Asymptomatic Hypotension and You...

[daveyjwin]

This isn't really something I see all the time, but It's happened twice in the past month, and I was just seeking guidance on what to do in the future.

Most recent patient, since I can't remember the specifics of the other one: Chronically ill Patient (bedbound, decubituses, PEG, Colostomy, Foley, etc, but awake and alert and otherwise a normal-ish person) with a history of chronic hypotension, normal reported SBP in the 70s-80s, take midodrine daily, gets up to the 90s sometimes, came to the ED from NH for UTI. SBP 70s-80s, completely benign exam, not tachy, no distress, states they feel kinda crummy, but generally pretty normal. WBC 20s, Normal lactic, normal renal function, and otherwise normal workup. Gave some fluids, BP didn't budge. HR solid in the 80s-90s.

Anyway, long story short, I kept getting harassed by both nursing and the admitting physician for not addressing the BP, lining her, starting pressors, etc. Where I come from, I was always told to treat the patient, not the numbers. I got her and her family on board with things, and charted that they don't want aggressive interventions for the BP, but still, it gave me a lot of stress for the five or so hours she was in the ED.

Thoughts on this case, or others like it?

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[iish]

On a beta blocker?

If not febrile and no concern for urosepsis, no reason to artificially inflate BP on a patient at their baseline BP. That's my take at least

 

[USCDiver]

Document document document and if the admitting physician or the nurse wants a central line and pressers then they can do it themselves!

 

[alpinism]

I've seen patients with SBP in the 80s completely asymptomatic talking with family members, sitting up in bed, and even walking to the bathroom.

Had this one patient last year leave AMA with a BP 70s/40s via A line.

Admittedly its rare but it happens sometimes.

 

[Perfect Hair Day]

Is the patient athletic?

 

[The White Coat Investor]

Is the patient athletic?

Yes. He just duct tapes the PEG, Foley and colostomy on and suits up for a basketball game a few times a week.

 

[Perfect Hair Day]

Yes. He just duct tapes the PEG, Foley and colostomy on and suits up for a basketball game a few times a week.

LOL, that's what I get for skimming.

 

[RustedFox]

Yes. He just duct tapes the PEG, Foley and colostomy on and suits up for a basketball game a few times a week.

Took care of an 86 year old man yesterday. Fell off his bicycle. He bikes several miles a day, as per his wife. Foley and leg bag and all.

 

[The White Coat Investor]

Took care of an 86 year old man yesterday. Fell off his bicycle. He bikes several miles a day, as per his wife. Foley and leg bag and all.

Like that's hard. What do you think all those tour de france guys do?

Seriously though, Tom Dumoulin might be interested in a colostomy. He was winning the Giro at the time (still did, despite this break)

 

[gro2001]

Like that's hard. What do you think all those tour de france guys do?

Seriously though, Tom Dumoulin might be interested in a colostomy. He was winning the Giro at the time (still did, despite this break)

Why did he have to take his helmet off though? Like, how bad was this diarrhea?

 

[gro2001]

This isn't really something I see all the time, but It's happened twice in the past month, and I was just seeking guidance on what to do in the future.

Most recent patient, since I can't remember the specifics of the other one: Chronically ill Patient (bedbound, decubituses, PEG, Colostomy, Foley, etc, but awake and alert and otherwise a normal-ish person) with a history of chronic hypotension, normal reported SBP in the 70s-80s, take midodrine daily, gets up to the 90s sometimes, came to the ED from NH for UTI. SBP 70s-80s, completely benign exam, not tachy, no distress, states they feel kinda crummy, but generally pretty normal. WBC 20s, Normal lactic, normal renal function, and otherwise normal workup. Gave some fluids, BP didn't budge. HR solid in the 80s-90s.

Anyway, long story short, I kept getting harassed by both nursing and the admitting physician for not addressing the BP, lining her, starting pressors, etc. Where I come from, I was always told to treat the patient, not the numbers. I got her and her family on board with things, and charted that they don't want aggressive interventions for the BP, but still, it gave me a lot of stress for the five or so hours she was in the ED.

Thoughts on this case, or others like it?

I agree with you. I would not chase the BP in the setting you describe. In fact, as I was reading your vignette I thought you would ask if it was crazy to discharge this patient back to the nursing home. Which I would be tempted to do if the patient wasn't febrile and the nursing home and family could be convinced to take her back.

Couple of questions: did this happen at a community hospital? Who was the admitting physician? Patient's PMD? Recently graduated hospitalist? Old timer hospitalist? IM resident? Was this an admission 40 minutes before their shift ended? I ask because I've noticed that when there is a significant disagreement over management it has often more to do with who you are calling, when, and what the system factors are than with the actual medicine. The exact same consultation question or admission can generate an entirely opposite response depending on things like time of day, bed census, etc.

 

[d2305]

The hard corps bikers pee while riding, and leave their mark on the road.

 

[The White Coat Investor]

Why did he have to take his helmet off though? Like, how bad was this diarrhea?

To get the jersey over his head so he could get the bibs off his shoulders.

 

[PlutoBoy]

This isn't really something I see all the time, but It's happened twice in the past month, and I was just seeking guidance on what to do in the future.

Most recent patient, since I can't remember the specifics of the other one: Chronically ill Patient (bedbound, decubituses, PEG, Colostomy, Foley, etc, but awake and alert and otherwise a normal-ish person) with a history of chronic hypotension, normal reported SBP in the 70s-80s, take midodrine daily, gets up to the 90s sometimes, came to the ED from NH for UTI. SBP 70s-80s, completely benign exam, not tachy, no distress, states they feel kinda crummy, but generally pretty normal. WBC 20s, Normal lactic, normal renal function, and otherwise normal workup. Gave some fluids, BP didn't budge. HR solid in the 80s-90s.

Anyway, long story short, I kept getting harassed by both nursing and the admitting physician for not addressing the BP, lining her, starting pressors, etc. Where I come from, I was always told to treat the patient, not the numbers. I got her and her family on board with things, and charted that they don't want aggressive interventions for the BP, but still, it gave me a lot of stress for the five or so hours she was in the ED.

Thoughts on this case, or others like it?

I think you did the right thing. As long as there's no evidence of hypoperfusion there's no need to take action, particularly given the patient's history.

 

[gro2001]

To get the jersey over his head so he could get the bibs off his shoulders.

I guess I just have to count my lucky stars that I haven't had diarrhea that requires me to fully disrobe. Yet.