What would you do for this patient?

[UM Review RN, ASN, RN]

Just curious.

What would you do for a patient who was a hemodialysis patient, tended to run SBP in the 100's, but was still a/o X 3 with a SBP like the high 60's to low 70's, who also was in ST w/ (very) frequent PACs vs. MAT (per the doc's notes).

Full code, of course.

Had HD that morning and a colonoscopy in the afternoon, was actually GIVEN fluids at HD. Was taken off Cardizem gtt toward the end of HD when HR was being maintained around 110's & BP dropped to 60's. Maintained LOC just fine also.

Anyhow, later that night, was unable to give po Cardizem, so of course, the HR popped back up again and the BP hung around the 70's systolic.

We worried that if she crashed on our floor, help would get there too late and that she needed titration of a gtt and closer monitoring, so we transferred to CCU.

But that only made me start wondering. What would you do for this patient? Would this patient be a candidate for pressors if she's in renal failure? What sort of treatments would you see her get on your unit?

What could we have done better? I kept feeling like we were missing something, but I didn't feel safe to do anything differently, given we were on a regular tele floor.

[joeyzstj, LPN]

I personally would have given the patient a little fluid while I was waiting on pharmacy to send me up 50 grams of albumin for volume expansion and to draw some of the fluid back into circulation. I would have also started this patient on Neo most likely due to the Heart rate. Neo is a pure alpha agonist. Levo is mostly alpha, however it does have some beta effects. Dopamine wouldnt have been a good choice due to the beta effects. Hespan is contraindicated in renal patients and vasopresin we dont really use as a first line drug for this. I would have went with a small fluid bolus, lay the patient flat temporarily and some albumin and Neo. What did you do?

[SuesquatchRN, BSN, RN]

Justr wanted to say, darn, you cardiac nurses are wicked smart!

[joeyzstj, LPN]

Sorry, I just realized you asked what would I do on a floor. You did the right thing. This patient needed to be transfered to Critical Care with a Bp of 60's. The patient should never have been allowed to have a sustained MEAN arterial pressure of less than 60, which is difficult to achieve with a SBP of 70's. Despite recieving fluids, the patient was most likely hypovolemic due to the dialysis. Despite being in renal failure, you cant allow a patient to remain with a BP in the 60's and 70's. Doing so can cause even further damage to the kidneys and other viatal organs. What type of cardiac history did this patient have?

-PS.....Hypovolemia can cause all sorts of weird arrythmias, as well as electrolyte imbalances. A BMP would have been nice to have as well.

[Valerie Salva, BSN, RN]

She'll probably be getting pressors, albumin, and blood during dialysis in ICU.

[UM Review RN, ASN, RN]

Sorry, I just realized you asked what would I do on a floor. You did the right thing. This patient needed to be transfered to Critical Care with a Bp of 60's. The patient should never have been allowed to have a sustained MEAN arterial pressure of less than 60, which is difficult to achieve with a SBP of 70's. Despite recieving fluids, the patient was most likely hypovolemic due to the dialysis. Despite being in renal failure, you cant allow a patient to remain with a BP in the 60's and 70's. Doing so can cause even further damage to the kidneys and other viatal organs. What type of cardiac history did this patient have?

-PS.....Hypovolemia can cause all sorts of weird arrythmias, as well as electrolyte imbalances. A BMP would have been nice to have as well.

I don't recall her cardiac hx, but let's just say that the patient was a spry 80-something and appeared to be tolerating all this quite well. Came into ER with the same rhythm, same s/s and LOC.

Her skin turgor indicated hypovolemia rather than third-spacing, so would albumin still have been a choice?

We couldn't have kept the patient on our unit as we don't run pressors. Can you tell I'm just picking your brains, trying to learn new things here.

[BBFRN, BSN, PhD]

I agree with Joey, but would like to see a CBC as well. HD patients are often anemic, and if you have a low Hgb in addition to the dehydration, you may want to increase their fluid volume with blood first. Sounds like this could be the case, since the pt was also tachy. Was she sat'ing OK?

The goal is to be able to get her off the Neo. Hopefully, blood will do the trick. You can tweak it after that, with Albumin or Lasix- whichever way you need to go. If her NA & K are off, then she could have some 3rd spacing.

This most likely doesn't apply to this patient, but some renal patients do get a low dose Dopamine gtt, if their problem is one of renal perfusion.

[UM Review RN, ASN, RN]

I agree with Joey, but would like to see a CBC as well. HD patients are often anemic, and if you have a low Hgb in addition to the dehydration, you may want to increase their fluid volume with blood first. Sounds like this could be the case, since the pt was also tachy. Was she sat'ing OK?

The goal is to be able to get her off the Neo. Hopefully, blood will do the trick. You can tweak it after that, with Albumin or Lasix- whichever way you need to go. If her NA & K are off, then she could have some 3rd spacing.

This most likely doesn't apply to this patient, but some renal patients do get a low dose Dopamine gtt, if their problem is one of renal perfusion.

Thanks, she was satting fine, I don't recall the H&H. Thanks for your input. I'm learning a lot in this thread.

[elizabells, BSN, RN]

Do y'all do renal dose Dopa in adults? In the babies we use 3mcg/kg/min if we're needing pressors and have renal insufficiency.

[BBFRN, BSN, PhD]

Yeah- I'd say with any HD pt you have, keep a close watch on their BMPs & CBCs- especially your little old ladies. They seem to be more sensitive to HD than most people, especially if they're small. They volume deplete more easily, and become anemic more quickly. At least that's been my experience. But if her crit was OK, then you'll probably find the answer to her problem in her 'lytes. I'd look at her NA, K, Ca, and Mg.

[NsgChica]

OK, check this out...Dopamine: the B-agonist dose is iniated at 5mcg/kg/min (just this little effect to increase renal perfusion...Dopee), as a vasopressor dopamine can be iniated at 10mcg/kg/min with it's maximum dose being 20 mcg/kg/min. It can even be titrated up to 50mcg/kg/min. However, at 20mcg and 50 mcg...renal perfusion is lost and is not indicated for renal failure because at this high dose it can decrease renal perfusion and cause azotemia. So if you're at the maximum dose of dopamine...it's time to consider another pressor such as levophed or Neo (what ever docs preference). This high dose is not recommended, what is is that once you start to titrate higher without + outcomes and another pressor. With that being said, my patient was on CVVH (slow hemo, for those who don't know), hypotensive, and in a low grade septic shock. Needless to say her bp was hangin' in the low 80's, her diastolic was 40's. She didn't tolerate any fluid removal...bp 60's...She was on the MAX amount of DOPamine...So my thought was how do you have a patient in renal failure on the max of DOPamine if this drug decreases renal perfusion at such high doses...why not add another pressor, even if Dopamine is indicated for patients in shock. So my take is that she was vasodialated out due to the shock portion and third spacing but needed albumin to bring fluid back and have it slowly taken off....What do you guys think?? Oh yeah and add another pressor or just let her go in peace since she is in MODS...

For your pt...Maybe trying a drug that took care of the HR, but didn't have much effect on the BP...I agree with most people on this thread about giving volume, going through H's and T's and sending her to the unit...it seems that she may need CVVH and then gradually work her way to hemo (since they had to give her fluid)...with a labile bp.

[ghillbert, MSN, NP]

Wow - I have definitely NEVER seen dopamine used at 50 mcg/kg/min as a pressor. We would most definitely use a more potent vasopressor if that much support was required.

Agree the OP's patient sounds hypovolemic and needs BP support. Anemia is also generally chronic in CRF patients due to lack of erythropoietin secretion and destructive effects of uremia on RBCs, so blood transfusion is likely.