Intraoperative hypotension early in case

[codeb1ue]

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I have a question regarding the physiology of this occurrence that I am hoping some of you may be able to answer.

I have noticed fairly often that I will have a patient very hypotensive early in the case. To the extent that I am constantly pushing phenylephrine and running them low on gas (MAC 0.6), still barely keeping their MAP in the 60s. This can persist well into a case (20-30 min) when suddenly the surgeon yells "patient is moving!" and I notice her hemodynamics swing the opposite direction, hypertensive, tachycardic. I would then quickly redose opioids, turn up the gas, and then notice that the patient is suddenly behaving normally for the rest of the case. MAC 0.9-1.0, no more pushes of pressors, etc.

Why does this happen? Is it the induction meds that are lasting that long and suddenly wearing off? Resuscitation of fluids during case? And why so sudden of a change instead of it being more gradual?

 

[nimbus]

Try inducing with no opioids (fentanyl), especially in older patients. Huge difference.

 

[pgg]

It's your induction agent, minimal stimulation during prep, maybe a dry NPO patient.


Also be careful slamming in opioids in response to a bit of tachycardia & hypertension during a case. This is how CA1s get acquainted with Narcan, aka the syringe of shame. 🙂 Esmolol or more gas will fix HR & BP and will be gone at wakeup.