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Why the bolus?

Posted

Specializes in Family planning, med-surg.

I had a patient a few days ago getting a blood transfusion, her UOP was low, she was in renal failure. The doctor ordered a 500cc NS bolus. Afterward her abdomen became distended and painful. Her UOP still did not increase. The doctor orders another bolus. By that point my shift was over, I had two days off with her on my mind. I came back and she is not the same lady, the fluid has third spaced, she is obtunded and no doubt will die soon.

I don't understand, why did he order the second bolus? Am I missing something? She obviously wasn't balancing fluid, did he think he could correct it by flooding it like a dam? This is the third time I have seen this, all by different doctors. Why the boluses? What can they possibly do?

You mention she was in renal failure. Was it ARF or CRF?

You also mention that her UOP was low. Was it lower than her norm (considering she's in renal failure)?

The patient was in renal failure from a prerenal cause; they had reduced renal perfusion and the boluses were an attempt to increase it. Prerenal failure is not only the most common cause of renal failure it's also relatively easily reversable. So if an initial 500 cc doesn't increase the B/P and urine output, a second bolus is given with the thought that the patient's fluid volume was still inadequate after the first.

Of course the patient can get fluid overloaded. Physical/clinical monitoring, or watching a CVP or wedge can help with that; the electrolyes can get thrown further out of wack also. So the patient might get some diuretics around all the fluids. And if the patient still isn't putting out urine, then eventually dialysis might be required.

In short, adequate fluids can likely reverse the kidney problem, and in turn might even prevent a progression to acute tubular necrosis etc. BUT the bottom line is the original problem which caused the prerenal failure must be identified and fixed, if possible. If you can do that, you can get rid of the excess fluid and adjust the lytes afterwords. On the other hand if the original problem is not fixable or is responding very slowly to treatment.....you can end up like the patient you described. One thing's an absolute certainty: that extra 500 cc of isotonic fluid did NOT make your patient like you saw her 2 days after---rather it was the underlying cause of the prerenal dysfunction.

LLLLiiiFFEsaveer

Specializes in Emergency Only.

I had a patient a few days ago getting a blood transfusion, her UOP was low, she was in renal failure. The doctor ordered a 500cc NS bolus. Afterward her abdomen became distended and painful. Her UOP still did not increase. The doctor orders another bolus. By that point my shift was over, I had two days off with her on my mind. I came back and she is not the same lady, the fluid has third spaced, she is obtunded and no doubt will die soon.

I don't understand, why did he order the second bolus? Am I missing something? She obviously wasn't balancing fluid, did he think he could correct it by flooding it like a dam? This is the third time I have seen this, all by different doctors. Why the boluses? What can they possibly do?

Acute should probably recieve 150 ml per hour fluids + monitor output. Chronic is another story though... Which one was she? Acute or chronic? Ascites only complicates things. Increases pain. Does nothing for the kidneys. Do they just want to take most of it back out thru paracentisis?

could it be that a goal of pulling off the accumulated fluid, would be to use it as a diagnostic test? Doubt it though...

Sounds like trying to restore effective intravascular volume at a rapid rate was attempted? Basically, without expected results. The increased ascites should have been a sign for re-evaluation of the plan, rather than pumping in more fluids, ultimately resulting in more ascites.Which is not good.

There really is just too much missing from the case you presented, that is, for most of us here to be of any real assistance to the matter. Truthfully, the dynamics are ten-fold per case, with much information required to get it right.

I mean we are probably not talking about postrenal obstruction here are we?

:cool:

diane227, LPN, RN

Specializes in Management, Emergency, Psych, Med Surg. Has 32 years experience.

I would have to know more about the case to comment.

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