Hypotensive dialysis patient in resp distress

[gman33]

Had an interesting patient the other day.

ESRD missed HD. Last session 4 days ago.
Respiratory distress, likely pulmonary edema.
B/L upper extremity grafts, currently has no IV access.

BP 140's systolic, but the BP cuff is on his lower arm because of the grafts, not sure if it is legit.
Reports O2 sat in field in the 60's, in ED on O2 it is 92%.

My thought is the guy will need to be intubated, but we give BiPaP a shot.
He looked terrible on arrival, but after 10 minutes of Bipap, he is looking a little better.
My attending wants to try some Nitro.
No bolus, start gtt at 20 mcg/min.
After 5 minutes, BP is now 105 systolic. Shut off gtt.

Sating 100% on bipap. But BP readings are labile.
Some readings 100. Some readinging 75 systolic.

Not able to get HD for at least a few hours.
Doing much better from a resp standpoint.
Electrolytes normal.

Any thoughts on how to manage this patient.

Looking back I might have changed a few things.
We screwed around trying to get an IV.
I would have put in an IO within 1 minute of looking.

This is probably a perfect guy to get an a-line.
I still have no idea what this guys true BP was.

The BP is a big deal in my mind.
If he was really hypertensive, the nitro may not be a bad idea.
If he was hypotensive, he may have coded.
Again, some thoughts on intubation or not.
If this guy had a true BP in the 80-90 range, intubating may have caused a hypotensive code.
Maybe a little push dose pressor prior to intubation.

I've done a few lit searches and looked in some textbooks.
Haven't been able to find too many discussions on this topic.
Any links to resources would be great.

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[RustedFox]

Wow. Good case.

Sadly, we have a patient that frequents my shop with resp.distress secondary to intentionally missed HD. She does this when she wants to get out of her ECF. No joke.

 

[Hair Police]

These folks (ESRD 2/2 HTN, noncompliant with HD, now in flash pulm edema) are often very hypertensive on arrival (SBP>180) and I will give NTG SL (400 mcgs right there) and BiPap while getting everything else going. Some will also add on captopril SL. That will buy the time to get the line + Tridil started.

IO is a good idea, but usually not well tolerated in awake patients. US-guided peripherals are an alternative. I have also placed central lines in these patients when we had no other access. Nephrology might not like you, but you can access the graft in a life-and-death situation. Consider putting the cuff on his thigh when the upper extremity BPs are in question (still not ideal, I know). I agree that getting an art line would help in this patient.

But your patient came in relatively hypotensive and responded briskly to the NTG. What did the EKG show? Maybe you dealing with cardiogenic shock instead? MI/PE?

 

[xaelia]

This is a nice example of a situation where bedside ultrasound gives you a little bit of useful information re: fluid status and cardiac output – to help differentiate between distributive (sepsis), obstructive, and cardiogenic shock.

If I had to guess, I'd probably suggest the cuff pressures were erroneous – and the initial BiPAP and whiff of nitro fixed the initial acute hypertensive emergency/pulmonary edema, especially if he were apparently stable afterwards.

 

[namethatsmell]

We get these players literally ALL the time (on an overnight a few months ago I had 4 on bipap waiting for HD).

As mentioned above, bipap/nitro is key...so too is prioritizing their potassium. Most of these players don't die quickly from respiratory failure if they're able to talk on arrival and you bipap them.

Too easy to hyperfocus on respiratory status while their potassium sinks them. Get an EKG as bipap is getting set up...don't always need blood to know if they need calcium/whatever else thrown at them asap. While access is still needed to treat them, having the EKG helps me determine if I can give the nurses some time to get a line while I see other pts or if I need to put whatever else I'm doing on hold and go join them. And the meds you want to give will be right there the second you gain access.

As for your patient's BP, if it was legit hypotension (compared to baseline) then there's a good chance something else is going on. Pt's I've had with this have all been septic. The early EKG helps here too.

 

[ORL10]

I feel their pulses if I don't believe their BP. Most people who are hypertensive have readily palpable pulses (yes not always true in its with PVD, but with limited data you use what you can like the thrill in the fistula).

Also US may show a markedly reduced EF which could be because of increased after load or reduced myocardial performance, so you still need to have an idea about "SVR" if you can't get a BP. (if it's a performance issue with increased SVR and low MAP then its cardiogenic shock and you need inotrope, if it's increased after load on a heart with reduced function at baseline and normal/elevated MAP, which is most likely, reducing the after load will improve myocardial performance as mentioned above).

If you put an arterial line in where are you going with that bad boy? Upper extremities with A-V fistulas, probably not ideal. Groin arterial lines in patients on HD are more complicated than you might think, especially if you don't place them that often, try putting a catheter in overweight patients with steel pipes.

 

[FDNewbie]

I just wanna add to always consider/eval for the "can't afford to miss" dx as well. That ESRD,DD player with hypotension = pericardial effusion until proven otherwise... Make sure you check. Takes 30 seconds, and if you miss it, nothing else will really help, and the pt. can decompensate as a result.

 

[engineeredout]

Get these patients so ridiculously frequently. As someone mentioned before, they almost always seem to come in severely hypertensive, and a little sl-ntg + bipap goes a long way.

Not sure I would have started with the nitro drip straight off the bat, as I have seen a little SL-ntg cause the pressure to drop significantly, probably a combination of vasodilation and decreased sympathetic tone from making the patient's breathing easier. Not to mention getting the SL will take about a 1/10th of the time it will to get the drip going, plus it can be started without IV access established yet.