What would you do for this patient?

[UM Review 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.

[SEOBowhntr]

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.

and

thanks, she was satting fine, i don't recall the h&h. thanks for your input. i'm learning a lot in this thread.

you have your answer here, you just don't realize it!!!!

angie,

the first thing we should worry about in a patient with prolonged hypovolemia is damage to the kidneys. since this patient really doesn't have kidneys to be too worried about, then we look at neuro status, and oxygenation. you say that she is "satting fine," therefore oxygenation is ok, and you mention that she's a&o x3, therefore, she's probably perfusing her brain just fine. did she have any vertigo or orthostatic neuro changes??? if so, then i would be more concerned were it my patient, if not, then i'd ride the wave. at some level you would worry about liver damage, and heart damage, but this a&o patient would be able to tell you if she has chest pain, and having her on a cardiac monitor, you could always watch her st segments closely for that fabled "silent" mi. i would like a h&h and a chem on her, but i'd be very cautious giving her too much fluid as she's not gonna get rid of it nearly as well as most.

and no, if she appears hypovolemic, the needs fluid, and albumin really isn't the best source of fluid, so you are correct to question why albumin would be a consideration. albumin is, as i explain it to my new nurses, a sponge, that sucks fluid into the vascular bed from the tissues, and if there's no fluid in the tissues then there's really little or no use for albumin. while blood may be a good option, probably only 1 unit would do enough to correct most of this ladies problem, even if her hemoglobin is ok.

[UM Review RN, ASN, RN]

Thanks, everyone. I love this site! I learn so much from so many of you!

:lvan:

[nurselizk]

A patient with low Hgb can have acceptable sats but too little oxygen-carrying capacity to maintain good oxygen delivery. It's great that her level of consciousness tolerated the low BP OK, but the rest of her organs might not have. Without labs, you don't really know what the underlying cause is.

[Wile E Coyote, ASN, RN]

A patient with low Hgb can have acceptable sats but too little oxygen-carrying capacity to maintain good oxygen delivery.

Yup, on that part. Remember that an oximeter reads the % of O2 saturation of each happy little hgb passing under the pretty red light...if the pt is at least moderately anemic, then their O2 molecules are 'concentrated' per se, amongst a lesser amt of happy little hgb's. Thus, the net effect would be falsely raising the measured SP02. What would be a decent measure of O2 delivery and consumption for our little lady would have been an SVO2. Of course the SVO2 is most accurate in the absence of fever, sepsis, shivering, and some other stuff, so a trend would be of most value. (I say this fully aware she started out of the ICU>>>she would have needed a swan line for continuous SVO2 monitoring. I'm just fully chasing down this tangient of mine:D) ONe last tidbit regarding her O2 carrying capacity. Note that in giving her packed red stuff, it would not *immediately* improve her end-organ profusion as banked blood lacks II-III DPG.

[joeyzstj, LPN]

A patient with low Hgb can have acceptable sats but too little oxygen-carrying capacity to maintain good oxygen delivery. It's great that her level of consciousness tolerated the low BP OK, but the rest of her organs might not have. Without labs, you don't really know what the underlying cause is.

This is an excellent point. It drives me crazy when someone says that despite the pt having a Hb of 6........"There sats are 100"%. A low Hb 100% saturated with oxygen doesnt mean that the PO2 or tissue oxgenation is sufficient.

[SWEnfermera]

An Amiodarone drip is another medication that might be considered for HR control, and hopefully conversion back to SR. It has less vasodilatory effects than most calcium channel blockers such as Diltiazem. As the HR slows, the B/P should improve. Phenylephrine (neosynephrine) would be a good med to use in conjunction with Amiodarone to support the B/P.

I also agree with the use of volume, especially if volume depletion from dialysis is suspected. No medication will work well if the patient's tank is empty.

[Babs0512]

Perhaps HD and a colonsocopy was too much in one day. The prep from the colonsocopy could through her electrolytes all out of whack. could explain some of the ectopy you witnessed.

Vasopressin probably would have been my choice if I absolutely HAD to give a pressor, maybe even neosenephrine - neither usually causes HR to increase so much as dopamine would. Love to hear other suggestions.

[gilf7243]

Sounds like moving this patient was the right thing to do. This patient is sick. She probably is septic or in shock from her colostomy surgery since her pressure is low. It's difficult to say for sure with such little information. She definately needed cardizem or amiodorone to get her heart rate under ctrl. Also, she may need Dopamine or something to get her pressure up. She needs the doctor to start checking her labs and figuring out what is going on?? Maybe her H and H is low from surgery, maybe she is bleeding, maybe they nicked the bowel in surgery. Who knows? Moving her was a smart move. Let me know if you can how this patient does?

[UM Review RN, ASN, RN]

As far as I know, the patient did well enough to eventually go to rehab, but had a very poor prognosis.

[SFRN]

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?

I think Neo may be jumping the gun a bit, especially since the BP may be baseline for this pt. and per report the pt. is Alert and Oriented. Albumin? not so sure about that either. I think checking some lytes is in order due to the ectopy.---maybe the pt. needed dialyzed...difficult to say--due to the fact that I don't know the pt's entire history.

[TLCinCICU]

This scenario reminds me a bit of what a nursing school instructor said "Treat your patient, not the numbers!" Some of our little cardiomyopathy patients are on such high doses of beta blockers, ace inhibitors/ARBs, and diuretics that their BASELINE SBP is usually around 85. They mentate well, even joke with you, and make urine (not so with an ESRD). I make certain the MDs are aware, but just watch the patient closely and hold off on fluids.

Since you said your patient had been GIVEN fluid during her dialysis treatment, it was a great idea to get her to a higher level of care. Some patients really NEED the better filling time that comes along with a lower heart rate. (The higher the heart rate, the less fill time between beats.) Getting the heart rate under control was a priority. Our docs would likely have gone with an amiodarone bolus & drip.

I'll never forget one occasion where I was able to wean a Neosynephrine drip OFF by GIVING metoprolol IV. The patient was in A Fib and on a cardiazem drip. The metoprolol lowered the heart rate, which then enabled me to wean the cardiazem off, which resulted in a higher BP - giving me the wiggle room to wean the neo drip off. One would never think that giving metoprolol would ever result in a higher BP!

[MarkHammerschmidt]

It's simple enough - slowing a patient's rate when they're in rapid AF or whatever gives them better chamber filling time, so their pressure improves. Breaking the AF will also give them back their atrial kick, which is something like 25% of cardiac output, so that's helpful too.