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Had this weird case recently. I’m still at a loss. Any insight would be great.
60s M, HTN, BPH, chronic cervicalgia coming from home for phase II (permanent) cervical SCS implant. MAC anesthesia w/ 2mg midaz and propofol. Entered epidural space around T1-2, leads threaded up to C2. BP steadily drifted down throughout procedure but never got properly hypotensive during actual case.
Get paged from PACU shortly after CRNA dropped off that patient is hypotensive.
Patient still drowsy, not following commands, but moving everything and maintaining sats on 2LNC. BP 80s/40s, HR 90s. Patient got no fluids because of the shortage and it was an afternoon case so assumed he was just dry. Gave some Neo and told nurse to give 1L crystalloid. Paged back about 20mins later that patient isn’t responding to fluid and BP still low, checked that dressings were clean (they were) gave 50mg IM ephedrine and tell nurse to give rest of fluid. Paged back 10min later BP worse. 70s/40s, strangely not tachy, HR in ~70. Cycle cuff again at bedside and we’re 60s/30s. Now I’m concerned. Called for some more hands, so the next few things happened in tandem.
Quick POCUS showed hyperdynamic LV, mildly dilated but normally functioning RV, IVC with not plethoric with normal respirophasic variation. Normal upright CXR. EKG NSR. Art line placed and correlating with cuff. Levo started. CBC, CMP, ABG, trop, lactate sent. Patient saying their name and following commands by now. Stat formal echo agreed with above and was otherwise unremarkable. Labs very unremarkable, just mild respiratory acidosis on ABG.
Patient ended up going to ICU on 15mcg of levo which was slowly weaned to off by POD1 afternoon then discharged POD2. No additional work-up from ICU team.
Anyone ever see/hear of anything like this before?
60s M, HTN, BPH, chronic cervicalgia coming from home for phase II (permanent) cervical SCS implant. MAC anesthesia w/ 2mg midaz and propofol. Entered epidural space around T1-2, leads threaded up to C2. BP steadily drifted down throughout procedure but never got properly hypotensive during actual case.
Get paged from PACU shortly after CRNA dropped off that patient is hypotensive.
Patient still drowsy, not following commands, but moving everything and maintaining sats on 2LNC. BP 80s/40s, HR 90s. Patient got no fluids because of the shortage and it was an afternoon case so assumed he was just dry. Gave some Neo and told nurse to give 1L crystalloid. Paged back about 20mins later that patient isn’t responding to fluid and BP still low, checked that dressings were clean (they were) gave 50mg IM ephedrine and tell nurse to give rest of fluid. Paged back 10min later BP worse. 70s/40s, strangely not tachy, HR in ~70. Cycle cuff again at bedside and we’re 60s/30s. Now I’m concerned. Called for some more hands, so the next few things happened in tandem.
Quick POCUS showed hyperdynamic LV, mildly dilated but normally functioning RV, IVC with not plethoric with normal respirophasic variation. Normal upright CXR. EKG NSR. Art line placed and correlating with cuff. Levo started. CBC, CMP, ABG, trop, lactate sent. Patient saying their name and following commands by now. Stat formal echo agreed with above and was otherwise unremarkable. Labs very unremarkable, just mild respiratory acidosis on ABG.
Patient ended up going to ICU on 15mcg of levo which was slowly weaned to off by POD1 afternoon then discharged POD2. No additional work-up from ICU team.
Anyone ever see/hear of anything like this before?