Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 101: Clinical Decisions in Orthostatic Hypotension
Orthostatic hypotension (OH) is a common finding in the acute care setting. So, the question is, are there any hard and fast rules surrounding orthostatic hypotension? Are there cut-offs for activity / exercise?
The quick answer is: it’s complicated and it depends. It requires knowledge, experience and clinical judgement every step of the way. Each case, each patient may have different symptoms and different levels of blood pressure dropping at different points in time.
One clear point is assessing vital sign response to position changes and activity are paramount. Assessing your patient and recognizing subtle changes are equally important. And lastly, trusting your gut/intuition has a role as well.
Join me as we discuss the definitions of OH, common symptoms and real case examples.
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Welcome to Talking All Things Cardiopulm. I am your host, Dr. Rachele Burriesci, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions treatment, interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation. Thanks for joining me today and let's get after it. Hello, hello and welcome to Talking All Things, cardiopalm. I am your host, Dr. Rachele Burriesci.
Rachele Burriesci:Happy Monday and happy belated Mother's Day If you're a mom out there, happy, happy Mother's Day. Truly, every day as a mom should be celebrated because of all that you do. But for this special day, I hope you had a wonderful day. I hope you were able to relax, enjoy your family or whatever it is that you wanted to do on that special day. Before we jump into today's episode, just a small call to action. I've officially made all things Cardiopulm business Facebook page something that has been on my to-do list for many years at this point, and I just kind of drug my heels about it. So it has officially been created. It is up and running. It's mostly going to mirror Instagram. Instagram is really my primary social media platform, but there are different populations on different social media networks, and so it does need to exist. So if you do have a Facebook, please give my page a follow. That is, at all things cardiopulm. It's a business Facebook page. It's greatly appreciated.
Rachele Burriesci:A couple other things I will have a product coming out soon. It is officially made, it's ready to go. Just need to start promoting so and get it up for purchase. Right, small details, but I have a breathing exercise home library for clinicians basically to utilize with their clients, and so I'll give a whole bunch more information once I roll that out. But that is coming. If you have interest in this, let me know. Shoot me a text message my text is below in the show notes or shoot me a message on Instagram. I'm curious to see if this would be something that you could utilize. At this moment in time it will be for the individual provider, not larger hospital systems, but we'll see, maybe we can get there.
Rachele Burriesci:One more thing so a couple of months ago I posted a video from Lines and Tubes Tuesday, or Lines Tubes Device Tuesday, and I was utilizing the Pro2. And so I have been utilizing respiratory muscle training with my personal clients. It was going to be my research line in academia and I was using the micro RPM for my MIP/MEP assessment. They have officially discontinued their product, so I was on the search for a new device and I came across Pro2, and I'm absolutely loving this device. It's a awesome assessment tool. I'm gonna do a whole podcast just on its ability for assessment, and then I'm probably gonna do a second podcast on the training aspect of it, and I wanna bring on the inventor. I've already met him. He's this awesome guy from the UK and he has literally 30 years of experience in RMT. Anyway, long story short, more people need to know about the Pro2. I'm hoping to work with them in the future as well. So if you can give a follow to Pro2 on Instagram, facebook and LinkedIn, that would be absolutely awesome. I'm super excited to see this company promote itself because its device is worth its use, and so we'll get more into that another day.
Rachele Burriesci:What I really wanted to talk to you today about was orthostatic hypotension. I have done another episode on orthostatic hypotension, but, as my business coach says, once is never and, more importantly, I have had so many patients with orthostatic hypotension in the last few weeks and months that I absolutely felt like we needed to talk about this. So, first of all, if you want to know more about how to assess and measure and causes and non-pharmacologic techniques to improve OH, go to my prior episode. It's episode 23, titled Assessing and Managing Orthostatic Hypotension. I'm going to go into a lot more of that nitty gritty in that past episode.
Rachele Burriesci:What I really want to talk about today is the clinical decision-making surrounding orthostatic hypotension, because it really is that. It's a clinical decision. There's no right wrong, yes, no absolutes, and I think that's the hard part, especially as new clinicians who are dealing with patients with profound orthostatic hypotension. So the question is like if your patient is orthostatic, is that it? Are you done Like? Are you immediately sitting down, laying down, legs up? Maybe it truly depends, and I'm going to throw it depends out for you right out the gate because it 100% depends.
Rachele Burriesci:There is one population that I'm a little more cautious, conservative with in the world of orthostatic hypotension and that's my post-surgical patients with epidurals. I don't have that episode in front of me, so let me see if I can find it real quick. Probably not, because I'd have to scroll around a little bit, but I have a prior episode on epidurals and just other anesthesias. Take a listen to that if you want nitty-gritty on the actual anesthesia piece, but in the world of orthostatic hypotension, if your patient has an epidural and you are orthostatic, that's pretty much play it safe because it's only going to keep going down.
Rachele Burriesci:The likelihood of syncope is high. I have told every single student I have ever mentored in my career that if you have a patient with an epidural, expect them to pass out until they don't Like. They have to prove you wrong. Until the moment you leave them, epidurals pass out period. End of story. If you have a patient who has an epidural that is post-op, you should be assessing vital signs in all positions throughout your session, even if it's not post-op day one. So back in the day I was in an orthopedic hospital. In that orthopedic hospital we had epidurals all over the place. We had syncopal episodes on the daily. I remember being the person that was always passing a room as someone was syncopating. It became part of my education to new hires on progressing patients with epidurals and to basically play it safe until that epidural is removed, and that includes assessing vital signs.
Rachele Burriesci:It is very, very rare that I ambulate patients with epidurals out into the hallway. Has it happened? Yes, if the patient is showing good vital sign response. Yes, I will progress. I will likely still have a chair ready. Have a chair, follow someone else on the ready, just in case, because you just don't trust an epidural. So the one population I would say is, if you have positive orthostatic response, that's the person that you're probably not going to progress.
Rachele Burriesci:Overall, you have to play the cautious card. If your patient is showing orthostatic, you have to have the thought in your mind that this person could pass out. So what are you going to do to prevent it? What are you going to do to offset it? What are you going to do just in case? Right, that is what this whole conversation is about. I have a whole bunch of different cases in front of me at the moment and I want to kind of talk about their response, maybe what I did or didn't do, and also like, what would you have done in that situation.
