Lobectomy Fluid Management

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

DocMcCoy

Full Member
10+ Year Member
Joined
Sep 4, 2009
Messages
1,064
Reaction score
734
Seeking comments and advice from those of you much wiser and more experienced than than I am. (All of you)

Question about intraoperative fluid management in this theoretical case:

Morbidly obese 67 yo F 5'2" 137kg with COPD and history of delayed emergence presents for right VATS upper lobectomy. Case goes for 8hrs induction to emergence (no conversion to thoracotomy). Difficult DLT placement takes 20 minutes of tweaking to sit right. Ultimately complicated by ~1200ml blood loss, lowest HCT was 36, hypotension, sluggish urine output and significant phenylephrine requirement (3x 250ml bags 80mcg/ml) running wide open pretty much throughout case.

Extubated on table but clearly not flying. Patient reintubated and bronch shows some edema and blood likely from initial tube placement. Also some froth concerning for pulmonary edema. Prior to the reintubation patient received 2800ml of fluid, gets another liter between second intubation and ICU drop off.

Surgeon obviously and probably rightfully PO'd that patient received 3800ml of fluid on the case. Prolonged postoperative course complicated by ARDS and now blame points directly toward fluid management intraop.

What guidelines do you follow in terms of fluid management for thoracic cases? What do you consider a "cutoff" for too much fluid?

How would you have managed this case?

We are told to essentially run them dry to the point they border on oliguria, but I felt this wasn't an appropriate strategy on this case.

Do I have only myself to blame?

I've read as much as I can find on the topic but looking for comments outside my institution.

Members don't see this ad.
 
Just me, but in light of the blood loss, 3.8L does not seem like a lot of fluid. That is barely replacing the blood loss.

A morbidly obese COPDer who gets part of his lung taken out in an 8 hour surgery with 1200cc blood loss? And that is as low as the actor got? I would say with confidence that it is worth just letting them chill in the ICU with a tube for a bit.

Kind of a weird clinical course there.
 
Seeking comments and advice from those of you much wiser and more experienced than than I am. (All of you)

Question about intraoperative fluid management in this theoretical case:

Morbidly obese 67 yo F 5'2" 137kg with COPD and history of delayed emergence presents for right VATS upper lobectomy. Case goes for 8hrs induction to emergence (no conversion to thoracotomy). Difficult DLT placement takes 20 minutes of tweaking to sit right. Ultimately complicated by ~1200ml blood loss, lowest HCT was 36, hypotension, sluggish urine output and significant phenylephrine requirement (3x 250ml bags 80mcg/ml) running wide open pretty much throughout case.

Extubated on table but clearly not flying. Patient reintubated and bronch shows some edema and blood likely from initial tube placement. Also some froth concerning for pulmonary edema. Prior to the reintubation patient received 2800ml of fluid, gets another liter between second intubation and ICU drop off.

Surgeon obviously and probably rightfully PO'd that patient received 3800ml of fluid on the case. Prolonged postoperative course complicated by ARDS and now blame points directly toward fluid management intraop.

What guidelines do you follow in terms of fluid management for thoracic cases? What do you consider a "cutoff" for too much fluid?

How would you have managed this case?

We are told to essentially run them dry to the point they border on oliguria, but I felt this wasn't an appropriate strategy on this case.

Do I have only myself to blame?

I've read as much as I can find on the topic but looking for comments outside my institution.
I don't worry too much about fluid management with a lobectomy. The piece of lung they remove is not big enough to be anal about it. With a bad heart, then you need to be cautious.

A lobectomy shouldn't bleed 1200ml and take 8 hrs. There is obviously a surgical issue going on.

I would disregard the concern about fluid. I think he is trying to divert attention from his botched surgery.

What was the urine output?

A case that long at the minimum would get 2L of crystalloid. Add 1200 for blood loss not even giving 3:1 back and you are already over 3L. You are not far off. It was a bad surgery.
 
  • Like
Reactions: 5 users
Members don't see this ad :)
I don't worry too much about fluid management with a lobectomy. The piece of lung they remove is not big enough to be anal about it. With a bad heart, then you need to be cautious.

A lobectomy shouldn't bleed 1200ml and take 8 hrs. There is obviously a surgical issue going on.

I would disregard the concern about fluid. I think he is trying to divert attention from his botched surgery.

What was the urine output?

A case that long at the minimum would get 2L of crystalloid. Add 1200 for blood loss not even giving 3:1 back and you are already over 3L. You are not far off. It was a bad surgery.

This.


The surgeon should be PO'd at himself. You and the patient should be PO'd at him too. You're not the one who f'd up but he is trying to blame you. WTF. That lung was bad to start with. Then it is deflated for 6+ hours while the monkey mashes it and traumatizes it. What did he expect? And the 1200ml blood loss. He should look at that.
 
