Perioperative Care—Hypotension in the Recovery Room
Concept
Easy to get lost in the myriad of possible diagnosis. The key is to be methodical and stepwise. Approach patient like a trauma patient working through your ABCs. DDx includes any form of shock: hypovolemic shock (inade- quate fluids intra-op), hemorrhagic shock (pt still bleed- ing), cardiogenic shock (MI, pneumothorax), also sepsis (unlikely so quick), transfusion reaction, malignant hyper- thermia, Addisonian crisis, air/fat embolism.
Way Question May be Asked?
“You are called to evaluate a 63 y/o male status post a AAA repair who was stable in the recovery room for about 2 h and now his BP has dropped to 80/40. What do you want to do?” Question could be asked in many different ways with the patient status post any major abdominal operation, had received blood intra-op, may or may not be given other vital signs at the start.
How to Answer?
Be methodical
ABCs while resuscitating the pt
Airway
Is pt on ventilator?
What is RR and Pulse ox?
Does pt need to be intubated?
Breathing
Are both lung sounds present?
Does patient need chest tube?
Circulation
Pulses
Cold extremities (hypovolemic shock) vs. warm (anaphylactic)
“AMPLE” History
Type of procedure Length of surgery Fluids/blood Previous PMHx CVP placed intra-op?
Physical Exam
Vital signs (fever very suggestive) Neck veins (flat or distended) Heart rate (arrythmia)
Rash (petechiae with txn reaction) Generalized oozing (DIC)
Pulses in extremities Abdominal exam
Surgical Treatment
(1) Order:
CXR, EKG, ABG, complete laboratory panel, U/A Send pt’s blood along with transfused bags if sus- pect txn reaction (also check urine for Hgb) (2) CVP or SGC to direct fluid management (3) Treat specific underlying problem
(a) for hypovolemic shock, fluid resuscitation (b) for cardiogenic shock, SGC plus pressors (c) for pneumothorax, chest tube
(d) for malignant hyperthermia, cooling, support- ive care, dantrolene
(e) for Addisonian crisis, bolus steroids (100 mg hydrocortisone)
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(f) air/fat embolism, supportive care
(g) transfusion reaction (key is to keep up urine output and avoid precipitation of Hgb in renal tubules)
fluids to maintain UO 100 cc/hr
2 amps bicarb plus add to IVF to alkalinize urine (check pH > 7)
mannitol (1–2 mg/kg) (osmotic diuretic)
Common Curveballs
Pt will have MI and you’ll be asked your manage- ment/pressors
Pt will have refractory hypotension to anything you do Pt will have txn reaction and you’ll be asked your spe- cific management including how to alkalinize the urine
Pt will need to be intubated Pt will need CVP/SGC
You’ll be given a set of SGC parameters to interpret Pt will develop renal failure (change scenario)
Strikeouts
Taking pt back to OR (usually, they are not trying to get you to take pt back to OR,
Not being methodical and going through ABCs You’ll miss a mucus plug)
Miss a pneumothorax or tamponade from CVP line anesthesiologist placed
Miss a kinked ETT
Missing vital signs (fever and hypotension point you in some specific directions)
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