Asymptomatic Hypotension

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Hey everyone -

So last week, I was called to see a patient by nursing who informed me that they couldn't get blood pressures on a patient. (I'm an intern). Very concerned, I rushed to the bedside and found an alert and oriented patient, who felt no different than usual (no lightheadedness, no diaphoresis, no pain/nausea/sob, etc, sitting up comfortably in bed and smiling). I breathed a huge sigh of relief. She had ESRD and had 4L removed the day prior in HD. We used dopplers to finally check a BP and got 60-70's/40's wherever we tried. She had weak but palpable periperhal pulses (her usual). I used the cuff/doppler on myself to ensure that it was working (it was). Manual BP's were also low. She was not tachy (I don't remember her HR, but it was not above 100). She had a history of HTN, but generally had very labile BP's in the past (per her PCP and during her hospitalization) and systolics had ranged from 90s to 140's systolic; a few hours prior she was in the 100's - 110's.

I called my senior in, who wasn't very concerned as the patient was asymptomatic. I agreed. My attending happened to stroll in at the time (this was during the day), and he also was not concerned given there were no symptoms and the patient was mentating as usual. However, nursing was very uncomfortable with these readings. He said to them - forget the number - look at the patient - she is FINE, and nursing made the argument that she could be hypoperfusing and we just can't tell. My attending said we could give up to a liter if we want as a series of 250 cc bolus and see if that would bring up the BP, but he did not want to give more than that.

Over the course of the next few hours, she contined to have a systolic in the 70's despite 4 fluid boluses, and she remained completely asymptomatic. Concerned that we weren't doing enough (or maybe they just wanted a fresh opinion) nursing called in the rapid response team. Rapid response (basically a chief resident) came by and once they saw the patient was asymptomatic, was also not worried. However, nursing continued to be really worried about these low blood pressures, and wanted her transferred to the step down unit for better monitoring, and they thought she might need pressors as fluid was not bringing her systolics up. So we transferred her.

The next morning, the attending on that patient came by to tell me that the patient was doing fine in the step down unit, her systolics were back to normal (without more fluid or pressors), and the patient never had any sequelae from that episode of prolonged, asymptomatic hypotension. He figured she probably never needed to be transferred.

So my question for you all is: what do you do when you have a patient who has hypotension but is COMPLETELY asymptomatic? Do you worry? If you do not, how do you reassure nursing? Do you transfer them to a different unit? I've heard that palpable pulses mean that systolic pressure is at least 80. In your experience, is this true?

I tried to find some literature on all of this, but couldn't. If any of you find something, please post it here!

Thanks.

 

[colbgw02]

When I did a rotation in cardiology I was assigned to a CHF service. We saw this type of patient routinely. Your, your resident's, and your attending's response were spot-on. Treat the patient, not a number. Not to pile-on, but your story is a protypical example of the difference between being a nurse and a physician.

 

[michaelrack]

Once you decided that the patient was asymptomatic and the low bp's didn't need treatment, you should have ordered less frequent bp checks on the patient. If you order frequent nursing bp checks on a patient, of course the nurses are going to expect you to treat abnormal values.

 

[OB1🤙]

Damn, you guys let yourselves get pwned by nursing.

This story is absolutely hilarious.

Treat the patient, not the monitors. And for Chrissake, treat the patient, not the nurses.

Nursing did what was absolutely appropriate- pointed out that these numbers scared the poop out of them. And you did what was absolutely appropriate- medically evaluated the patient and determined that all was well.

That really should have been the end of the story.

 

[dragonfly99]

This is a common situation on the medicine wards, particularly with renal dialysis patients and cardiac patients. There are many CHF patients who ALWAYS have a BP in the 80's or 90's systolic at best, and will be awake and normally mentating at that blood pressure. I totally understand why you were initially concerned about this.

It sounds like they probably might have taken a little too much off during her last dialysis session, perhaps. However, I think that 250cc boluses are weeny boluses and really you are treating the nurses with those...your attending knows this but was trying to help you out by giving you something to do so that they would stop harrassing you!

I agree with everything you did. The only things I would have done differently were
a) When the nurse first called you about the very low blood pressure, woudl have asked her if the patient was awake and alert...she will probably get irked and tell you you have to come see the patient, blah blah blah, which is fine and warranted (initially) but it tells you whether you need to run/rush to the bedside vs. normal speed.
b) You didn't need to transfer the patient because it wasn't medically indicated. The patient had a stable low blood pressure of known etiology (because she's a renal dialysis patient with known labile blood pressure, and was awake and alert with no change in her clinical status, which seems to have been at her baseline). You probably could/should have gotten your resident (i.e. someone higher) to help you resist the pressure to transfer the patient to a higher level of care.

Calling the "rapid response team" is a common occurrence when the nurses don't agree with the intern and/or resident's medical assessment of a patient. Occasionally the nurses are right, so don't feel offended by that. Sometimes they are not right...your RRT's response here just shows that you were in the right with your original decision.
I do think you should have gotten your resident's help (and or the renal fellow) to try to resist the nurse's demand that you transfer the patient, because it wasn't medically indicated. However, I have been in a similar situation and the problem is the nurses may often "write you up"
if you won't do what they want, which can be more trouble than it's worth...I mean is it worth it to end up in your program director's office b/c a nurse got mad at you? I say no.

Interesting post!

 

[Joe Richards]

Hey everyone -

So last week, I was called to see a patient by nursing who informed me that they couldn't get blood pressures on a patient. (I'm an intern). Very concerned, I rushed to the bedside and found an alert and oriented patient, who felt no different than usual (no lightheadedness, no diaphoresis, no pain/nausea/sob, etc, sitting up comfortably in bed and smiling). I breathed a huge sigh of relief. She had ESRD and had 4L removed the day prior in HD. We used dopplers to finally check a BP and got 60-70's/40's wherever we tried. She had weak but palpable periperhal pulses (her usual). I used the cuff/doppler on myself to ensure that it was working (it was). Manual BP's were also low. She was not tachy (I don't remember her HR, but it was not above 100). She had a history of HTN, but generally had very labile BP's in the past (per her PCP and during her hospitalization) and systolics had ranged from 90s to 140's systolic; a few hours prior she was in the 100's - 110's.