Rachele Burriesci:So orthostatic hypotension, just to kind of put a you know definition around it is defined by a drop in systolic blood pressure greater than 20 millimeters of mercury and or a drop in diastolic blood pressure greater than 10 millimeters of mercury within three minutes of standing or greater than 60 degrees on a tilt table In my setting in my acute care world I typically don't have patients on tilt tables. In past places I would use tilt tables to help with orthostatic hypotension management, but for the most part I have not used a tilt table. In my most recent world You're typically helping patients mobilize out of bed for the first time and so you might be going from supine to standing or head of bed elevated. You know the whole bit In theory and I go more into this in episode 23,.
Rachele Burriesci:The way to measure orthostatic hypotension has changed. Orthostatic hypotension has changed. You're now supposed to go from supine resting five minutes to standing, then taking a blood pressure at one minute and three minutes. This is a change. It used to be supine for five minutes, seated for three minutes, standing for three minutes. Definition was the same Drop in systolic greater than 20, diastolic greater than 10. The reason why it was changed was in the world of diagnosing orthostatic hypotension you want to create the most profound effect, so you're going to get a more exaggerated response if you go from supine to stand. So if you're trying to qualify or diagnose someone for orthostatic, that is technically how you do it Supine straight to stand. In the institution that I'm currently at. They still recommend going supine sit, stand for one minute, stand for three minutes.
Rachele Burriesci:As an acute care therapist I'm usually not trying to quote unquote diagnose orthostatic hypotension. If I know someone has orthostatic hypotension, my job is really to try to offset that response. Can I get them to do more for longer and tolerate upright position for longer? So I typically would go supine, head of the bed, elevated bed therex, sitting bed seated therex, reassess, reassess. You know we're doing okay, standing, assess blood pressure. Still unsure I'm going to be doing pre-gate activities like marching heel raises, anything in standing, sidestepping. The goal is to buy yourself time and that is my personal opinion. You want to do enough activity to try to offset orthostatic hypotension and buy yourself time.
Rachele Burriesci:Because there are many different definitions of orthostatic hypotension. It has very much changed in how we approach it, how we look at it. There's a great article I believe it's by the acute care section on orthostatic hypotension, but they basically classify it as the classic orthostatic hypotension, which is a definition that we just talked about dropping 20 systolically, 10 diastolically, within three minutes of standing. Then there's a definition that's considered initial orthostatic hypotension, where your person has an immediate drop but then rebounds, essentially. Then there's the delayed orthostatic hypotension, which can be a little bit more dicey because they're a little bit more unpredictable, and just goes to show how important it is to continue to monitor vitals throughout your session pre, during, post because your patient may present different than other patients, and so a delayed orthostatic basically means that you're going to have the drop in systolic or diastolic after three minutes of time. I actually had a patient recently who we're going to discuss today, because he didn't even fit his own definition, but he would have these syncopal episodes 10, 15, 20 minutes after being up and about like out of nowhere. He would be walking with his wife, he had been up for, you know, a good amount of time and then lights out. It's different, different responses.
Rachele Burriesci:We're not going to go into all the causes. There's a ton of causes for orthostatic hypotension. As a PT, it is not my job to determine the underlying cause, but what I will say is you are part of the conversation and if we can get the team A to recognize potentially orthostatic hypotension, you might be the first person to recognize it. You might be the person to address non-pharmacologic management, but the overall goal here is to help address the underlying cause. So you are part of the conversation with the team. If the underlying cause is addressed, the orthostatic hypotension might be less symptomatic, might be less profound in how much change is occurring. Either way, you should be part of the conversation. I had a point that I was just about to hit and I totally lost it. So, different definitions of orthostatic hypotension In the world of documentation, I like to say impairment of postural tolerance.
Rachele Burriesci:Another way of saying it is orthostatic intolerance, and that essentially gives the reader the information that this person is not tolerating upright positioning. And then you can be more specific to that right, like how far are they able to get? Are they able to maintain sitting? Are they able to maintain standing? Does it occur at a certain point in standing? Either way, that's part of it, right? So I have another episode way back, I think it's like episode three, episode four.
Rachele Burriesci:It's called like do you have a crystal ball? And this is something that I always talk with my students about. As PTs, we're expected to foresee certain things discharge, destination, time for completing goals and recognition that something may or may not happen. We don't have a crystal ball. What we have is clinical experience and knowledge, and when you put those two things together. Over time you can start to predict what can and cannot happen or will or will not happen. And that's really what it's about. It's about using all of your skills. It's about doing a good chart review, utilizing your knowledge, your skill set, reading patients, paying attention to them, their changes, whether it's profound and obvious or subtle.
Rachele Burriesci:Typically, with orthostatic hypotension, the primary symptom is dizziness or lightheadedness. These words are sometimes very difficult because people associate dizziness with spinning and so people like I'm not spinning, I'm not dizzy, and so that can actually be really good in helping to rule out other pathologic things. Right, like BPPV. But sometimes people might just utilize words like I just feel off. When I was in the world of POTS and I was like pre-syncopal, I wasn't dizzy, I felt off, I felt not clear in the brain, I felt the blood rushing to my feet. Right, there's like different verbiage I give.
Rachele Burriesci:I ask patients, right, because they come in and they're like I'm having episodes of syncope or you read it in the chart what do you have? Do you have a symptom? Do you have any sort of warning sign? That's usually how I ask the patient Do you have any warning sign before you pass out? And sometimes they're very specific. Right before I pass out, I get spots in my left eye. Right before I pass out, I get really hot and sweaty. Right before I pass out, my vision starts to close in on itself. Whatever it is, ask Because it might not be just the normal. I feel lightheaded right. There's usually other symptoms just the normal? I feel lightheaded right. There's usually other symptoms nausea, weakness, confusion, distraction. One that I find quite a bit in clinical practice is people's demeanor change. So they get quiet. If your patient goes quiet, pay attention. So they get quiet. If your patient goes quiet, pay attention.
