RRT vs ICU transfer

Lev, MSN, RN, NP · May 8, 2016

I think a day or two in ICU would have done him good. He is stable for now but he could crump. He needs at least step-down level care.

TheCommuter, BSN, RN · May 8, 2016

This thread has been moved to our Critical Care forum to generate additional replies and perspectives on this situation. Good luck to the original poster.

akulahawkRN, ADN, RN, EMT-P · May 8, 2016

I want your opinions â€¦tell me if i should have still sent this guy to the unit?
Relevant hx: chf, esrd, dm, severe pvd. Lasix drip DCed around 1pm. Pt returned from first HD treatment around 530pm.
708pm. pt enters junctional rhythm. Symptomatic bradycardia (30-40s). VERY weak peripheral and apical pulses. Lethargic, but arousable. Confused. Hypotension (90/40â€¦manual). Randomly hyperglycemic (412) after not eating all day and coming back from HD.
Call to cards â€¦ Start dopamine at 5mcgs and transfer to unit. Consult Dr BlahBlah as intensivist.
Started dopamine. Corrected hyperglycemia.
Call to Dr BlahBlahâ€¦.agrees with dopamine and a transfer to the unit.
So after doing all that and making the correct phone calls to charge nurses and the ICU â€¦it's about 845pm. And the dopamine increased his CO. As soon as his HR got above 60, he converted to sinus rhythm. The insulin corrected the confusion and lethargy.
So my report to the ICU RN went something like so um don't hate me, but I kinda just fixed him.â€
Soooo guys â€¦ Would you have kept the patient on the floor after he was stabilized? If I would have called a rapid, that's what would have happened. But honestly â€¦ Calling back cards and intensivist didn't really seem like an option. Haha guys never mindâ€

Disclaimer: I'm an ER nurse. Given what happened, I would have transferred him to the ICU. If you'd have "fixed him," the patient would no longer need dopamine to maintain CO. Also, in your description of what happened, I don't see any labs done with the exception of a blood sugar level. People normally don't drop into a junctional rhythm for no reason and then convert to a sinus rhythm for no reason other than a dopamine gtt. My feeling is that something else is going on that you've put a bandaid on and deeper investigation in the cause of this patient's symptoms is needed.

Rightly or wrongly, that's what I see at this point with the info provided.

ErraticThinkerRN · May 9, 2016

I think a 24-48 ICU stay is called for, and agree with the posting above saying that the dopamine is kind of just a bandaid. He'll definitely need more of a work up, and more intense monitoring in the meantime in case the dopamine needs to be titrated or a pacing wire needs to be floated emergently. The only other thing that I can think of is that it was his first HD treatment, maybe he was experiencing dialysis hypotension that can elicit a vagal reflex causing bradycardia and hypotension. Either way, an ICU stay is probably still called for if that's his response to a preliminary HD treatment.

Chisca, RN · May 9, 2016

He was in ICU. If you could have continued to provide that level of nursing care he would have remained in ICU. Or were you questioning whether or not to move him to a room with the title "ICU"?

nurs1ng · May 9, 2016

What unit was he in? Regardless whether he was "'fixed", he still needed to be transferred to the ICU for observation, just in case. Also looking back at your post, it seemed like you got an order from the MD to transfer to the ICU but that order was ultimately defied. That's a big no no. A call back to the MD for an update should have been in order. But that's just me.

InArduisFidelis · May 9, 2016

What unit was he in? Regardless whether he was "'fixed", he still needed to be transferred to the ICU for observation, just in case. Also looking back at your post, it seemed like you got an order from the MD to transfer to the ICU but that order was ultimately defied. That's a big no no. A call back to the MD for an update should have been in order. But that's just me.

nurs1ng's question about what kind of unit you work on is kind of key here. Nationally there is too much variability between what ICU level care means at different hospitals. Was this a medsurg floor? I am assuming he was at least on Tele since you noted his rhythm change. You said this was his first HD treatment, was it first like initial HD run ever? or first since admission?

Pheebz777, BSN, RN · May 10, 2016

So the patient was started on dopamine, kept on dopamine and stayed on the floor?

As what others have already said, a day or 2 in the ICU would be needed as well as a cardiac consult. Someone just does not go into symptomatic bradycardia without reason. But not really having any labs, EKGs, prior 2Decho to gauge cardiac contractility I would have to geuss that him being a first time HD patient had a simple hypovolemic bradycardic episode that's common when HD is given too fast. Was the HR elevated during HD? Usually when sympathetic tone reserves are depleted from continuous hypovolemia (during HD), a precipitous fall in sympathetic tone ensues and vagal tone activation takes over. Which would explain the lost of SA node firing in your junctional rhythm.

Dopamine is a potent Beta 1 agonist (sympathetic stimulant) and would explain the patient converting back to sinus rhythm. I doubt the insulin corrected his confusion, it was more likely adequate perfusion to the brain that fixed that.

Bluebolt · May 10, 2016

I always get annoyed when I get report from the floor and they didn't call my co-worker to do a RRT workup and give us the opportunity to fix or at least figure out whats wrong. I know on the floors it's fun to exercise your critical thinking skills and get some action in but please abstain from the urge and just call us to come.

I've seen tons of cases that would have been inappropriate admissions avoided by using RRT. On the other hand I'll say I've responded to RRT pages only to realize the patient is about to code imminently and needs to be immediately transferred and the page should have been placed hours prior in hopes of prevention.

In the case of your patient listed here with only the basic info provided I would say he needed to be transferred to a cardiac step down unit. I don't think he needed ICU intervention but on a cardiac step down they could monitor him closely and allow the cardiac workup they need to do to figure out if there is a serious underlying issue going on.

I definitely would have done stat labs to check a CBC, BMP, Mag, Phos especially considering they just did HD.

Greenclip · May 14, 2016

You made the right call for the patient to go to the unit.

NPOaftermidnight, MSN, RN, NP · May 15, 2016

I agree with the others. I think you did a good job within your scope on the floor, but the patient should be at least on a step-down service for closer monitoring and a full workup.