I called my senior in, who wasn't very concerned as the patient was asymptomatic. I agreed. My attending happened to stroll in at the time (this was during the day), and he also was not concerned given there were no symptoms and the patient was mentating as usual. However, nursing was very uncomfortable with these readings. He said to them - forget the number - look at the patient - she is FINE, and nursing made the argument that she could be hypoperfusing and we just can't tell. My attending said we could give up to a liter if we want as a series of 250 cc bolus and see if that would bring up the BP, but he did not want to give more than that.

Over the course of the next few hours, she contined to have a systolic in the 70's despite 4 fluid boluses, and she remained completely asymptomatic. Concerned that we weren't doing enough (or maybe they just wanted a fresh opinion) nursing called in the rapid response team. Rapid response (basically a chief resident) came by and once they saw the patient was asymptomatic, was also not worried. However, nursing continued to be really worried about these low blood pressures, and wanted her transferred to the step down unit for better monitoring, and they thought she might need pressors as fluid was not bringing her systolics up. So we transferred her.

The next morning, the attending on that patient came by to tell me that the patient was doing fine in the step down unit, her systolics were back to normal (without more fluid or pressors), and the patient never had any sequelae from that episode of prolonged, asymptomatic hypotension. He figured she probably never needed to be transferred.

So my question for you all is: what do you do when you have a patient who has hypotension but is COMPLETELY asymptomatic? Do you worry? If you do not, how do you reassure nursing? Do you transfer them to a different unit? I've heard that palpable pulses mean that systolic pressure is at least 80. In your experience, is this true?

I tried to find some literature on all of this, but couldn't. If any of you find something, please post it here!

Thanks.

Once I had a patient with chronic CHF. His ejection fractions were very low and he could not exert himself at all. During regular walking he would get winded but when sitting around he was fine. Obviously his blood pressure was very low even with all medical intervention.

If you patient is asymptomatic and you have a good regular pulse and she has been hypotensive for some time then she really does not need anything more than observation.

The fact the she has lost blood recently is important and she could have suffered myocardial damage. Therefore simple observation is important. Regular BP, rate etc. If she gets lightheaded or has palpitations it may be time to do something.

If you did not put her on fall precautions then it should have been done. A rapid drop in blood pressure could cause her to get dizzy and fall.

Oh yes the nursing staff. Let's see 2 attending, a chief resident and several interns all said there is nothing to worry about.

So did you ask the nurses where they got their collective MD from? 🙂 just kidding.

They were just practicing the politics of CYA. Go along with it because intership and residency could be very long and because sometimes you can't ignore a good nurse's call to action. They are on the front line.

 

[Samoa]

Sometimes hospitals have policies that allow the nurses to transfer patients even if the physician doesn't think it appropriate. The usual excuse is that the patient was taking up too much nursing time. So you have to be careful about over-monitoring a stable patient just to appease nursing.

 

[NotAProgDirector]

Perhaps I am naive, but in my experience the problem here is usually a failure of medicine and nursing to communicate. The nurse was worried about the patient's low blood pressure -- which is a good thing, because I'm sure there are stories of a nurse finding a BP of 80/40 and deciding not to worry about it, which is much worse. She contacts you. You evaluate the patient. You get backup. You decide that the BP is not a concern. So far, so good.

What happens next? You need to sit down with the nurse, and explain the situation. Why is she uncomfortable? Probably because 1) the book says this is bad and can lead to death; 2) she has 15 other patients and doesn't have enough time to check the BP every 10 minutes, etc. Perhaps (in my world which is populated with free milk and cookies at all nursing stations for the hard working interns) if you explained what was going on, why you were not worried, etc, you could calm her fears. Perhaps not -- but in that case all is not lost either. You would tell her that you'll be back in 30 minutes to assess the situation again, that gives her a plan with an endpoint, which is what she needed. There are plenty of "needy nurses" out there, and the best defense is a good offense. "Don't worry about it" isn't going to cut it for most nurses, especially those that are new or have poor backup systems themselves.

I'll probably get flamed for this, but in my experience it takes an extra 5 minutes to get the nurse involved with the plan and then saves hours later. It can be frustrating, as some nurses seem to have no clue about clinical care.

 

[Soup]

Similar to what others have said . . .sometimes it's necessary to help nursing figure it out. In this case -- You're worried about hypoperfusion? Hypoperfusion of what? The pt's brain? What happens when the brain is not getting enough blood? confusion, lighheaded, sleepy, dizzy, loc? Does this pt have this? if no, then no hypoperfusion. I'll check back later but unless something changes I'm not terribly concerned and neither should you be.

 

[SLUser11]

Perhaps I am naive, but in my experience the problem here is usually a failure of medicine and nursing to communicate. The nurse was worried about the patient's low blood pressure -- which is a good thing, because I'm sure there are stories of a nurse finding a BP of 80/40 and deciding not to worry about it, which is much worse. She contacts you. You evaluate the patient. You get backup. You decide that the BP is not a concern. So far, so good.

What happens next? You need to sit down with the nurse, and explain the situation. Why is she uncomfortable? Probably because 1) the book says this is bad and can lead to death; 2) she has 15 other patients and doesn't have enough time to check the BP every 10 minutes, etc. Perhaps (in my world which is populated with free milk and cookies at all nursing stations for the hard working interns) if you explained what was going on, why you were not worried, etc, you could calm her fears. Perhaps not -- but in that case all is not lost either. You would tell her that you'll be back in 30 minutes to assess the situation again, that gives her a plan with an endpoint, which is what she needed. There are plenty of "needy nurses" out there, and the best defense is a good offense. "Don't worry about it" isn't going to cut it for most nurses, especially those that are new or have poor backup systems themselves.

I'll probably get flamed for this, but in my experience it takes an extra 5 minutes to get the nurse involved with the plan and then saves hours later. It can be frustrating, as some nurses seem to have no clue about clinical care.