Rachele Burriesci:I typically A&O patients throughout and I typically ask them questions about themselves, like very simple things, and I ask it before we really start moving when are you from? I'm from New York. What's your wife's name, nikki? How many kids do you have? Three, what are their names? Right? And so I start hearing these answers. When I have them sitting, standing and we're really assessing orthostatics, I start asking those questions again. Why? Because I know them. They're not just the date where you're at, you know, it's more specific to the person. Plus, people get really annoyed when you ask them where are you right now? But I ask right, and I just want to see what their answer is and how quickly they respond. When they start slowing their response time, when they start delaying their answers, when they cannot remember their three kids' names when they just quickly barreled them off beforehand, those are all warning signs to me. Those are things that make me pay attention. What's their level of alertness? Are they keeping their eyes open? What's their color look like? Did they lose color in their lips? Did they lose color in their face? If someone has an orthostatic response with numbers and their lips go pale, I am not leaving a safety zone. If I am working with a patient and they are orthostatic and they have really slowed responses, they're having a really hard time keeping their eyes open. I'm seeing beaded sweat. We're not leaving the safety zone and for me the safety zone is likely the bed underneath, right.
Rachele Burriesci:I'm going to do everything else. I'm going to do pre-gate activity. I'm going to do sidestepping. I'm going to do marching. I'm going to do heel raises. I'm going to do sidestepping. I'm going to do marching. I'm going to do heel raises. I'm going to keep them in a safe place so that if we're not looking good, we sit, we lay down, we're safe.
Rachele Burriesci:You start to get into trouble with people who have to use the bathroom to use the bathroom, and I've actually had a number of these stories recently and I truly I get it. I know that it's got to be difficult using a bedpan versus a toilet, that I had a guy the other day who was like I don't want to sit on the commode, I want to go in the real bathroom, and I was like I'm sorry, sir, there is no way in hell that we're making it to the bathroom at this moment. I'll give you the commode, but we're not walking the 10 feet to the tiniest bathroom and we're not going to get stuck in there, right? You have to start to make those concessions and there are times and I'm like we are not making it to that commode. If you cannot stand and keep your eyes open, I am not getting you in that commode and you passing out on that commode, because it's not easy to transfer off of that.
Rachele Burriesci:The commode doesn't move. It's not on wheels. You may or may not have a drop handle, which could be helpful, but it's not the place I want people passing out. I don't want people passing out, right, like in theory. I just I prefer to prevent it. Does it happen? Yes, but let's try to be proactive and prevent.
Rachele Burriesci:A move that I use a lot to sort of offset the commode thing or the bathroom Walking to the bathroom is actually to place a bedpan under the person in sitting. It is not the most comfortable but it's not, you know, technically worse than in the bed pending position if you put the head of the bed down. But it gets kind of like best of both worlds if you could put the the bedpan under the person sitting edge of bed and they can pee in a gravity, you know, helpful position or have a bowel movement right. Sometimes that happens too. Um, I would prefer that than going to the commode and getting stuck. Now there are times that people will fight you tooth and nail. If I have that strong intuition, that gut feeling I don't bypass gut feelings If I'm on the fence, maybe I can get in with trying the commode. Hopefully you have a second person on hand. Usually I let the nurse know like, hey, if I call you, text you or hit the call button, come my way. I usually give those heads up before I go in to know that I am safe and also going to keep the patient safe but honestly I can't give a black and white answer. There's no like specific number.
Rachele Burriesci:A lot of the orthostatic hypotension articles I have read basically talk about like who might be symptomatic. Is it the person who has a 20 point drop? Is it the person that has a 60 point drop? Is it the person who's got the lower map? There's no answer. It depends on the person. And from a clinical perspective it depends on the person.
Rachele Burriesci:I had a patient literally yesterday, older guy, he was 87, history of cancer now has a potential new cancer, has had a significant weight loss. Let's say he came in two days ago. Two days ago he was able to walk to the bathroom. Today was my, yesterday was my eval. He had a 20, just 20,. Maybe it was 19 point, 19 millimeter mercury drop from supine to sit. He wasn't more lethargic. He's like I just don't feel right, I need to lay down, we're going to lay down, we're not going to push it. And then there are times where I'll have a 50 point drop and I'm like we're looking good, we're alert, maybe we can try standing right and you start to kind of see how the person's responding.
Rachele Burriesci:At the end of the day you have to make decisions that you feel good about and play like the cautious card, do everything that you can in a safe place before deciding to maybe walk ahead, and I'll have these conversations, especially if I get to see someone more than one day at a time. Sorry, I keep hitting my mic. Maybe we'll try and we'll have a really close chair follow, or if I'm by myself, I'll typically set up a chair five or 10 feet away so that I know that I have a stopping point and a safety spot. Those are kind of my clinical tips on how to trial in a safe place and usually if I'm kind of about it, I'll either have a co-treat if possible, or I'll let the nurse know like hey, come and check on me If I or if I hit the call bell, come my way, and usually if they have that awareness they're a little quicker.
Rachele Burriesci:So since we're kind of on the commode conversation, I'm going to talk about this one guy who I had make sure I have his information nearby. I haven't been fired by many patients in my career. I can actually think of two. One was at the VA and one was a little bit more recent, none of which were like it was mostly because I was an assertive female was the two issues. But this guy that we're going to talk about right now, he was pissed. He was totally pissed at me. What is actually comical in some ways is that I was advocating for him.
Rachele Burriesci:So, younger guy who is admitted for orthostatic hypotension. He was actually a transfer from an outside hospital, had significant renal issues. His sodium was real low, was like 122, 125. Let me see if I have his little past medical history note next to me. Yeah, that was the day, okay. Okay, here we go. He has past medical history of amyloidosis, which he was actually going to get worked up for, and now there is quite a bit of information on patients with amyloidosis having orthostatic hypotension.
Rachele Burriesci:He had significant chronic kidney disease, he had hypothyroid, he was hypertensive. He had history of hypertension, history of gout, diabetes. He went to an outside hospital because he was having falls due to hypotension. He claims, if I'm remembering correctly, never actually. Nope, that's a lie. He has passed out before. But he was hypotensive, which is what eventually took him to the outside hospital and he was having worsening liver function. So he was like kidney and liver. I believe they were trying to get worked up for a transplant, but he's got a lot of other things happening in that world. And his sodium like I see it's so funny, certain people you like remember his sodium was 122.
