What would you have done?

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Hi everyone, I had an awful day in the world of acute dialysis today and I hope you can give me some feed back. I went to dialyze a pt today who was admitted last night for hypotension and decreased LOC. THis morning before I started her treatment she had a bp of 91/56. I anticipated that there would be problems removing fluid so I called the doctor for permission to do Na modeling and have albumin on hand if needed. Anyway, pt got through most of tx then with 30 minutes left BP dropped to 55 systolic and went into A fib and went unresponsive. I immediatly terminated tx and gave fluid. Wound up giving 2 liters of fluid just to get a BP of 105/50, hr 116 and get her responsive again. When nephrologist heard she got 2 L he freaked ! I know it was alot of fluid, but WHAT ELSE COULD I HAVE DONE? She wasn't responding till then. I am a wreck and totally questioning that I should be in the acute environment. The nephrologist said "now we have to hook her back up to UF her" and I said well she needs to be in the ICU than and get on some pressors. SHe was then moved to ICU to be dialyzed tomorrow. I truly don't know what else I could have done, I mean I took every precaution to maintain her BP's while on the machine and she still crashed. I am a wreck over this and I hope some of you can advise me on how else I may have handled this situation.

Thanks

MJ

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Was she actually overloaded in the first place? I have had several patients that "lose" weight in between treatments and need fluid. I know it isn't the norm, but they have colostomies or iliostomies and unless they take tons of anti-diarrheals, all fluid goes out there.

Sounds like you had NO choice but to do what you did. What was the dx for admission?

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To me, it sounds like you saved her life. Was there anything else you could have done? If not, rest in your decision.

Kris

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Thanks for the replies so far. As I said previously, she was admitted for hypotension and decreased LOC. Right before she crashed her pre HD labs came back and her WBC count was extremely high. She had a stage two decubti on her back which I am sure is what is causing her to be septic and contributing to her hypotension. She had a pre HD temp of 99. She was not fluid overloaded and I was only doing gentle fluid removal (as per MD order and nursing judgement).

I guess what is so disturbing to me is that I believe I did the right thing but the attitude from the floor nursing staff and MD seemed to be that I came in and just reeked havoc on their unit.

I keep going over how the MD responded to my giving her fluid and I just think what, should I have just stopped giving fluid and said Im sorry the patient is not responsive but she is a dialysis patient and I really can't give her anymore fluid?

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It sounds like the exact right thing you could have done. Believe me, we have had the same thing happen too. You just cant help it some times. saving the pt is sometimes greater than "getting the fluid off". Sounds like this person is having more procedures than they can handle. If she has all those other complications along with dialysis, she should have been in the ICU to begin with and THEY could have dealt with her. In my experience, some pt's and their families think that dialysis is going to cure everything. Sorry to say this but, there are some pt's that come through our unit that I think, "they should not be here". Why put a loved one through dialysis when it is just going to prolong the inevitable. (Especially when they are on their last leg with multiple problems) I think you did exactly as I would have done. Doctors can be real shits sometimes. Its okay. You will get through it!

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hi! does your md have standing orders for acute runs? did you give the albumin as ordered? i'm sure you also tried putting the pt in min.ufr to help w/bp's. i'm asking these questions because i've just had the worst 4 acute treatment runs over this past week but thank goodness our md is really great and i can call him prn during runs, mx.times if needed. he's also really good about ending treatment early if pt.is not tol. well. would your md be willing to listen to your suggestions? i hope your day goes better tommorrow!

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Do your machines have profiles?

I had to start using one because I can't tolerate any fluid being removed in the last hour-- the profile I'm on takes most of the fluid off in the first two and a half hours, so the remainder of the treatment is easier, less cramping and crashing.

Congrats on catching that patient before she got into serious trouble! It sounds like no matter what you did, it'd have been the wrong thing according to that nephro... thankfully, you did what you did and the woman is still with us. Too bad the nephro is more concerned with being inconvenienced.