I don't think it's unreasonable for a nurse to be worried about an elderly patient with systolics in the 60s and thready peripheral pulses. Especially when you just took 4L off her. Transfering her to a stepdown unit for the night, especially if the nurse is uncomfortable and is going to bug you all night, seems like a prudent course of action.

These are by far the two best posts I've read in this thread, and I should point out to the medicine residents that one of them came from an orthopaedic. I think it's very cavalier and careless to dismiss someone's new-onset hypotension as "probably nothing" because they're asymptomatic.

I don't think being asymptomatic means a low blood pressure doesn't need a workup. Therefore, simply talking to the patient and deciding she is asymptomatic is an inadequate workup.


We see plenty of these hypotensive dialysis patients on surgery, as where I'm from, they're usually admitted to the transplant service. The patient was probably fine, but there was an acute decrease in their blood pressure, to the point where you had to use a doppler to get a reading. In this situation, do you really trust the cuff reading? If there is any doubt about the pressure, you can always get invasive monitoring as well.

It sounds like you guys did a poor job of communicating with the nursing staff as well, which is an extremely important aspect of this story.



Take home point: Be very careful about the bad habits that you absorb from your senior resident. Until you know WHY you shouldn't worry about something, you should freaking worry about it.

I'm just very surprised that most people have seen this as being a nursing problem....

 

[DarthNeurology]

I don't think it's unreasonable for a nurse to be worried about an elderly patient with systolics in the 60s and thready peripheral pulses. Especially when you just took 4L off her. Transfering her to a stepdown unit for the night, especially if the nurse is uncomfortable and is going to bug you all night, seems like a prudent course of action.

When I first read the post it seemed like a patient who most likely was "OK", but one that might require a higher level of monitoring and evaluation. I felt really stupid reading the posts from the attending and felt that I was overeacting, but hearing APD and a resident pipe up makes me want to chime in.

There is a bit of a difference between a blood pressure of say 62/40 versus 78/49. I think we all would agree that the amount of fluid taken off during dialysis was the cause. In any patient I would be a little concerned when the MAP is below 60, especially in a known hypertensive. It wasn't as if she normally had low blood pressure. I would not take the lack of tachycardia to mean that she is not volume depleted as she could be on a beta blocker and she is obviously hypotensive secondary to volume depletion.

I know, I have heard the "Don't treat a number, treat a patient" more times than I care. But we do treat numbers. For example an asymptomatic clinic patient with BP of 190/120 . . . would lead to treatment i.e. medications. Conversely, we have probably all seen COPD patients with sky high PCO2 that wouldn't require intubation in such a patient who looks fine. It is reassuring to see a patient who has good mentation, but that is all it is, reassuring. A number like a CD4 of 0 or a very low blood pressure needs to be evaluated, i.e. ID consult for suspected hiv/aid or like our patient here. While some numbers are meaningless in certain patients, vital signs are always important and should be evaluated to one extent or another.

The lynch pin for the medicine team in determining management seemed to be that she was neurologically intact. What if this changed though? The only way to know would be with more frequent observation, i.e. in a step down unit or higher level of care. I think leaving her on a busy ward might be a bad idea as the nurses wouldn't have time to do neurochecks q 2 hours or so . . .

I would have stated to infuse 1 Liter slowly and check her myself every hour or so, and continue to bolus. It might be nice to take a look at another end organ, i.e. monitor her urine output hourly (which would require again higher level of care) which if low then you would want to be more aggressive with fluid and pressors regardless of neuro level. I have seen patient who were more or less neurologically intact, but had hypotension and were in the ICU being treated with pressors and fluids so I don't think using neuro status alone is good as it is just part of the picture.

I don't think rapid response is much help as this isn't acute, but is a potentially life threatening condition which you treat with more long-term care over hours instead of during a crash situation.

I would have gone the in between route and told the nurses that we would bolus 1 liter of fluid, and that I would comeback in a hour to reasses the patient at that time. . . Considering the clinical course it probably would have meant making 5-6 trips to check up on this patient at night, perhaps 30 minutes total time. What I wouldn't want to happen is not to check the patient for 8 hours and in the morning they discovered she died.

What does "not being worried" mean? Does this mean doing nothing, i.e. no fluids, no neurochecks until rounds tomorrow, or does this mean staying on top of the situation with boluses and checking up on the patient every 2 hours but not letting the nurses freak me out? I'd rather be wrong for too much vigilance than not enough in this case.

The nurse might not be wrong in wanting more care as she is the one, she probably figured, would have to check the patient's bp throughout the night as well as neurochecks. If this patient did have neuro changes, chest pain 2ndary to MI, or low urine output it would not be a surprise. If she didn't have CHF I don't see why more than 1 liter would be OK as I assume she didn't present in fluid overload. 4 Liters sounds like too much to take off to me . . .

 

[DarthNeurology]

These are by far the two best posts I've read in this thread, and I should point out to the medicine residents that one of them came from an orthopaedic. I think it's very cavalier and careless to dismiss someone's new-onset hypotension as "probably nothing" because they're asymptomatic.

I don't think being asymptomatic means a low blood pressure doesn't need a workup. Therefore, simply talking to the patient and deciding she is asymptomatic is an inadequate workup.


We see plenty of these hypotensive dialysis patients on surgery, as where I'm from, they're usually admitted to the transplant service. The patient was probably fine, but there was an acute decrease in their blood pressure, to the point where you had to use a doppler to get a reading. In this situation, do you really trust the cuff reading? If there is any doubt about the pressure, you can always get invasive monitoring as well.

It sounds like you guys did a poor job of communicating with the nursing staff as well, which is an extremely important aspect of this story.



Take home point: Be very careful about the bad habits that you absorb from your senior resident. Until you know WHY you shouldn't worry about something, you should freaking worry about it.

I'm just very surprised that most people have seen this as being a nursing problem....

What would be adequate workup for this patient? I am guessing urine outputs, maybe a cardiac echo just to see where she is, serial neurochecks q 6 hours, then see what her reaction is to one liter of fluid, maybe d/c htn meds too if not already done, ??