Rachele Burriesci:His other vitals not really significant. His albumin was a bit low, which is very common in these chronic illness cases. But anyway, he came in because he was admitted from the outside hospital with basically this persistent hypotension and orthostatic hypotension. And the question the patient really wanted to go home. He had only been there like a day or two but he wanted to discharge. So he was like a discharge pending person for me and I remember having I had two nurses on two separate days. I actually was able to see him both days and I fought to keep him on my list because I was like, you know, there's a lot going on here.
Rachele Burriesci:So we knew he was orthostatic. I knew he was orthostatic. They hadn't tried compression socks yet, they hadn't tried abdominal binder yet. It was like on the table. It was like on the table. I ended up getting him Ted hose to try because, at you know, it's what we have available. I was doing measurements for them to actually buy their own compression socks and essentially I was like listen, we know that this is what's going to happen. So let's see if we can try to offset it. So I had him do ankle pumps, quad sets and heel slides and if I'm remembering correctly I don't have like my official note in front of me we did like five heel slides on each side with active assist. He did 10 ankle pumps and he did 10 quad sets and I remember heel sides already being difficult and he's like oh, you're really working me out and I was thinking this is very low level activity and it's wearing him out. I was like I don't know what we're going to be able to accomplish today.
Rachele Burriesci:So in supine he actually had one of his better blood pressures. It was 103 over 75 with a MAP of 82, heart rate 92. Pulse ox it's like 95% With bed Therax. He dropped to 92, 91% Not dramatic but technically abnormal. A drop in four is abnormal and he had some information on atelectasis and hypoventilation and he also had like a wet productive cough we were working on that as well. So we sit at your bed and he drops to 87 over 62 with a map of 68. So not quite within the definition here, but he's symptomatic when he sits up and so we just did some heel raises to see you know how he's doing. And then we did a couple of long arc quads Again, we did five because he was fatiguing pretty quickly, doing some breathing exercises in between because his pulse ox was like 91, 93.
Rachele Burriesci:He's kind of just low level. So we're doing a whole bunch of breathing. He did good with inspiratory holds. He actually popped up a few times but then dropped right back down on retake and I have the times written down. Six minutes later his blood pressure was 119 over 101 with a map of 105. I was not sure if it was 100% accurate, but it was the, you know, technically in line.
Rachele Burriesci:Diastolic seemed a little exaggerated to me, so ended up sitting some more. He told me he was fatigued. We checked it again it was 87 over 58, which would be more in line with what he was. Not much of a drop, a little bit of a drop, but I'm assuming the 119 over 101 was inaccurate. It just happens sometimes, right, it's kind of like out of a little bit wild.
Rachele Burriesci:Retake 87 over 58. Sat a little longer, retake again 87 over 62. He told me that's it. We laid back down. Blood pressure 136 over 94. Gave him some time, he wanted to try again. So we sat up again 83 over 61. So immediate drop, right, significant drop.
Rachele Burriesci:He remained symptomatic. We tried one more time to stand because that was the goal. Right, he wants to go home and he's got two steps to get into his house. I'm like, well, we're sitting in the same place, we can just stop because you're very symptomatic. And he's like, no, I want to try. So we tried standing and he was a pretty significant assist. I wouldn't quite call it max, let's call it mod. As soon as he stands up he gets really shaky. His symptom was that he gets left eye spots and so we sat back down. We couldn't do any more after that and when he returned to Supine he was 101 over 79.
Rachele Burriesci:So you know, we talked about what he would have to do to go home and we talked about his home setup. He had two steps to get in no part of the house, had no stairs on home setup. He had two steps to get in no part of the house, had no stairs on the entry. He had no handrail. He had like a washing machine next to his stairs that he typically holds onto. We discussed using a wheelchair and being able to bump up on the wheelchair Two steps is very doable and he was really against it, and so we had a lot of education on what you know like at minimum what we can do to get you home.
Rachele Burriesci:We know that this is a ongoing issue. We can go home wheelchair level, but you haven't been sitting like you haven't tolerated sitting, and he wanted to go home that day. I'm like, at the end of the day, you're your own advocate, you make your own decisions, you have the ability to make your own decisions. In my personal opinion, it would not be safe to go home. You might end up coming right back, which is just worse all around, worse, all around. So we discussed at least trying to maybe sit at the edge of bed later again with the nurses, maybe sit edge of bed to eat his lunch If he could get to the chair with the nurses. We discussed slideboard. Tomorrow we could try slideboard transfers, because even if we could keep him wheelchair level, chair level, in theory, he could go home. Ambulation really doesn't seem feasible. Sit to stands was a pretty significant assist. His wife was half his size, I mean it all depends.
Rachele Burriesci:So anyway, I really relayed all this information to the docs and they were in agreement. They were basically telling me we're in no rush to send him out. He just is really adamant about going home. So we talked about compression socks, we talked about abdominal binder. I told them that we tried to do like some very low level exercise in between transition changes to help to see if that would offset his dizziness. It really didn't help. Maybe we had that one blood pressure that was high Was it real? I really don't know but he was symptomatic the whole way and he was so fatigued so he saw the docs later in the day. He basically told them that I wore him out, so he couldn't go home because he was worn out from the exercises that we did. And you know, fair enough, he hasn't done much activity. He's been very low level.
Rachele Burriesci:So he, um, I ended up keeping him on my list and he the next day he kicked everyone out of his room, all of his family out of his room, and he was like very direct with me that he wanted to go home and whatever. So I was very frank. I said listen, at the end of the day I'm here to advocate for you and my goal is to help keep you safe and I understand that you want to go home. At the end of the day, I want all my patients to go home, but we need to decide what is safe for you to accomplish at home, because at the end of the day, if you pass out and have a fall and then a break, we're going to be in a much different situation. And so he softened pretty quickly. I said this is what we're going to do. We're not going to try to get a blood pressure in standing, because literally we couldn't get a blood pressure in standing. He couldn't stand low long enough for it to cycle and it may have been so low that I just couldn't read it. I said and we're not going to do anything significant with exercises, I said but we might try at least some ankle pumps to make sure that we're like able to circulate some blood.
