As usual, my Wednesday assignment is a liver and bowel resection for carcinoid. This surgeon gets referrals from literally all over the country. The routine hemodilution technique has me drawing off two units of blood (replacing with crystalloid) and storing on ice until the bloody dissection is done (many hours later), then giving it back. I usually don't think twice about it, but last week:......... Pt was a 73 little ole lady with h/o CABG in 2003, stented in 2006, with cardiologist clearance. Needs SL NTG with activity routinely. Preop crit was 34, and the BUN/creatinine ratio was almost 10:1. I felt reasonably confident it was a dry crit. I really didn't want this lady's crit to drop below 30 given her history. I felt her real non-dry crit was probably closer to the upper 20s which perhaps is not a good starting point to draw off two units. Anyway, surgeon asks me as usual to hemodilute as he's making skin incision. We discuss it and he agrees I can wait until we get some fluid in. After one hour (abdomen is now open) and one liter her crit per I-stat is 27. Would you have drawn off two units? To the med students: can't use ephedrine or epi on these cases. Why?