 

[holidoc]

I agree with SLUser11 (i think that was the usrname). It would be concerning if you WERE NOT compelled to rule out some sort of decompensation in this scenario. One should clinically assess perfusion of the vital organs (brain, liver, kidney, heart), especially with vasculopaths, diabetics, and hypertensives. Hypoperfusion can be readily assessed with good clinical observation (uop, loc) and routine labs (CK's/MB's/Trop's, LFT's, ABG). Confirming good IV access and placing an art-line will lower nursing sphinctor tone and spare the patient unnecessary misadventures.

 

[SLUser11]

What would be adequate workup for this patient? I am guessing urine outputs, maybe a cardiac echo just to see where she is, serial neurochecks q 6 hours, then see what her reaction is to one liter of fluid, maybe d/c htn meds too if not already done, ??

You mention urine output a few times in your posts, but you forget the patient is ESRD. If she makes any urine at all, it definitely won't be a good measure of fluid status.

The main workup, which may have been done, but not conveyed by the OP, would start with:
1. a thorough chart review: PMHx, Details of
dialysis, BP trends, meds (including B-block, other anti-hypertensives).

2. Thorough PE, examining mucous membranes and other physical signs of dehydration, subtle signs of organ hypoperfusion, arrythmia, etc.
----This would also include an assessment of the reliability of your recorded blood pressure and your means of obtaining that pressure. Perfect example of an inadequate but frequently used method: BP cuff on the calf of a super-fatty. Or, which arm is being used, and which arm has the AV fistula....


These are the first two that I see missed alot. I got the impression from the OP that the senior resident gave the patient a weak once-over and said "don't worry about it."

3. Goal-directed testing: This has to be based on clinical suspicion, so I can't really say for this patient specifically, but:
---Can the pt's problems be cardiogenic? Med related? Do they need an EKG? Silent MIs are rampant in the diabetic renal failure community. Do they need labs?

---Can it be sepsis? Do they need cultures/antibiotics? This obviously would be unlikely for this patient, but still needs to be considered.

---Does the patient need better access? Does she need an art line for reliable invasive measurements? Does she need a central line for CVPs? Once again, I think it's reasonable to avoid this in the patient of question.

4. Decision regarding disposition: Are they safe where they're at? Do they need closer monitoring?

------And my answer here is: If the nurse doesn't feel comfortable taking care of the patient, and you have the reasonable resources to transfer the patient, you should probably do it.




Basically, a good physician has a systematic way of considering multiple explanations and ruling them out in an efficient and goal-directed manner. This is something that is obtained over time (which as a PGY-3 I obviously haven't perfected yet), and which an intern is not expected to be able to do alone. However, if that intern is a cowboy, or the senior resident sets a bad example, you may get away with it 99 times....but the 100th time, your patient dies.



:::::Stepping down off of soapbox, and headed to ER to drain butt-puss:::::

 

[sandraf]

You mention urine output a few times in your posts, but you forget the patient is ESRD. If she makes any urine at all, it definitely won't be a good measure of fluid status.

The main workup, which may have been done, but not conveyed by the OP, would start with:
1. a thorough chart review: PMHx, Details of
dialysis, BP trends, meds (including B-block, other anti-hypertensives).

2. Thorough PE, examining mucous membranes and other physical signs of dehydration, subtle signs of organ hypoperfusion, arrythmia, etc.
----This would also include an assessment of the reliability of your recorded blood pressure and your means of obtaining that pressure. Perfect example of an inadequate but frequently used method: BP cuff on the calf of a super-fatty. Or, which arm is being used, and which arm has the AV fistula....


These are the first two that I see missed alot. I got the impression from the OP that the senior resident gave the patient a weak once-over and said "don't worry about it."

3. Goal-directed testing: This has to be based on clinical suspicion, so I can't really say for this patient specifically, but:
---Can the pt's problems be cardiogenic? Med related? Do they need an EKG? Silent MIs are rampant in the diabetic renal failure community. Do they need labs?

---Can it be sepsis? Do they need cultures/antibiotics? This obviously would be unlikely for this patient, but still needs to be considered.

---Does the patient need better access? Does she need an art line for reliable invasive measurements? Does she need a central line for CVPs? Once again, I think it's reasonable to avoid this in the patient of question.

4. Decision regarding disposition: Are they safe where they're at? Do they need closer monitoring?

------And my answer here is: If the nurse doesn't feel comfortable taking care of the patient, and you have the reasonable resources to transfer the patient, you should probably do it.




Basically, a good physician has a systematic way of considering multiple explanations and ruling them out in an efficient and goal-directed manner. This is something that is obtained over time (which as a PGY-3 I obviously haven't perfected yet), and which an intern is not expected to be able to do alone. However, if that intern is a cowboy, or the senior resident sets a bad example, you may get away with it 99 times....but the 100th time, your patient dies.



:::::Stepping down off of soapbox, and headed to ER to drain butt-puss:::::

Great post, thank you. 👍

 

[DarthNeurology]

You mention urine output a few times in your posts, but you forget the patient is ESRD. If she makes any urine at all, it definitely won't be a good measure of fluid status.

The main workup, which may have been done, but not conveyed by the OP, would start with:
1. a thorough chart review: PMHx, Details of
dialysis, BP trends, meds (including B-block, other anti-hypertensives).

2. Thorough PE, examining mucous membranes and other physical signs of dehydration, subtle signs of organ hypoperfusion, arrythmia, etc.
----This would also include an assessment of the reliability of your recorded blood pressure and your means of obtaining that pressure. Perfect example of an inadequate but frequently used method: BP cuff on the calf of a super-fatty. Or, which arm is being used, and which arm has the AV fistula....


These are the first two that I see missed alot. I got the impression from the OP that the senior resident gave the patient a weak once-over and said "don't worry about it."

3. Goal-directed testing: This has to be based on clinical suspicion, so I can't really say for this patient specifically, but:
---Can the pt's problems be cardiogenic? Med related? Do they need an EKG? Silent MIs are rampant in the diabetic renal failure community. Do they need labs?