Rachele Burriesci:And what he did the night before was he used the commode with the nurses two or three times and he said he was fine. So that was wonderful. So I talked to the nurse before all of this and I said listen, this is the situation. Be on the lookout. If you see the call bell go off or my text from me, just come my way. So he's like I want to try to walk today. And again I told him that we would do the best that we could. We'll pay attention to his symptoms, but we also have to be safe.
Rachele Burriesci:So he had to use the bathroom and he's like I want to use the commode. So I said, okay, we'll try to use the commode, he's like, but I want you to move the commode. He wanted me to put the commode. Actually he wanted to use the bathroom. That's a lie. He wanted to use the bathroom and I said absolutely not, we are not going to the commode. And I had a chair in between. That was the recliner. So if we had to sit I could put him in the recliner and elevate his legs. So we didn't do any of the prolonged stuff. I didn't have him do any exercises that would wear him out. I elevated his head slowly and we just kind of worked our way upwards. Then I had him sit edge of bed. What was interesting was he was more fearful and he was fearful of, like, trying to stand. And so then I'm encouraged, like now I'm the coach, I'm encouraging and I also told him that we didn't have to walk to the chair, like at the end of the day, all he has to do is be able to get into a wheelchair and that would be a good first go.
Rachele Burriesci:His blood pressure was 98 over 60 in supine, 100 over 66 in sitting, so technically better. He had a better response today. Heart rate was pretty steady. It was like heart rate 94, heart rate 99, a slight increase with upright positioning. I did not get a blood pressure in standing because I knew if we tried to stand long enough to get the blood pressure we wouldn't make it to the commode. So this is one of those times where I made a decision to try and compromise with the person. We finally stood. He actually stood better than he did the day before and he confidently took it was literally four steps forward to the commode sat. As soon as he sat I got a blood pressure on him. He denied any of his left eye stuff. He also got face flushing when he was about to pass out. He denied all of it On retake.
Rachele Burriesci:His blood pressure is 73 over 45 with a MAP of 51. I have the nurse on the phone now she comes in. I was like I just need a second pair of hands in case we have to like make a game, pivot him to the chair. He's still fine, he's alert, he's following all commands. He doesn't end up having a bowel movement. He's sitting there. I make him wait it out. We retake it. 76 over 56, a map of 60. We retake it again 83 over 67, a map of 70.
Rachele Burriesci:Sorry, this is a bad time to record because there's usually mail people coming. He says he's fine, so goal is to get to the chair and I have the chair in between the bed and the commode and so we stood up Again. I did not check his blood pressure in standing. We walked forward three steps. I had the nurse keep the recliner chair right underneath him and we walked an additional like three more steps. Sat in the chair and we walked an additional like three more steps. Sat in the chair 86 over 61, with a MAP 66, heart rate is 95, waited't a great idea, but this was the situation where we had to see what he could do in order to go home and also, if he couldn't do that, he needed to know.
Rachele Burriesci:This one works out in my favor. We had no event. It's dicey, right, like the whole thing is dicey In theory. He drops from 98 over 60 to 73 over 45. So pretty significant diastolic drop A little over orthostatic systolically right. But now we're dealing with low MAPs. We have a MAP of 51. That's below a MAP of 60. 60 is usually like the gold standard for enough perfusion to your vital organs, which includes your brain. That typically is like when people tend to pass out.
Rachele Burriesci:We let his wife back in because he kicked her out at one point and she was pissed because she's like I have to help you with all of this. And so we discussed like listen, this is what he was able to do today. He technically needs to be able to sit in this chair. So that was my next like goal for him. Then he had a three hour drive home, so I told him I was like you need to be able to sit in this chair for at least an hour and a half. The goal would be three hours. Can you sit in this chair for three hours and be fine?
Rachele Burriesci:He had not been out of bed in a week at this point upright, and so he could not understand why sitting in a chair matters. And so we discussed that when you sit in the car and you have to get to the car, transfer the car and then sit in the car for three hours and there is no stopping to use the restroom, I'll send you home with the urinal. These are the things you need to keep in mind. I do not recommend you doing the stairs. Had the conversation to why? Because walking four feet on level ground tanked your blood pressure. We discussed bumping up in the wheelchair. We discussed being wheelchair level. We discussed having a home health PT coming in. We discussed keeping a diary for blood pressure throughout the day.
Rachele Burriesci:And this was one of those conversations where this person was adamant on discharging home. It happens that way. This was a judgment call to try to do a little bit more than I probably would have For this person. I would not have pushed forward ambulation. I would have been doing marching in place, sidestepping, maybe getting to the chair. It he was adamant about walking and trialing that and after doing that low level of activity he was whipped. So he ended up going home that day, which was actually surprising, and that happens sometimes, right and so in his defense, like he has been orthostatic, he does not want to be in the hospital setting.
Rachele Burriesci:I get that they had started Midodrine the day before, so that was helpful. I was talking with the docs to see if they were going to do anything to like increase his salt because his sodium was 122. And they were discussing whether they could do salt tablets or just increase salt from a food perspective because he has other things going on. So they had to have renal on board, right, like all of these different teams needed to be in the same conversation discussing this and he was still being worked up for other things. So looking at like the numbers, I probably would not be pushing right, but this is someone who I'm holding back from what he wants to do and I think smartly. So I think if I would have tried to ambulate him into the hallway like he wanted to, I think we would have had a syncopal episode. The numbers usually help guide you, right, they don't tell the whole story, but they're there to help guide you. So that's just one patient Epidurals.
Rachele Burriesci:I'm going to say pretty blanket statement If you have an epidural that's dropping, stay safe, get back in the bed. I have another patient here, 44-year-old, so young. He had an Whipple procedure, has an epidural, pretty active moves really well, right, his pain was relatively controlled but in supine he was 102 over 70 with a MAPA 74, heart rate 96. Sitting edge of bed 96 over 69, mapa 73, heart rate 85. And withstanding he goes to 87 over 55, map of 63, heart rate 108. So his heart rate is trying to compensate, which is always a good sign. Oxygen's fine. I'm not. I'm not going to progress this person because with that epidural you're likely not going to get that rebound. Typically we still have that slow decline down.
