have protein restricted diets.
As a liver nurse, you give the albumin for renal protection to increase vascular volume and thereby improve renal perfusion