---Can it be sepsis? Do they need cultures/antibiotics? This obviously would be unlikely for this patient, but still needs to be considered.

---Does the patient need better access? Does she need an art line for reliable invasive measurements? Does she need a central line for CVPs? Once again, I think it's reasonable to avoid this in the patient of question.

4. Decision regarding disposition: Are they safe where they're at? Do they need closer monitoring?

------And my answer here is: If the nurse doesn't feel comfortable taking care of the patient, and you have the reasonable resources to transfer the patient, you should probably do it.




Basically, a good physician has a systematic way of considering multiple explanations and ruling them out in an efficient and goal-directed manner. This is something that is obtained over time (which as a PGY-3 I obviously haven't perfected yet), and which an intern is not expected to be able to do alone. However, if that intern is a cowboy, or the senior resident sets a bad example, you may get away with it 99 times....but the 100th time, your patient dies.



:::::Stepping down off of soapbox, and headed to ER to drain butt-puss:::::

Thanks for the reply!

I can't believe I suggest UOPs for an ESRD patient, guess that is what happens when you post late at night while trying to do two other things. If the patient is afebrile (which I guess wasn't mentioned) and had no obvious source, i.e. wasn't being treated for a UTI, then I would put sepsis lower down on the list.

I would be worried also about cardiac etiology and would consider EKG and echo too maybe.

 

[Joe Richards]

Thanks for the reply!

I can't believe I suggest UOPs for an ESRD patient, guess that is what happens when you post late at night while trying to do two other things. If the patient is afebrile (which I guess wasn't mentioned) and had no obvious source, i.e. wasn't being treated for a UTI, then I would put sepsis lower down on the list.

I would be worried also about cardiac etiology and would consider EKG and echo too maybe.

This patient required observation first with a close eye on the vitals.

An EKG MAY have been called for but Echo? No.

As the original post noted the patient was stable the next day. Even the ATTENDING did not want to do anything.

Asymptomatic was the key word. Close observation was the treatment of choice along with a good physical exam. Re-assurance and good communication with the nurses should have been the next step.

I'm not making light of the situation but taking the shotgun approach is not a good idea.

 

[NorCaltoSoCal]

Great post. I second the idea of checking BP again yourself. Got called as senior once to bedside of "hypotensive" pt, BPs 60s-70s/40s, to help out the junior resident who was having trouble with a central line. I get to the bedside and the the introducer is already in place but the wire isn't threading smoothly past 10cm. I look and the BP cuff is on the ankle in a thin woman. I put the cuff on her arm and she had BP 140/80. She ended up being fine and not needing a line in the first place.

 

[SLUser11]

This patient required observation first with a close eye on the vitals.

An EKG MAY have been called for but Echo? No.

As the original post noted the patient was stable the next day. Even the ATTENDING did not want to do anything.

Asymptomatic was the key word. Close observation was the treatment of choice along with a good physical exam. Re-assurance and good communication with the nurses should have been the next step.

I'm not making light of the situation but taking the shotgun approach is not a good idea.

I absolutely agree. That is what I meant by "efficient and goal-directed." It is reasonable to do numbers 1 and 2 of my previous post, and decide no tests are necessary, but you can never jump to a decision not to worry about this sort of thing.

Still, I don't think that you can focus entirely on the patient being "asymptomatic," especially without knowing how deep the residents probed to find subtle symptoms. Also, the patient being fine the next day seems somewhat irrelevant to the argument, as plenty of patients survive crappy care.

Overall, I agree that the two most important factors here are 1) close observation and 2) communication with the nursing staff.

 

[Substance]

I don't know enough about the patient to form a completely valid opinion, but I'll try with the information I have.

If a patient acutely drops her BP down into the 70s with a crappy pulse, I believe a workup has to be done regardless of the patient's symptoms.

The fluid that was removed was more than a day ago, so the fluid that was lost probably isn't the cause of her acute drop.

Thusly, with an acute drop, I'd be worried most about cardiogenic causes of hypotension. I will assume that this patient has diabetes, since most people with ESRD seem to. Since diabetes can mask the pain and tachycardia of an MI, I'd be hard pressed to just put off her hypotension as a normal variant. Thus, I'd ECG her, and get some Troponins. I mean, she's gonna be in the hospital for a while anyway - might as well get a Trop.

Her renal failure probably makes her nice and clotty too. So, I'd be worried about DVT/PE formation. Unfortunately, this is a bitch to diagnose. I'd have to get more information before I decided whether I'd spiral CT her. But then I'd have to weigh that against the ESRD...rock and a hard place, anyone?

I don't know what drugs shes's on, so I'd review the nursing notes. Maybe they doubled her beta-blocker dose by accident? Who knows?

A thorough physical exam is important too, looking for sources of bleeding or fluid collections etc.

And I'd move her to a step-down unit, just in case everything goes south. She has ESRD, so south is a very likely place for her to go.

 

[SLUser11]

Thus, I'd ECG her, and get some Troponins. I mean, she's gonna be in the hospital for a while anyway - might as well get a Trop.

While I don't necessarily disagree with your line of thought, what are you going to do if those troponins are mildly elevated in your renal failure patient?

Her renal failure probably makes her nice and clotty too. So, I'd be worried about DVT/PE formation. Unfortunately, this is a bitch to diagnose. I'd have to get more information before I decided whether I'd spiral CT her. But then I'd have to weigh that against the ESRD...rock and a hard place, anyone?

This seems like overboard, since PEs of any significance probably wouldn't present as asymptomatic hypotension. That being said, if there was some reason to suspect this, I think someone already on dialysis is actually an excellent candidate for CT, since their kidneys are already done dealing, so no real rock/hard place there.



------I'm not being critical of your reasoning, just pointing out some other things to consider. I guess my point is that these patients are extremely complicated, and in my opinion, they're out to trick you. They may look great, and then someone opens a pepsi can in their room, and they go into multi-system organ failure and die in a manner of hours.

I'm just trying to vividly illustrate the point that you can't do a once-over and say "they're probably fine." You'll get away with it alot, but eventually it will bite you.

OK, I feel like I'm done beating the dead horse now......