Rachele Burriesci:If your epidural is showing orthostatic, in my opinion, do what's safe If they can stand. Great, he took some sidesteps, got him into a better position, did a little marching in place, done steps. Got him into a better position, did a little marching in place done. Could I have gotten him to the chair? Maybe. But then the problem is, once you're in the chair, do they recover? What happens when they're sitting in the chair and they continue to decline? The recliners are nice because at least you can get the legs up and that will help a bit. But I also don't want to put the nurses in a situation where he's going to bottom out on them later in the day. So if you're showing orthostatic with that epidural, I would personally play it safe pre-gate march in place, sidestep, all that Unless that blood pressure is rebounding pretty consistently. Your person's completely asymptomatic. That blood pressure is is rebounding pretty consistently. Your person's completely asymptomatic. I'm. I'm going to be very safe with those epidurals period. End of story.
Rachele Burriesci:Another guy similar thing, status post pancreatectomy with splenectomy has an epidural 74 years old, supine, 122 over 49, mapa 68, heart rate 94, sits at your bed 101 over 54 over 49, mapa 68, heart rate 94. Sits at your bed, 101 over 54, with a MAPA 64, heart rate 107. So 21 millimeter mercury drop, technically positive orthostatic at that point. He's still looking okay. We do. Bed there seated thorax heel raises long arc quads just to kind of help him recover. He's still doing okay. Let's try standing. See how we do. Blood pressure is 79 over 46, mapa 54, heart rate 110. We're done. We're not pushing Epidurals.
Rachele Burriesci:Do not do well with pushing period. This is also Do well with pushing period. This is also again another plug that you have to be assessing vitals. I know that this thing is dropping as significantly as it is because I'm taking vitals. People can look fine but you don't know what that number is right, or they don't start showing dizziness until they're standing. But then you take a blood pressure. That blood pressure holds a lot less weight if you don't have a prior blood pressure, always at minimum get a baseline blood pressure and then if your person is symptomatic, then you can have data to say this is a significant change. It's also helpful when you give report back to the nurse or the physician. If you don't have those prior numbers, it's a very different conversation. So this guy ended up laying back down blood pressure returns to 116, over 57, with a MAP of 67,. With a MAP of 67, heart rate 93.
Rachele Burriesci:With an epidural the likelihood of orthostatic hypotension is high. If they're showing it, respect it, because if you continue to push it's just going to keep going down. It's very unlikely that that thing is going to recover and we're going to be blood pressure up with activity. It's typically going to keep going and that's important to then relay to the team because the anesthesiologist can potentially adjust and help offset the pain while maybe having a better hemodynamic response. Right, it all depends.
Rachele Burriesci:I'm going to give you one more case. I probably took too long on that first one. So I had oh, this guy, I had another patient who came in. He's technically on the trauma unit. It he had a fall hit his head and he had a fall because he passed out. Not his first rodeo. He's had multiple syncopal episodes. He had been started I believe he had been started on Midodrine prior I'm pausing because I have a note that says he had declined medication but he had prior episodes of very similar things.
Rachele Burriesci:And he's the guy who in his history to me told me kind of just happens out of nowhere, I could be up walking for 20 minutes and then all of a sudden lights out. So he was interesting. He had been up to the chair multiple times with the nurses and he was very cautious and I was given this handoff that he always wants two people. He's very fearful, he anticipates that he's going to pass out and he gets very shaky in the upright position. So took all that Um and when I walked in the room it was, you know, spot on. He kind of like laid the lay of the land. This is the situation, um, I don't want to fall. I'm afraid to fall. I've done this before. It took me three days to get walking. I'm here for it, I understand. I'm pretty cautious too.
Rachele Burriesci:He's like actually it was a PT that discovered that I actually had orthostatic hypotension because they started checking my blood pressures in our outpatient PT. I guess he went for balance. I think that's why he was in outpatient PT and they must have noticed a change in his upright activity and they started checking vitals, which I was like hell yes, pt, let's be checking vitals. So he is known orthostatic hypotension. He is known syncopal episodes. He had a hard time describing symptoms prior to passing out and he was super fearful. So you know, fear is a real thing. He had actually told me that he was going to start working with a therapist in regards to his fear and so I told him you know, we're going to check his vitals every step of the way. We're going to take it slow and if we're not able, then we lay back down. And I think he was also discharge pending. I don't have all my notes in front of me but he was like we have to see him today. So he actually qualifies. And actually one thing I didn't say at the start of this I may have said it in episode 23, is that if you are hypertensive in the supine position, then a drop in 30 is considered orthostatic hypotension and hypertensive and supine is considered SBP greater than 160. So his blood pressure was 158 over 89, map of 109. So he's like just under that threshold.
Rachele Burriesci:We did a lot of talking. I was with him for quite a bit of time. I was with him for an hour, based on my notes here and we chatted, we talked. We talked about his fears, we talked about what he normally does, we talked about his activity levels. We did supine Therax. I elevated the head of the bed some more. We sat edge of bed and he had an 18 point drop right out the gate. So he was 140 over 75 with a MAP in 93, which means that he had an 18 point drop systolicly and a 14 point drop diastolicly. We sat at your bed. He's asymptomatic. We sat at your bed. We did seated Therx. I had the nurse on standby so that if we were about to stand she was going to come in, and so at this point I had alerted her to come into the room. We stood and he dropped to 108 over 70 with a map of 82. So now we have technically, a 50 point drop systolically, um, and a 19 point drop diastolically. So map is still good. We have a map of 82, but that's a profound drop. At this point I'm already kind of like we're probably gonna end here here.
Rachele Burriesci:He was very adamant about trying. All of a sudden his confidence switched and I was very confused by it, because this guy was so fearful when I came in and I was thinking like we need to be as safe as possible Because if we have any sort of episode, this is only going to amplify what's happening. He was good, he was talking, he was alert, he was oriented times, all of the things, all of the questions I had asked him. He was like rapid fire, very clear. He was not shaky and that seems to be his symptom. He kind of becomes tremulous, which is a side effect or sign of orthostatic hypotension. And so I made him do marching, we did some heel raises, we did some sidestepping and before we left the bed I said we need to check blood pressure one more time. He's like I'm good, I'm like let's check one more time. So we checked one more time and he dropped again. Now he's 95 over 55 with a MAPA 63.
