Senior Nurses Any Insight Into This Patient Case?

[All4NursingRN]

Perhaps some more experienced nurses can help me out.

So last shift I had a 60 yr old GI bleeder. PMH of liver CA, renal insufficiency and came to hospital c/o weakness. H&H of 6/18. Potassium of 8. Was to receive 2 units PRBC and insulin, dextrose and bicarb for elevated potassium. Received first unit of PRBC, I redraw chemistry and cbc. Those came back with potassium of about 7 and H&H of 5/17. Doc doesn't understand why H&H dropped after 1st unit PRBC and decides to gastric lavage him to r/o upper GI bleed, comes out negative. Pt stable as far as VS, says he feels fine just alitte dizzy (also very orthostatic) but doesn't look comfortable, sort of sob in our opinions, but pt still says he feels ok. Pt ask to use restroom. Curious I examine the stool, and it's it a large bm of dark red stool.

Doc orders

Lasix 100mg IVP: which I question, I knew he would be getting a few units of PRBC's and they didn't want to overload him, but the patient also had history of renal insufficiency, although he put out about 1200ml of urine. I consult another physician who says because of RI 100mg of lasix would'nt do anything for him anyway and it's no problem to give that much. I; still uncomfortable convince the doc to split the lasix half and half. 50mg IVP after 1st unit PRBC and 50mg later.

Octreotide (sandostatin) drip 25mcg/hr: I see this this ordered with bad GI bleeds. Usually I see a protonix drip (which personally I don't think does anything for our GI bleeders) I wasn't sure what the octreotide would do?

DDAVP (desmopressin) 2mcg SQ : Completely surprised by this order. I ask doc to explain his reasoning for it. He says it's related to platelet function, and can be of some benefit for certain platelet disorders. Although my patient didn't have a platelet disorder I suspect it may have been to put a damper on the bleeding?

I also had to give him the potassium lowering coctail (as I call it) insulin, dextrose, calcium gluconate, bicarb about 3 times as his potassium wasn't coming down obviously due to the continuous GI bleeding.

Finally after hours of the ICU resident scratching his head wondering what was going on/unable to get to bottom of case, he accepted patient to MICU. I sorta wish I pushed the resident to accept the patient sooner, but at my hospital they love keeping patients as ICU evals just to see if their labs/condition stablize then downgrade them hours later. *sigh*

Any insight?

[XingtheBBB, BSN, RN]

so, op, you are a relatively new nurse? on the floor? must have been a crazy day for you! sounds like you did well! good job. this pt should have been admitted right to a unit.

i see a lot of good info already. hepatorenal came to my mind also. the bicarb-insulin-d50-ca++ cocktail is great but usually works best with kayexelate (contraindications already mentioned) since the k that was shifted out of serum shifts back. any ectopy? the pt was on tele? a dialysis run seems warranted to me with that refractory k.

i see this pt being admitted to the unit under an intensivist, ffp given, egd at bedside asap, prbc running (in the icu, we can run these products much faster)

to reinforce and speculate-

octreotide drip- yes!- lets clamp up the blood flow to slow the bleed

pantoprazole drip- we can use both!- the body is in a stress state, likely hyper-secretory, lets nip that in the gluteus

ddavp- maybe something they pulled out of the heme-onc history? i'm not an onco person at all. some day i'll work that department to brush up! i have used ddavp in di, von willebrand's (pre- and post- elective sx), and ttp/itp. all those patients were in the peds population. is it possible that we are adding in lasix as prophylaxis for the fluid retention/hyponatremia/chf that could develop when this is given to a renal pt? ensure the med is excreted by the kidneys in a timely fashion? dump k+? also, the ddavp would assist the octreotide in vasoconstriction of splanchnic flow, would it not? (highlighted because i want feedback!)

you remembered a lot. i am curious about the rest of the chem- bun/creat, na, co2 (bicarb) but that's ok. i also wonder about coags and plt count (sounds like you remember plt as wnl, though)

maybe i'll think about this more? i love armchair medicine!

[All4NursingRN]

GrnTea, me too. Especially swooning over the detailed pharm/pathophys explanations.

OP, was this in the ED or on the floor?

