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Interesting case
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get his pain under control, use IV narcs until epidural kicks in. neo qtt if needed for BP/HR.
also probably hyperventilating off a mild metabolic acidosis. i wouldnt expect measured lactate to be too helpful here. TTE if you can to assess volume status, straight leg raise if tolerated. my hunch is hes dry and will need judicious volume of choice in addition to the other therapies.
where did you place your epidural. did it surprise you that you got "immediate pain relief" with the test dose? a laparotomy incision is a lot of ground to cover.
cannot rule out intraabdominal bleeding or retained foreign body.
also probably hyperventilating off a mild metabolic acidosis. i wouldnt expect measured lactate to be too helpful here. TTE if you can to assess volume status, straight leg raise if tolerated. my hunch is hes dry and will need judicious volume of choice in addition to the other therapies.
where did you place your epidural. did it surprise you that you got "immediate pain relief" with the test dose? a laparotomy incision is a lot of ground to cover.
cannot rule out intraabdominal bleeding or retained foreign body.
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Check his HCT. May need blood to increase his oxygen carrying capacity. Give colloids in meantime. Will help with bp and won't overload him. He's probably opioid tolerant plus big surgery hence the pain. Can try just putting opioids into epidural until bp stabilized and then can add local. Neo drip is good idea. Will improve myocardial perfusion and decrease heart rate. Watch out for too much after load though. Don't want him tachy. Consider surgical bleeding. This is a good case.
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Whoops. I didn't see the new Hb with the ABG. Sorry. Doesn't look like he needs blood. At this point I would think hypovolemia, although it seems he got a lot of fluids, surgical bleeding, or a cardiac event, although ECG and troponins and TTE seem reassuring.
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How long did the surgery take? Laparoscopic or open?
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Subarachnoid block. Immediate relief with 3cc test dose shouldnt happen.
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Maybe he's vasoplegic? Is he on ace inhibitors? May need a little vasopressin.
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Subdural then.
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Whats the rhythm? Just ST?
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Or stress dose of steroids.
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this was my first thought
are you serious with this?
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ST depression and hypotension after exertion. Are we really sure his AS is just moderate?
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Albumin really?? 😱
Anyway with Cyrstalloids: 3 L Colloids: 750 CC + 500cc and good preload at the end of the case i have a hard time believing he's hypovolemic unless there's ongoing bleeding in the abdomen. Test with passive leg raise
Bleeding? i'd do a belly US
MI? repeat troponin, TTE?
Don't see any other plausible causes for post-op hypotension
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With a starting Hgb of 12 and estimated EBL of 700cc, a postop ABG showing Hgb 9.8 is lower than I would expect...and a colectomy really shouldn't be that bloody. With increasing fluid and pressor needs I would be very worried about a bleeder. Would definitely FYI page the surgical team while I'm doing the rest of my workup. I'm not happy with him developing an NSTEMI, plus he has a history of moderate AS, so I'll give him a dose of esmolol to get his heart rate down, bolus albumin and reassess.
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Jesus Christ, I'm getting blue balls over here...
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At this point i'm resuscitating with blood to get him over 10g/dl, he's agitated and hyperventilating so best thing to do to decrease oxygen demand is to put him back on mechanical ventilation.
I would induce with a healthy dose of long acting opioid and midaz + NMB. Proceed with 300mg of aspirine get his rate down with esmolol and keep his pressure up with levo.
While waiting for the cath i would still want to rule out any bleeding with an U/S exploration.
I would induce with a healthy dose of long acting opioid and midaz + NMB. Proceed with 300mg of aspirine get his rate down with esmolol and keep his pressure up with levo.
While waiting for the cath i would still want to rule out any bleeding with an U/S exploration.
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Given this patient's past history of MI, he should be on ASA every day of his life, and continue for surgery. Also should be on a statin too. I didnt see any mention of ASA in the Preop. Did you guys give ASA PO prior to the OR? I know the point of this thread is post op hypotension and DDx. I'd break that down to Problems with HR, SVR, preload, after load, or contractility. You can get a nice differential from there.
Acute MI, treat with pain med oxygen ASA and nitro. Put TTE on his chest to see what distribution is affected. I'm indifferent on transfusing him to hgb of 10. Keep pressures up and HR low.
Acute MI, treat with pain med oxygen ASA and nitro. Put TTE on his chest to see what distribution is affected. I'm indifferent on transfusing him to hgb of 10. Keep pressures up and HR low.
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EKG changes in V2-V5 point to trouble with the circumflex artery, septal wall hypokinesis points towards the LAD. I wonder if he has some sort of anomaly or collateralization keeping his heart from pooping out.
does he have dynamic outflow obstruction (SAM)? May only reveal it self when tachy and empty but couple that with a moderately tight AV and narrowed left main and could certainly see something like this
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So was he just symptomatic from his AS or did he have a SAM?
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it got eerily quiet around here
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Sorry folks, a colleague spotted this post and advised me to delete it seeing as it was a fairly recent M&M case. It was my case.
The diagnosis was left main disease with near complete stenosis in the ostium. TEE, stress tests, EKG, early troponins all failed to recognize it. The only modality that picked it up was coronary angiogram. I wanted to make the educational point that "cardiology clearance", stress tests, TEE, negative troponins, and minimal EKG changes can still miss a massive MI. As anesthesiologists we need to be extremely vigilant with any prolonged hypotension. MI should always still be in our differentials even if the troponin/ekg/echo are negative. This is especially true in the post op period.
The diagnosis was left main disease with near complete stenosis in the ostium. TEE, stress tests, EKG, early troponins all failed to recognize it. The only modality that picked it up was coronary angiogram. I wanted to make the educational point that "cardiology clearance", stress tests, TEE, negative troponins, and minimal EKG changes can still miss a massive MI. As anesthesiologists we need to be extremely vigilant with any prolonged hypotension. MI should always still be in our differentials even if the troponin/ekg/echo are negative. This is especially true in the post op period.