Rachele Burriesci:He was like I feel good, I have no symptoms, and I'm thinking I'm having that like caution flag going off and I'm thinking we probably should just end right here and with a good note, sometimes in these situations I'll just walk around the bed so that there is a place to sit. At every stopping point he's like I really want to try. I was like, okay, we're going to do the closest chair follow note to man. So we walked 10, 20 feet. I stopped him, checking in on him. His color is good. He's still telling me I can't remember what he was telling. He was telling me a story in like detail and I had to stop him and was to check in on him and he's like I'm good.
Rachele Burriesci:So we walked an additional 20 feet, still good. I stopped him at 40 feet. I was like you know what we did better than we probably should have. So let's sit and check your blood pressure before we decide to do anything else. And so we sat and we checked blood pressure and his blood pressure went up 121 over 72 with a map of 87. So not quite resting. We stayed in the chair. We did some more seated Therx. We were talking, some more rechecked BP's 143 over 78 with a MAP 98.
Rachele Burriesci:If he was at all concerned about trying I would have stopped it. If he was tremulous, I would have fought him and said no. If I was by myself, I would have absolutely said no. We trialed with as safe as we could and his blood pressure rebounded. Now this is one of those, if I was a alertness his lack of tremors, lack of lightheadedness, lack of vision changes it gave me a little bit more of that. Let's try and see. Especially because he was likely going to discharge.
Rachele Burriesci:I still wasn't convinced that this guy should go home, for obvious reasons, right Like I was not convinced. So as soon as we were done I told him we were done. After that we were going to sit, let him recover. If he wanted to try again, he would do it again with a very close chair. Follow position change you know take time between transition changes. Change you know take time between transition changes.
Rachele Burriesci:But I called the physician who was overseeing him this day and gave her the whole rundown. Discussed potential compression socks. We discussed abdominal binder. I asked if there was any talk about using pharmacologic measures to help offset with this. Now here's the thing with orthostatic hypotension. Before I end here, because this is longer than I anticipated going today, in theory, with orthostatic hypotension there's no specific number that's going to say someone's symptomatic With orthostatic hypotension, when they are treating it, they are actually looking to improve symptom management and functional management versus improvement in numbers, which I actually find quite amazing.
Rachele Burriesci:The goal is to be asymptomatic and be able to live your life, not to necessarily improve the blood pressure response. I can argue the opposite. I can really truly argue like we probably need to have a less profound response. We need to be able to maintain MAP and trial non-pharmacologic and pharmacologic if needed, trial non-pharmacologic and pharmacologic if needed. But, with that being said, with the fact that improving orthostatic hypotension is improving symptoms, not numbers, there is a good percent patients that have orthostatic hypotension are asymptomatic. So I think I have a number here. It's like 30% of patients. Only 30% of patients with orthostatic hypotension experience lightheadedness or dizziness. Other patients might experience things like headache, worsening mental function where they're like not clear confusion, where they can't, you know, tell you their first and last name fatigue, nausea, weakness, shakiness or tremulous visual disturbances and then coat hanger pain, which is actually described as pain across the shoulders very similar to angina, and the description behind that is that we're actually not getting good perfusion to the heart. In other patient populations, like Parkinson's disease, they have a very high rate of orthostatic hypotension and are typically asymptomatic.
Rachele Burriesci:So this is where OH becomes a little bit tricky to manage and where you really have to use your clinical decision-making and your experience to help weigh in on making these decisions. There isn't a hundred percent right answer. This guy was probably the most I don't want to say. I don't know what word I want to use. I was probably a little bit more lenient with trying with him because I knew we had history. This wasn't new. They were still working up an underlying cause.
Rachele Burriesci:He was potentially going to go home same day, so I wanted to see what his response was same day. So I wanted to see what his response was. And he was also one where he doesn't always have like a specific response, so he might be one of those asymptomatic people. So his, his symptoms aren't like every time I, every time I pass out right before I go black, or like I have black vision or I have the left-sided spots like my other guy or I become sweaty Right. So he's already tricky in that world.
Rachele Burriesci:The one thing that really made me like let's see what happens was that he was alert and he was following every command and he was so conversational. If he had any sort of symptom, that would have been a done for me. He wasn't. He was the most confident. He had been that whole session, which also made me a little bit cautious too, because when you have someone who is fearful of falling, the last thing you want to do is have a syncopal episode right, and then decrease that trust. But he was showing all signs of clarity and feeling good and confident and I had the safety back up of the close chair follow. He was one of those ones where little hesitation If I had less experience, if I had less, if I had that inkling of like, do not try. Like the other guy, I fought right, like we are not doing that.
Rachele Burriesci:This guy was way more with it, way more mobile and completely clear, no pallor, like good color. It was very interesting. I was, you know, looking at those numbers and thinking, if I'm just going based on numbers, I I'm leaning towards no, but he looked good and what was really interesting about him was that he actually improved his blood pressure with that short bit of walking. So there's no black and white. This is a truly it depends scenario and you have to weigh in clinical experience and decision-making and safety right. Like at the end of the day, if you would have stopped and said, nope, we're done, maybe we just get to the chair or we're gonna lay back down. You have absolutely every right and reason to do that. If you are making the decision to go, you also have to have some reason as to why. And my reason is he was clear, he was alert, he was confident and we had a safety check with the chair. Follow right behind. This is not someone I'm just going to go willy-nilly and go for it. I actually stopped him. He wanted to do more and I was like nope, that's good. This is more than anyone thought you were going to do with those numbers. Let's go see what they look like. If they were really low I would have got them back to bed, but they recovered. So I was like, okay, let's sit in the chair.