It was the ED

[All4NursingRN]

so, op, you are a relatively new nurse? on the floor? must have been a crazy day for you! sounds like you did well! good job. this pt should have been admitted right to a unit.

i see a lot of good info already. hepatorenal came to my mind also. the bicarb-insulin-d50-ca++ cocktail is great but usually works best with kayexelate (contraindications already mentioned) since the k that was shifted out of serum shifts back. any ectopy? the pt was on tele? a dialysis run seems warranted to me with that refractory k.

i see this pt being admitted to the unit under an intensivist, ffp given, egd at bedside asap, prbc running (in the icu, we can run these products much faster)

to reinforce and speculate-

octreotide drip- yes!- lets clamp up the blood flow to slow the bleed

pantoprazole drip- we can use both!- the body is in a stress state, likely hyper-secretory, lets nip that in the gluteus

ddavp- maybe something they pulled out of the heme-onc history? i'm not an onco person at all. some day i'll work that department to brush up! i have used ddavp in di, von willebrand's (pre- and post- elective sx), and ttp/itp. all those patients were in the peds population. is it possible that we are adding in lasix as prophylaxis for the fluid retention/hyponatremia/chf that could develop when this is given to a renal pt? ensure the med is excreted by the kidneys in a timely fashion? dump k+? also, the ddavp would assist the octreotide in vasoconstriction of splanchnic flow, would it not? (highlighted because i want feedback!)

you remembered a lot. i am curious about the rest of the chem- bun/creat, na, co2 (bicarb) but that's ok. i also wonder about coags and plt count (sounds like you remember plt as wnl, though)

maybe i'll think about this more? i love armchair medicine!

i'm really sorry i can't remember the renal labs or coags.. but yes i know they were elevated. i know his abg was fine. in hindsight i wonder why he didn't get ffp too. this was at night so usually the attendings aren't on hand, the residents usually speak to the fellows or attending on the phone. i felt kinda bad for the resident he was really stumpted! and yes the patient went to the icu. i asked the resident how he did yesterday and he said they got his k+ down and his was downgraded to the floor. unfortunately he was so busy we couldn't talk specifics, but he again admitted to being lost with that patient.

i didn't want to run the prbc too fast because of the rf although the patient made about 1200ml of urine over about 7 hours, maybe i should've just ran it in faster like 1.5 hours instead of 3?

yes he was on the cardiac monitor, no ectopy, not tachy or hypotensive, slightly dizzy but very orthostatic and yes still bleeding from bowels.

i'm almost atlittle embarrassed i didn't pick up on alot of this stuff you guys mentioned at the time. aaargh i guess that's just being a new er nurse for ya! not to mention i had like 6 other patients (although he was the sickest)

i never thought that maybe the liver ca was causing some out of wack coags and clotting function, i just thought the gi bleed was independent of his other issues.

i also feel bad for not knowing if the rf was new, all i knew was that he had a history of it, how recent idk.

thanks all for the input.

[psu_213, BSN, RN]

12 lead EKG? Peaked T waves/widened QRS? If so, Ca gluconate with the rest of the hyperkalemia cocktail.

Otherwise, without acutally seeing the pt and the lab values, the orders seem reasonable. I especially like the octreotide. Not sure for the reason for the DDAVP (but just because I don't know the exact reason does not mean that it is wrong).

I am definitely not a fan of the idea of letting them sit in the ED until the can possible be downgraded rather that just sending them to an ICU. If the unit has beds available, get the up there...especially in the pt who is clearly very sick.

[All4NursingRN]

12 lead EKG? Peaked T waves/widened QRS? If so, Ca gluconate with the rest of the hyperkalemia cocktail.

Otherwise, without acutally seeing the pt and the lab values, the orders seem reasonable. I especially like the octreotide. Not sure for the reason for the DDAVP (but just because I don't know the exact reason does not mean that it is wrong).

I am definitely not a fan of the idea of letting them sit in the ED until the can possible be downgraded rather that just sending them to an ICU. If the unit has beds available, get the up there...especially in the pt who is clearly very sick.

Yeah guess what the ICU had 4 open beds. It was not until my manager asked me if I was ok and I told her I have a MICU eval that's not improving she then got on the phone to speak with MICU then the patient was accepted and upstairs within an hour after sitting there for 8 hours!

The issue I have is the residents (because at night there aren't any attendings) taking so long to make a decision whether to accept or downgrade the patient. We've had patient be evals all shift only to get downgraded or accepted by end of shift.

I just don't like the system of doing things. And forget it if the ICU is full that patient is all yours for the night on top of all the other patients triage sends you.

Not to mention I took report and it was never mentioned to me that the patient was a ICU candidate, I'm assuming the off going nurse wasnt aware either (as that she is a good nurse) so I didn't make a fuss. thank god my curiousity spurred me (because of the patient's condition) to inquire whether the patient was a MICU candidate or not and sure enough he was!

[ckh23, BSN, RN]

Just because the attending may not be in house, doesn't mean there is not one on call. There is always someone, they just don't let the residents run loose after 5. If you aren't getting any resolution with the resident, just by mentioning that you are going to be calling the attending may get them moving in the right direction. It may even get them to make the call themselves. I agree with others, this patient needed to be stabilized as best as possible and then sent to the unit.