 

[DarthNeurology]

If a patient acutely drops her BP down into the 70s with a crappy pulse, I believe a workup has to be done regardless of the patient's symptoms.

The fluid that was removed was more than a day ago, so the fluid that was lost probably isn't the cause of her acute drop.

Thusly, with an acute drop, I'd be worried most about cardiogenic causes of hypotension. I will assume that this patient has diabetes, since most people with ESRD seem to. Since diabetes can mask the pain and tachycardia of an MI, I'd be hard pressed to just put off her hypotension as a normal variant. Thus, I'd ECG her, and get some Troponins. I mean, she's gonna be in the hospital for a while anyway - might as well get a Trop.

Her renal failure probably makes her nice and clotty too. So, I'd be worried about DVT/PE formation. Unfortunately, this is a bitch to diagnose. I'd have to get more information before I decided whether I'd spiral CT her. But then I'd have to weigh that against the ESRD...rock and a hard place, anyone?

I don't know what drugs shes's on, so I'd review the nursing notes. Maybe they doubled her beta-blocker dose by accident? Who knows?

A thorough physical exam is important too, looking for sources of bleeding or fluid collections etc.

And I'd move her to a step-down unit, just in case everything goes south. She has ESRD, so south is a very likely place for her to go.

It is hard to correlate the time of HD, i.e. was it 12 or 24 hours ago? Regardless, hypotension post dialysis is common, it may be that the 4 Liters taken off put her on the road to hypotension and that perhaps poor PO intake or something pushed her over the edge. Such as if her HTN meds were just administered and then her bp dropped, I have seen this in patients before, still being down 4 Liters is significant and this patient has dropped her bp post-dialysis in the past.

I would expect her troponins to be elevated as she has ESRD, but I guess good to get a baseline was what you were saying.

If she is not dyspneic then I wouldn't be worried about pulmonary emboli at this point. Surely it would be important to have her on DVT prophylaxis though as for any patient.

 

[DarthNeurology]

This patient required observation first with a close eye on the vitals.

An EKG MAY have been called for but Echo? No.

As the original post noted the patient was stable the next day. Even the ATTENDING did not want to do anything.

Asymptomatic was the key word. Close observation was the treatment of choice along with a good physical exam. Re-assurance and good communication with the nurses should have been the next step.

I'm not making light of the situation but taking the shotgun approach is not a good idea.

I don't think it is a "shotgun approach" to order a TTE in a patient with unexplained hypotension, this is par for the course in many ICUs.

"In the general critical care population, current TTE imaging identifies the great majority of cardiac causes of shock. TTE should be considered not only the initial, but also the principal echocardiographic test in the critical care environment."

[SIZE=-1] (Chest. 2004;126:1592-1597.) Transthoracic Echocardiography to identify or exclude cardiac cause of shock.

Obviously this is not an ICU patient, but that doesn't exclude the possibility of serious cardiac dysfunction as a cause of her hypotensive episode. As an intern I would have gone through the whole possible DDx of hypotension for this patient and tried to eliminate at least a couple of possible etiologies. Since she is ESRD, I would guess that she more likely than most patients could have a component of cardiac dysfunction and I would like to send a cardiac echo report to her PCP with the info about her hypotensive episode as perhaps this could impact her future care. At least where I work, it is easy to order imaging and there aren't any hassles about being to vigilante.
[/SIZE]

 

[OB1🤙]

Upon further review, I agree with the above commentary, and concur that the patient needs serial trops, cordis, a-line, and a TEE. Transfer to the unit nownownow.

After that's done, send for CT-angio head-to-toe. All you really need is the chest, but you know, she's gonna be in the hospital a while anyway. And her kidneys are already boxed anyway, so no worries about the contrast.

Obvious cardiac cath once this workup is complete because, you know, she might have diabetes or something, so everytime she gets hypotensive without a single clinical symptom after dialysis she's probably having a silent MI and should get a full cardiac workup.

On second thought, just make her NPO tonight and schedule her CABG tomorrow.

 

[Joe Richards]

I don't think it is a "shotgun approach" to order a TTE in a patient with unexplained hypotension, this is par for the course in many ICUs.

"In the general critical care population, current TTE imaging identifies the great majority of cardiac causes of shock. TTE should be considered not only the initial, but also the principal echocardiographic test in the critical care environment."

[SIZE=-1] (Chest. 2004;126:1592-1597.) Transthoracic Echocardiography to identify or exclude cardiac cause of shock.

Obviously this is not an ICU patient, but that doesn't exclude the possibility of serious cardiac dysfunction as a cause of her hypotensive episode. As an intern I would have gone through the whole possible DDx of hypotension for this patient and tried to eliminate at least a couple of possible etiologies. Since she is ESRD, I would guess that she more likely than most patients could have a component of cardiac dysfunction and I would like to send a cardiac echo report to her PCP with the info about her hypotensive episode as perhaps this could impact her future care. At least where I work, it is easy to order imaging and there aren't any hassles about being to vigilante.
[/SIZE]

As an attending I disagree but your as an intern you could have done those exercises in your mind to aid in your learning process.

Also, the patient was not in shock and is not in the ICU. She was stable and had been for some time. Shock can sneak up on you but the patient had been stable for a very long time.

If the patient had myocadial damage then an EKG would show something to be concerned about. Something acute.

If the patient had heart failure there would have been edema, SOB, cough, etc.

If she had a PE etc etc............

I can go on but I think you get the point.

Also she just had like 4L removed and has ESRD. Her body is adjusting to this change.

INITIAL WORKUP:

CMP
CBC with diff
EKG (maybe)
AND and excellent Physical Exam (if any abnormalities go from there)
Place the patient on fall precautions and regular BPs, monitor urine output and do regular neuro checks, O2 if sats start to fall below 90 and page intern.

Besides, lets say you did an echo and found that she had heart failure. What would you do for a patient in heart failure with BPs very low and in ESRD???

So you pharmacologically stimulate their failing heart and you can do more damage to the kidneys or the heart. She is already hypotensive and you can't really bolus her too much because she is in heart failure and ESRD. So now you have taken an asymptomatic patient and made her symptomatic to satisfy your curiosity.