Rachele Burriesci:We then did education. We talked about hydration. We talked about eating meals if it was ever around eating meals. He said he had compression socks. So we actually called his wife, who did not leave the house yet, to bring said compression socks to the hospital so we could help him, don, help, help, don them and see if that would have an improved response. I then had a very long conversation with the physician, a very good conversation with the physician, and so they, you know, although knew he came in for trauma for fall, orthostatic was, like, not their biggest concern. So taking those numbers, having the data then, would help them make a plan too.
Rachele Burriesci:So again, it's not black and white, it's a depends which people really don't like to hear, really don't like to hear. But at the end of the day you have to make decisions and from my clinical experience, if those were my numbers and I had an epidural we're done Like there is no question, we're done. There's no talking me into walking to the bathroom. There's no trying to move ahead. There's no, you know, follow me with a chair. We're done. To move ahead. There's no, you know, follow me with the chair, we're done.
Rachele Burriesci:This person who doesn't really have an underlying cause, so to speak, who has had a history of orthostatic hypotension, who we're trying to figure out if he actually has symptoms and from our conversation, tremulousness seemed to be like the number one sign he didn't have any of it and if they're going to send him home and we're not trying to ambulate, then we're setting him and everyone else up for failure. So set yourself up for success, set your patient up for success, be as safe as you can be and feel good about the decision that you're making. I think that's the biggest advice I can give in this scenario making. I think that's the biggest advice I can give in this scenario.
Rachele Burriesci:Patients who just take pain medication that's another one. This happens a lot, right Like especially post-op, pre-medicate your patient I can't tell you how many times I have nurses oh, let me give you Oxy, let me give you Fentanyl, let me give you Dilaudid right now before you get up, and I'm like whoa, hey, oh, let's, do we need it? Is he covered? Right, in my opinion, in the world of pain medication, keep the person covered and comfortable. But to give pain meds like right before, especially IV pain meds that work much quicker, right before you get up, doesn't always set the patient up for success. And so that's another scenario that if my blood pressure is tanking right after meds are given, I'm not going to push. So this is always that like, how much do you push on the pedal, off the pedal? I don't know if that was helpful for you. I hope it was and I hope that you have these conversations right, and I think that's part of it.
Rachele Burriesci:What do you do in this situation? Ah God, I had another good one right in front of me too. I had another patient post-CABG a week out trying to get into IPR or needed to start to increase activity to get into IPR. And when I came in she was just like really lethargic. I let the nurse know I'm like listen, we're going to get up, but I like I might need a set of hands and like let's pay attention. And she had a pretty dramatic. She had a 20 point drop which is like supine to sit, but then when she went from sit to sand had a very dramatic drop, still coherent, still alert and oriented, took some sidesteps but that was it. That was another time where it was time to let the docs know that we were having this pressure change.
Rachele Burriesci:And maybe it's medication, maybe they're over-diuresing or maybe she's dry instead of, you know, norm and those things matter, right. They matter when you're assessing patients. And so someone who has been seen, or someone who's been in the hospital setting for over a week, who has been seen by PTOT consistently, you know maybe we're not taking vitals. In my opinion, we have to be taking vitals because every day is a different day, especially if you're in the hospital. You cannot trust a day before's vitals to tell you what's going to happen in this very moment.
Rachele Burriesci:And having that data is so important because you don't want to be in a situation where you haven't taken a vital and then your patient's like not looking great. Maybe you're in the chair, you take a vital and it's like really low. Well, what does it mean? Right? Or maybe it's not that low in the world of like a map, but you don't know where it came from. Right, meaning I started at 168 over whatever, like my other guy was right, 158 over 89. And let's say, we check him and his blood pressure is 108 over 70. In theory, 108 over 70 isn't alarming. 108 over 70, map of 82, like if that's the first pressure you took, it's not alarming. But if you knew that you had a 50 point drop, it matters more, right? And so having the data, having the consistency in vitals, yes, it takes more time, but I'm telling you that if you're trying to help yourself make decisions or, you know, decide if you're going to do this versus that, that's part of it. The last thing I want to say because I am way over this I was really chatty today Document, document, document, document.
Rachele Burriesci:If you took 15 blood pressures, document all 15 blood pressures and then write an assessment as to what happened. Give backup information. Who did you tell? Give the handoff in your recommendation piece Not notified RN, notified MD, whoever that documentation helps, tell the whole story and if something comes up because sometimes it does that documentation is going to lay out exactly what you did and who you contacted and why you did what you did and how the patient responded. That information is so important to document. So good clinical decision-making is sometimes a team effort. It's using your clinical experience, it's using your knowledge, it's using your gut, right Like your intuition matters.
Rachele Burriesci:And if you have that intuition that this is a bad idea, listen to it, period. If your gut instinct is to stop, then stop. It is better to be overcautious than to be very aggressive in your approach. I think more mistakes happen when we're overly aggressive. When you're more cautious and when you're taking your time, it gives you time to make decisions. It gives time for the patient's symptoms to maybe show themselves. Buy yourself some time when you have that like question mark of should I keep going, should I not go? Okay, and always watch your patient.
Rachele Burriesci:Your patient will tell you that this is safe or not safe. If they're going pale, their lips go pale If they're slowing their speech, if they were really chatty and now they're quiet, if they're having a hard time identifying the person in the room who might be their spouse. If they were able to rattle off the date in the hospital and their kids' names five minutes prior and now they're like having a real hard time thinking about it. All those things matter. Pay attention to them, not just the numbers. Look at your patient, okay, and if you have an epidural and you're showing orthostatic, hit the brakes because and you're showing orthostatic, hit the brakes Because those epidurals show themselves and if they're telling you the numbers are dropping, the numbers are dropping. So respect them. All. Right, I think that is all I have for you today.
Rachele Burriesci:If you have any questions about orthostatic hypotension, if you have similar situations, if you have, you know question of when you should push and when you shouldn't push. If you are interested in mentoring, I have my one-on-one mentoring link below. If you have a quick question, happy to answer in the DMs and always appreciative for you being here. Sorry this was a long one, but this one's really been on my mind and has literally been in my life and I felt like we needed to discuss this. No two patients are the same. No two patients can be treated the same. Make sure you're always using your clinical judgment, make sure you are assessing vitals, and that will always help you make good decisions. All right, I hope you all have a wonderful day and whatever you have to do, get after it.
