Should i have questioned this order?

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Here is the scenerio... MVC who entered our unit intubated. no fx's, no pulmonary contusions, and no blount trauma warrenting surgery. Pt's respiratory function stabilizes, extubates w/ no s/s of resp distress, and is moved out to stepdown same day. nearly a week passes by with no bowel movement, contracts an acute ileus, abdomen becomes extremely distended, pt becomes short of breath, is readmitted to ICU and is intubated once again (why there was no bowel stim is beyond me). pt remains intubated for 3-4 days until bowels are more than adequately working again, distention decreases, vent weened to where pt is adequately ventilating on PS with minimal peep and fiO2. Pt extubated at the beginning of my shift. through the whole shift, his ABGs, sats, breath sounds and breathing rate are fantastic. The pts bicarb was a little low, and he was slightly tachycardic (110-115). towards the end of the shift because of the mentioned symptoms, the resident orders a 1L LR bolus (FYI-we usually dont treat a low bicarb with LR bolus) but because we do treat tachycardia with bolus, i went ahead and hung it....shift ends, go home come back for next shift 12-13 hours later. Pt is complaining of shortness of breath and lots of rhonchi all over. ABG shows pO2 of 57! YIKES!!! Few hours of aggressive pulmonary toiletry, few hours of bipap...no improvement...pt reintubated.........Now, I knew that rapid infusion of blood and blood products on a non mech ventilated pt was a no no, but it had never crossed my mind about IV fluids. The resident is young in his residency, and completely new to the trauma world, but this didnt hit me until the shift after i gave the bolus. My question is: can rapidly infused IV fluids cause pulmonary flash edema the same as blood? Is this something i should have known and questioned the MD on? Or is this something that is hospital policy specific? thanks for any help

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Specializes in CTICU.

Yes, it could definitely cause the problem. A liter is a lot of fluid to give as a bolus if someone is not acutely shocked! Particularly since it's not a colloid, which would sit better in the vasculature - the crystalloid would shift into tissue cells.

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Specializes in CVICU, ICU, RRT, CVPACU.

I would say that their was either some renal or cardiac envolvement if I had to guess. Ive given a lot of people 1 liter boluses with not adverse effects. The fact that the guy had other health issues as well would make me think that it wasnt the bolus alone that did it either.

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Specializes in critical care: trauma/oncology/burns.

Hi

Yeah, I agree it certainly sounds like rapid onset pulmonary edema a/k/a flash edema.

A patient will develop the dyspnea associated with the rapid accumulation of fluid within the lung interstitial and alveolar space which would result in a patient's acutely elevated cardiac filling pressures (cardiogenic pulmonary edema) and it can also present as elevated LV filling pressures and dyspnea without pulmonary edema, like it presented in your patient.

And I agree that that particular patient probably didn't need that whole liter of fluid as a bolus

Hey, but at least y'all caught it and your patient is hopefully extubated and doing better.

athena

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Specializes in Infusion Nursing, Home Health Infusion.

You will sometimes see LR ordered for a patient with mild metabolic acidosis b/c it contains the bicarbonate precursor.So his thinking may have been along those lines. This isotonic crystalloid fills both the interstitial and intravascular spaces.

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I would say that their was either some renal or cardiac envolvement if I had to guess. Ive given a lot of people 1 liter boluses with not adverse effects. The fact that the guy had other health issues as well would make me think that it wasnt the bolus alone that did it either.

Actually, your right...the pt had a history of bipass surgery and A-fib, for which we were infusing a dilt drip. The pt had been converted out of a-fib for a few days, but he was showing S-T depression. He may have very well been in the early stages of heart failure prior to the accident. Good call joey!

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Specializes in CTICU.

With a crappy heart, you definitely need to beware of infusing large volumes of fluid - the heart may not have the stretch/contractility to compensate and pump harder.. which means the fluid will just back right up to the pulmonary vasculature - and immediate pulm edema.

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With a crappy heart, you definitely need to beware of infusing large volumes of fluid - the heart may not have the stretch/contractility to compensate and pump harder.. which means the fluid will just back right up to the pulmonary vasculature - and immediate pulm edema.

i almost feel guilty about the guy having to be reintubated. Lesson learned! Ill definately question this in future situations.

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Specializes in CTICU.

Don't feel guilty! You didn't order the fluid, and you learn by doing these things. It's great that you thought to put the events together and do some further research.

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Yep, it sounds like flash pulmonary edema. His LV probably couldn't keep things moving in the right direction. It sounds like he might've had some LV dysfunction. If he was also in afib at the time...you definately have someone backing up...Speaking of backing up, if he had an ileus and no bm for that long...it is very possible that his diaphragm could've been pushed up and escalated the problem.

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Yep, it sounds like flash pulmonary edema. His LV probably couldn't keep things moving in the right direction. It sounds like he might've had some LV dysfunction. If he was also in afib at the time...you definately have someone backing up...Speaking of backing up, if he had an ileus and no bm for that long...it is very possible that his diaphragm could've been pushed up and escalated the problem.

Absolutely! That was the reason he got intubated the 1st time..though when this particular episode happened he had been having bowel movements and the distention had gone down alot. Our trauma doctors give out bowel stims like candy. I have no idea why they let him go so long w/o one and get so distended while he was in the stepdown unit...

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Specializes in Critical Care.
Here is the scenerio... MVC who entered our unit intubated. no fx's, no pulmonary contusions, and no blount trauma warrenting surgery. Pt's respiratory function stabilizes, extubates w/ no s/s of resp distress, and is moved out to stepdown same day. nearly a week passes by with no bowel movement, contracts an acute ileus, abdomen becomes extremely distended, pt becomes short of breath, is readmitted to ICU and is intubated once again (why there was no bowel stim is beyond me). pt remains intubated for 3-4 days until bowels are more than adequately working again, distention decreases, vent weened to where pt is adequately ventilating on PS with minimal peep and fiO2. Pt extubated at the beginning of my shift. through the whole shift, his ABGs, sats, breath sounds and breathing rate are fantastic. The pts bicarb was a little low, and he was slightly tachycardic (110-115). towards the end of the shift because of the mentioned symptoms, the resident orders a 1L LR bolus (FYI-we usually dont treat a low bicarb with LR bolus) but because we do treat tachycardia with bolus, i went ahead and hung it....shift ends, go home come back for next shift 12-13 hours later. Pt is complaining of shortness of breath and lots of rhonchi all over. ABG shows pO2 of 57! YIKES!!! Few hours of aggressive pulmonary toiletry, few hours of bipap...no improvement...pt reintubated.........Now, I knew that rapid infusion of blood and blood products on a non mech ventilated pt was a no no, but it had never crossed my mind about IV fluids. The resident is young in his residency, and completely new to the trauma world, but this didnt hit me until the shift after i gave the bolus. My question is: can rapidly infused IV fluids cause pulmonary flash edema the same as blood? Is this something i should have known and questioned the MD on? Or is this something that is hospital policy specific? thanks for any help

Yes! Your hindsight is 20/20! I hope the patient made it. In a teaching institution, one must ALWAYS diligently check orders and definitely question when appropriate. ew

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