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Hi everyone, I had an awful day in the world of acute dialysis today and I hope you can give me some feed back. I went to dialyze a pt today who was admitted last night for hypotension and decreased LOC. THis morning before I started her treatment she had a bp of 91/56. I anticipated that there would be problems removing fluid so I called the doctor for permission to do Na modeling and have albumin on hand if needed. Anyway, pt got through most of tx then with 30 minutes left BP dropped to 55 systolic and went into A fib and went unresponsive. I immediatly terminated tx and gave fluid. Wound up giving 2 liters of fluid just to get a BP of 105/50, hr 116 and get her responsive again. When nephrologist heard she got 2 L he freaked ! I know it was alot of fluid, but WHAT ELSE COULD I HAVE DONE? She wasn't responding till then. I am a wreck and totally questioning that I should be in the acute environment. The nephrologist said "now we have to hook her back up to UF her" and I said well she needs to be in the ICU than and get on some pressors. SHe was then moved to ICU to be dialyzed tomorrow. I truly don't know what else I could have done, I mean I took every precaution to maintain her BP's while on the machine and she still crashed. I am a wreck over this and I hope some of you can advise me on how else I may have handled this situation.

Thanks

MJ

You did a great job anticipating the possible outcomes here...GOOD FOR YOU! As for the doc...How the HECK could he think you could get a bunch of fluid off from a pt. who's admission problems was HYPOTENSION????? DUH??? Right! She should have either have had orders for albumin etc FIRST, or have been admitted to ICU. And if she drops her pressure and you can't do hemo, she needs CRRT! THAT is good pt. care! What an idiot about that Doc. Keep up the critical thinking skills!

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Specializes in Hemodialysis, Home Health.
You did a great job anticipating the possible outcomes here...GOOD FOR YOU! As for the doc...How the HECK could he think you could get a bunch of fluid off from a pt. who's admission problems was HYPOTENSION????? DUH??? Right! She should have either have had orders for albumin etc FIRST, or have been admitted to ICU. And if she drops her pressure and you can't do hemo, she needs CRRT! THAT is good pt. care! What an idiot about that Doc. Keep up the critical thinking skills!

Agree... sheeesh ! You already KNOW the patient's BP is going to drop during tx., and she was ADMITTED for hypotension.. did the nephro give you any suggestions reagrding interventions for a drop in BP before you ever hooked her up? If he didn't, he SHOULD have... jerk.

You did what you needed to do.. and this woman is alive because of it. Did you ask the jerk what HE would have done INSTEAD? Just how would HE have resolved the issue? I'd sure be asking him. :rolleyes:

You can always get the fluid off later again.. but you can't get her LIFE back should something have happened there.

Good for you. :balloons:

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I would have acted in the same way. No BP is no life. Treat the cause for now. We use critlines in instances like this along with dopamine and albumine. Also some times people who are septic get this way or the ones who have fluid in the pericardiem. Do you ever use CVP central venous pressure to asses a pts fluid overload status. If is is 6-8 that person is pretty dry. Hope I may have shed some light on you. I would have definalty given that person all the fluid she needed to get a bp. I might have suggested to md that with a bp like that why isnt she in the unit anyway.

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Hi all ! Thanks again for the replies. Just to answer some of the questions posed:

Yes, I did use the albumin ordered and I also questioned why the patient was not in ICU in the first place. No, our machines do not have UF profiling and I agree that this patient would have been better off on CRRT. Unfortunatley our company does not provide this service and believe it or not the Hospital does not do it either ( Not sure why, I thought all critical care units had CRRT?!). As far as the nephrologist is concerned, Ya know, at this particular hospital they are all like that. For instance when I called in the morning to get the order for the albumin and Na modeling he was all annoyed that I called so early. But ya know, like someone else said, why wasn't it written in the first place , espeically because of the admitting diagnosis!! Knuckle head (thats me venting one last time. :rolleyes: ) Anyway, good news is I dialyzed the patient yesterday with no incident and she is doing fine now.

Thank you all so much for the support. It really helped alot. I am so happy that this board exists!!

Thanks again!

MJ

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glad to hear you had a much better treatment run!

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