You have to remember that an patients with ESRD have adjusted to the problem. Their bodies dynamics have changed.

 

[Joe Richards]

Upon further review, I agree with the above commentary, and concur that the patient needs serial trops, cordis, a-line, and a TEE. Transfer to the unit nownownow.

After that's done, send for CT-angio head-to-toe. All you really need is the chest, but you know, she's gonna be in the hospital a while anyway. And her kidneys are already boxed anyway, so no worries about the contrast.

Obvious cardiac cath once this workup is complete because, you know, she might have diabetes or something, so everytime she gets hypotensive without a single clinical symptom after dialysis she's probably having a silent MI and should get a full cardiac workup.

On second thought, just make her NPO tonight and schedule her CABG tomorrow.

Yes, I feel the same. In fact lets just fix this person right now. I mean really fix her.

Why do we need to stop at a CABG. She needs a new heart and a new kidney and while we are at it lets give her a new look complete with a new wardrobe.

 

[Joe Richards]

I don't know enough about the patient to form a completely valid opinion, but I'll try with the information I have.

If a patient acutely drops her BP down into the 70s with a crappy pulse, I believe a workup has to be done regardless of the patient's symptoms.

The fluid that was removed was more than a day ago, so the fluid that was lost probably isn't the cause of her acute drop.

Thusly, with an acute drop, I'd be worried most about cardiogenic causes of hypotension. I will assume that this patient has diabetes, since most people with ESRD seem to. Since diabetes can mask the pain and tachycardia of an MI, I'd be hard pressed to just put off her hypotension as a normal variant. Thus, I'd ECG her, and get some Troponins. I mean, she's gonna be in the hospital for a while anyway - might as well get a Trop.

Her renal failure probably makes her nice and clotty too. So, I'd be worried about DVT/PE formation. Unfortunately, this is a bitch to diagnose. I'd have to get more information before I decided whether I'd spiral CT her. But then I'd have to weigh that against the ESRD...rock and a hard place, anyone?

I don't know what drugs shes's on, so I'd review the nursing notes. Maybe they doubled her beta-blocker dose by accident? Who knows?

A thorough physical exam is important too, looking for sources of bleeding or fluid collections etc.

And I'd move her to a step-down unit, just in case everything goes south. She has ESRD, so south is a very likely place for her to go.

That is an excellent thought process.
A couple of points.

1. If she had a PE or DVT bad enought to drop her BP that much she would not be asymptomatic.

2. Diabetes may mask the pain but not the Tachycardia or the SOB of MI or and acute CHF or A-Fib.

3. Medication check is an excellent idea. In the original post they said the patient has a history of hypertension. ESRD and hypertension go together.
What if she took her BP meds had the fluid taken out.

4. ESRD, she could be third spacing some of that fluid.

Your thinking is great. This case is good because it lets you look at so many systems all at once.

 

[dragonfly99]

Medicine fellow here,
Agree with drrichards (his workup plan, except collecting urine [b/c she probably won't have any due to being ESRD and dialysis-depended] and opinion about not doing an echo b/c it won't change your management). However, getting cardiac enzymes and/or an echo isn't totally unreasonable (esp. the cardiac enzymes). Remember that depending on which troponin analysis your hospital uses (Trop I vs. Trop T) it may be positive all the time anyway, so trop. by itself is not very useful in dialysis patients. It really sounds like this is just due to the dialysis and patient's h/o labile blood pressure, +/- perhaps just having taken her HTN meds. If I had a dollar for every patient I've seen like this on the renal ward....I'd have my student loans half paid up by now! In our hospital, this patient wouldn't need to be on a step-down unit, b/c the floor nurses are good about monitoring this type of this on the renal/medicine floor, and also you could put the patient on tele, which would put her on additional monitoring without having to transfer her.

But I really like how you all were concered about assessing this, and your thought processes are good. You can take care of my little old lady relatives in the hospital any time!

 

[DarthNeurology]

Also, the patient was not in shock and is not in the ICU. She was stable and had been for some time. Shock can sneak up on you but the patient had been stable for a very long time.

If the patient had myocadial damage then an EKG would show something to be concerned about. Something acute.

If the patient had heart failure there would have been edema, SOB, cough, etc.

If she had a PE etc etc............

I can go on but I think you get the point.

Also she just had like 4L removed and has ESRD. Her body is adjusting to this change.

INITIAL WORKUP:

CMP
CBC with diff
EKG (maybe)
AND and excellent Physical Exam (if any abnormalities go from there)
Place the patient on fall precautions and regular BPs, monitor urine output and do regular neuro checks, O2 if sats start to fall below 90 and page intern.

Besides, lets say you did an echo and found that she had heart failure. What would you do for a patient in heart failure with BPs very low and in ESRD???

So you pharmacologically stimulate their failing heart and you can do more damage to the kidneys or the heart. She is already hypotensive and you can't really bolus her too much because she is in heart failure and ESRD. So now you have taken an asymptomatic patient and made her symptomatic to satisfy your curiosity.

You have to remember that an patients with ESRD have adjusted to the problem. Their bodies dynamics have changed.

First of all, I think that this patient lies in a grey area. A clinic patient with a history of long standing assymptomatic hypotension would most likely not need treatment. This patient's blood pressure has dropped perhaps as low as low 60's over 40's from a hypertensive blood pressure, such that her MAP apparently was less than 60 and more importantly the change in MAP was large. This is not the definition of stable vitals. If anyone presented this patient to an attending and said that she had been "stable" overnight, but that her bp dropped suddenly hasn't painted the whole picture.

I don't see any evidence that her body is adjusting to the loss of 4 Liters per se. Her heart rate hasn't increased to offset her hypotension, perhaps secondary to medication effects. Some dialysis patient's bodies really can "adjust" well to dialysis and don't have such a drop in blood pressure.

A cardiac echo won't make the patient worse as you seem to suggest. This is just another piece of information.

