Treatment for isolated low diastolic BP?

[SB100]

I had a patient on night float recently that I was paged about because of a low diastolic BP (17 yo, DBP around 40-45) on routine vitals. Assuming this is a stable kiddo and there is an absence of other abnormal vital signs or clinical findings, is there a need to intervene? I wasn't sure how to approach this aside from looking at acute change in pulse pressure, but there was no change in his clinical status.

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[BigRedBeta]

Clinical picture is everything...

For the "normal" 17 y/o patient who comes in b/c of a CF exacerbation, DKA or a flare of their IBD, probably doesn't matter much assuming they're warm and well perfused. Your heme/onc patient admitted for fever and neutropenia may be in septic shock and this could be one of your first clues - and one that warrants careful consideration when choosing a pressor (after giving fluid, obviously).

 

[Stitch]

Agreed, more info is needed. Why was the kid hospitalized and what else is going on? What's his exam like? What's the mean pressure?

The question of how much blood pressure is 'enough' can be difficult to answer, but remember that BP isn't the same as cardiac output, and that the young and healthy can often have lower BPs and heart rates. Or, as BRB notes, it can be an early sign of compromise.

 

[J-Rad]

Agree with above, but first thing is to recheck with a manual cuff and realize that automated cuffs over estimate diastolic hypotension- the "ears" of machines are better than human ears, but human ears hearing the change in Karotkoff sounds (the diastolic BP point) is set by human standards. As part of the clinical scenario, meds are important. If this was an asthma admission and the kid was getting gobs of albuterol, that could cause a (real) diastolic hypotension. More data needed.

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[SB100]

Sorry for the lack of other details. I gave that BP range because that is where it stood after rechecking 3 times over an hour. Without getting into too much details the pt had a presumed upper GI bleed from PUD.

 

[Giic]

Hmmn, what was the weight of the child and what was the systolic BP? A diastolic of 40-45 may be normal for a 17-year old...

In general, (assuming the value was real, and the systolic was normal/high, and the value was considered low for this child, i.e. it was a bigger 17yo who should have a higher pressure, or you had a baseline BP for him that was higher), THEN:
(1) Diastolic BP generally reflects the patient's volume status or reflects the vascular tone.
(2) Diastolic BP is important because it is during diastole that the coronaries (heart) get perfused.
(3) Diastolic BP could be low because there is hypovolemia, or because there is vasodilation (same amount of volume but bigger tank, so not full).
(4) I would start by repeating the BP a few times, then examining the patient --> capillary refill, mental status, heart rate, cool/warm extemities.
(5) If there are no contraindications to fluids, I would try a fluid bolus next. (For example, if the BP is 120/40....... However, if it is 90/40, I may not do anything, with the assumption that maybe this teenager just has lower BPs to begin with).

Let me know if there are questions.