With elders, be cautious with fluid resuscitation
With elders, be cautious with fluid resuscitation
Your patient could be harmed
Aggressive fluid resuscitation, which normally would be used in younger trauma patients, potentially could do serious harm to an elder patient, warns Rhyan Weaver, RN, BSN, CEN, clinical supervisor in the ED at St. Joseph's Hospital and Medical Center in Phoenix, AZ.
"This could cause new problems, such as pulmonary edema in the elder with a preexisting condition such as congestive heart failure," she says.
Also, chronic diuretic therapy can cause chronically contracted vascular volume and low serum potassium, says Weaver. "Rapid crystalloid infusion in this population can potentially cause electrolyte imbalances," she adds.
Normally, fluid resuscitation prompts potassium to shift out of the cells to maintain a normal serum potassium, explains Weaver. "Elders with chronically low potassium levels may not have intracellular reserves to maintain normal serum levels, causing hypokalemia and lethal complications," she warns.
Assess frequently
Hypoperfusion can result in decreased oxygen transport and organ damage, notes Weaver. "So not addressing hypotension can also be fatal," she says. "Be aware of the unique needs of the elder. Complete frequent, thorough assessments to maintain the elder's delicate homeostatic state."
Fluid resuscitation has to be goal-directed to prevent over-resuscitation in the elderly population, says Glenn Carlson, MSN, ACNP-BC, CCRN, a clinical nurse specialist/acute care nurse practitioner at Bronson Methodist Hospital in Kalamazoo, MI. "Markers of resuscitation, such as lactate and/or tissue oxygenation, can be used to help direct efforts to avoid heart failure," he says.
Elevated levels of lactate are related to tissue hypoperfusion that might be the result of under resuscitation, explains Carlson. "Normalizing lactate levels early, within the first 24 hours, has shown to be beneficial," he says.
Steven Glow, MSN, FNP, RN, associate clinical professor at Montana State University College of Nursing in Missoula, notes that the evidence regarding fluid resuscitation in trauma is changing significantly.
The current trend is fluid resuscitation to only 80 mmhg systolic, or a mean arterial pressure of 60 to 65, until all significant bleeding sources have been identified and controlled, says Glow.
"We used to try and resuscitate trauma patients back to a 'normal' blood pressure like 120/80," he says. "Large volumes of fluid that raise blood pressure to 'normal' levels increase the risk of bleeding and death." (See related story, below, on assessment of shock in elder ED patients.)
You could miss these shock signs in elders If you are assessing an elder for the need for fluid resuscitation and shock treatment, your patient's "normal" blood pressure and heart rate might be misleading, says Karen Hayes, PhD, ARNP, assistant professor at the School of Nursing at Wichita (KS) State University. "Elderly patients may appear to have normal blood pressure, heart rate, and urine output while still in shock," she explains. Elder patients are likely to have a history of hypertension and beta blocker use, says Hayes, and therefore, "their underlying comorbidities and decreased physiologic reserve are not always understood." As a result, an occult shock state might go unrecognized. "The majority of traumatic injuries in older adults are from automobile accidents and falls," says Hayes. "These patients must be carefully triaged so that shock signs are not missed." She says to consider these items: Detecting hypoperfusion relies upon invasive monitoring of blood pressure and cardiac function. "This can be accomplished by placing an arterial line and central venous catheter, as well as considering early placement of pulmonary artery catheter insertion," says Hayes. Hayes points to a study that compared elderly trauma patients who appeared clinically stable after initial resuscitation and underwent early-invasive monitoring with historical controls. Researchers found that 43% of patients were in cardiogenic shock, despite normal initial vital signs.1 "The study went on to show that early invasive monitoring led to earlier therapeutic interventions, and reduced mortality by half," says Hayes. "Using invasive monitoring may also assist in preventing fluid overload during fluid resuscitation." Use invasive monitoring via a pulmonary artery catheter to follow cardiac output in shock resuscitation, she recommends. Adequate fluid resuscitation reverses hypoperfusion, while minimizing the complications associated with fluid overload. "This is best accomplished by using end points of resuscitation, which are different from those of younger patients," says Hayes. Reference
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Use lactate levels to gauge elder status If your elder patient is taking beta blockers or has a history of hypertension and end organ dysfunction, then heart rate, blood pressure, and urine output are unreliable markers for shock, says Karen Hayes, PhD, ARNP, assistant professor at the School of Nursing at Wichita (KS) State University. "Instead, lab values such as lactate levels may be a better measure of improvement in an elder," says Hayes. "Lactate levels are drawn if shock is suspected, and should improve if shock is adequately treated. A lactate greater than 4 increases the patient's odds of death."1 Reference
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