Rather the main treatment decision is how much fluids to give (aside from level of care). Since her dialysis was linked strongly to the hypotensive episode most people would look at giving her some fluid back figuring they took off too much during HD. A cardiac echo consistent with CHF would make me be more conservative when it comes to fluids. I don't know if anyone listen to her lungs for evidence of rales secondary to left heart failure, . . . but that she is not SOB is reassuring, but I have seen patients who did not appear in overt heart failure who had surprisingly poor systolic function on cardiac echo. If this patient is obese and on oxygen anyway it might be easy to overlook signs of CHF, . . .

 

[Hova2005]

Upon further review, I agree with the above commentary, and concur that the patient needs serial trops, cordis, a-line, and a TEE. Transfer to the unit nownownow.

After that's done, send for CT-angio head-to-toe. All you really need is the chest, but you know, she's gonna be in the hospital a while anyway. And her kidneys are already boxed anyway, so no worries about the contrast.

Obvious cardiac cath once this workup is complete because, you know, she might have diabetes or something, so everytime she gets hypotensive without a single clinical symptom after dialysis she's probably having a silent MI and should get a full cardiac workup.

On second thought, just make her NPO tonight and schedule her CABG tomorrow.

Great thread, by the way.

 

[Trifling Jester]

Wow... I guess I am the few (only?) people here who would not have done a damn thing other than sending the intern to do a quick PE to determine that it was actually asymptomatic, after having the nurses confirm that the BP was actually that low with a manual check. No bolus of fluids. No transfer to any stepdown unit or ICU. No additional labs (I'm assuming the patient already has recent labs as they were just dialyzed). No EKG. No echo. Nada.

-The Trifling Jester

 

[SLUser11]

Wow... I guess I am the few (only?) people here who would not have done a damn thing other than sending the intern to do a quick PE to determine that it was actually asymptomatic, after having the nurses confirm that the BP was actually that low with a manual check. No bolus of fluids. No transfer to any stepdown unit or ICU. No additional labs (I'm assuming the patient already has recent labs as they were just dialyzed). No EKG. No echo. Nada.

-The Trifling Jester

I wouldn't say that you're one of the only ones. It seems like this thread is very black and white, with half of the people wanting to do a million dollar workup, and the other half not wanting to even see the patient, when in fact, the situation is in a gray area.

Hopefully, there are some level heads that recognize the happy medium. A thorough review of the chart, physical exam, and close observation are very much in order.

Like I said, though, we're really beating a dead horse here. It's very easy, given the vagueness of the OPs storyline, for each of us to cleverly mold the story in question to support our points. You can focus on the patient's stability and lack of symptoms, and I'll focus on the acute change in pressure, lack of good measurements, etc.

The only reason I got so heavily involved in this thread, which has since turned into a very IM-heavy discussion, was to emphasize to the junior residents to 1) not take uncertainties at face value, and 2) not inherit the bad habits of their senior residents.

 

[Joe Richards]

I wouldn't say that you're one of the only ones. It seems like this thread is very black and white, with half of the people wanting to do a million dollar workup, and the other half not wanting to even see the patient, when in fact, the situation is in a gray area.

Hopefully, there are some level heads that recognize the happy medium. A thorough review of the chart, physical exam, and close observation are very much in order.

Like I said, though, we're really beating a dead horse here. It's very easy, given the vagueness of the OPs storyline, for each of us to cleverly mold the story in question to support our points. You can focus on the patient's stability and lack of symptoms, and I'll focus on the acute change in pressure, lack of good measurements, etc.

The only reason I got so heavily involved in this thread, which has since turned into a very IM-heavy discussion, was to emphasize to the junior residents to 1) not take uncertainties at face value, and 2) not inherit the bad habits of their senior residents.

Part of the reason for all the discussion is that no one has actually seen or touched the patient except the OP. We don't know as much history.

Maybe SDN should start a Case Study section where we can review cases like in Journal club or morning rounds.

 

[Anka]

I don't think it is a "shotgun approach" to order a TTE in a patient with unexplained hypotension, this is par for the course in many ICUs.

"In the general critical care population, current TTE imaging identifies the great majority of cardiac causes of shock. TTE should be considered not only the initial, but also the principal echocardiographic test in the critical care environment."

[SIZE=-1] (Chest. 2004;126:1592-1597.) Transthoracic Echocardiography to identify or exclude cardiac cause of shock.

[/SIZE]

A lot of whether a TTE is going to be appropriate will depend on the environment of care. At many community hospitals, you can't get a TTE in the middle of the night without calling a cardiologist in -- there aren't cards fellows or techs there at two in the morning. So, you do the other stuff first and only get a TTE if you need it.

In an ICU at a large tertiary care center, you have the resources to do a TTE as part of your first line. Which might be a great thing; but it still might be more resource intensive than you really need.

If you're thinking about getting a stat TTE on a floor patient who the RNs are worried about... you should probably transfer them to a higher level of care. It indicates your level of concern is not that of a typical "asymptomatic hypotension" who you're going to observe, wait for tests to come back, not mind waiting for the already high troponins to trend up, etc.

Anka

 

[roja]

I think to start quoting all the advice would suck up half the page. There is alot of good advice here and I think wha the op is seeing is that when you ask 10 doctors a management question, you get 15 different answers.

aPD brings a great point about nursing communication. Make sure to take this as a time to educate and discuss. (However, I have seen this NOT work before and at that point it is time to get a nursing supervisor involved if it involves transfers etc that are inappropriate).

Tired makes an excellent point about transfering. Pick your battles.

In terms of what to do, the most salient advice here seems to be:

Look at the patient
Make sure you have thought about what might be the bad causes of what is going on.
Ask yourself if the results of any test you are ordering is going to change anything you are going to do for the patient.

 

[DarthNeurology]

Part of the reason for all the discussion is that no one has actually seen or touched the patient except the OP. We don't know as much history.

Maybe SDN should start a Case Study section where we can review cases like in Journal club or morning rounds.

That is a really great idea, if someone like a resident could give a little more info about a patient, although the OP did an ok job, such as past med history, meds, a more complete picture, and then work through the case overtime as inpatient workup occurs.