Last edited:
  • Like
Reactions: 1 users
8h surgery COPD and morbid obesity are not words you want to put together if you are looking for a smooth p.op course.
Maybe with a surgical home this patient would have done better :D
 
  • Like
Reactions: 1 user
This is probably more anecdotal than evidence based, but my preference in general for thoracic cases is to use 5% albumin boluses once the pt has received 2L crystalloid, titration based on intraop lactate/base deficit/pulse pressure variation trends. Wouldve also switched to norepi pretty early as tachyphylaxis can become an issue with prolonged neo infusions. Also, probably would've not extubated given morbid obesity, copd, delayed emergence, ebl, high pressor requirement, and prolonged case duration.
 
  • Like
Reactions: 3 users
Why so much pressor? Why'd it take so long? I probably would've switched to a single lumen tube and left the patient intubated.

Morbidly obese, copd, lots of pressor, and 8 hrs (majority of which was w OLV) isn't a good recipe for awesomeness all around. Hopefully your attending said as much to the surgeon.
 
  • Like
Reactions: 1 users
8 hours is a crazy long vats isn't it? I'd say like 1% of vats go even close to that long?
 
  • Like
Reactions: 1 user
1. Fluid overload does not produce ARDS, but pulmonary edema, which should respond to diuretics. On the other hand, ARDS (from other causes) is worsened by hypervolemia; that's true. One could also argue that many liters of crystalloid are pro-inflammatory, but that number is much higher than 3.8. My guess is that this patient has a ton of postop inflammation at the surgical site. Best prevention? How about a much shorter procedure and less messing around with the lung?

2. You should have replaced some of the blood loss (once significant) with blood. Crystalloids (and even colloids) will leak into tissues, especially the dependent ones, including the lungs. I would have kept the fluids to less than 1.5-2L. But then you would have been accused of causing TRALI or TACO. When the surgeon is incompetent, just blame it on anesthesia. ;)

3. PPV induces ADH secretion, i.e. fluid retention. If the MAP is over 75, I wouldn't worry about low urine output or AKI. I would worry about poor peripheral perfusion due to too much pressor.

4. COPD, elderly, BMI 57, h/o delayed emergence, long surgery, big fluid shifts... WTH was wrong with your attending to even try to extubate her in the OR? She must have had as much sevo in her almost 100 kg of adipose tissue as the sevo reservoir on the anesthesia machine.
 
Last edited by a moderator:
  • Like
Reactions: 10 users
It's obvious that the fluid management here was not the issue but the surgeon will claim it is, and his opinion will be heard much louder than anything you and your department might say.
This will happen frequently to you in the future and you will always be blamed when a surgeon needs someone else to blame. All you can do is defend your management objectively if this ends up in an M&M but don't expect to be able to escape the blame. After all you are "anesthesia" which means by definition "have no balls".
 
Thank you to all. Very helpful for my learning. Surgeon didn't want to convert to open. His usual VATS are about 3hrs. Should have thought about replacing with blood. Probably could have communicated better. Very terse surgeon. Our exchange for the whole case was "geez that's a lot of blood" and "are you still on pressors". Went up to the unit on phenylephrine.
 
As an aside to the above comments, it doesn't sound as if the phenylephrine was working. If pressor is necessary and what is infusing isn't working, I switch pressor.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
As an aside to the above comments, it doesn't sound as if the phenylephrine was working. If pressor is necessary and what is infusing isn't working, I switch pressor.
I bet you this patient was on an ACE inhibitor or ARB and that's why they were fighting hypotension throughout the case.
 
  • Like
Reactions: 1 user
Eh I think the ARB/ACE is overreported. Yes they can get hypotensive but the majority still respond to neo. Very few need vaso (but this could be the case here). Are you a CA-2 ? I assume you are and should probably have asked your attn if it was a good idea to extubate or why? If you are running neo wide open that should give you a clue that either A) the pressor is doing minimal or B)Patient has significant blood loss/shock state etc aka something is not right. Probably should have replaced blood or done ABG's which I'm sure you were doing? Op yes in lung cases we try to minimize fluid but they also don't last 8 hours and loose >1L of blood! This is your garden variety academic surg who can't make it in the real world, but is allowed to butcher patients in the academic hospital.
 
  • Like
Reactions: 1 user
Not sure why people are so pissed at the surgeon. This is academics we're talking about here, where a lot of surgeons suck ass. I remember thoracic cases from residency with significantly more ebl. I've seen even the best PP thoracic surgeons lose a lot of blood on lobectomies. Very rare but it happens, especially with more being done robotic. Some points - should've changed to a single lumen ett and kept pt tubed; if you're worried about too much fluid, use albumin, 25% if you have to, or give blood products; with all the hypotension and blood loss, to help with pressures dial down your anesthetic and narcotics and keep the pt well paralyzed; ARDS was not caused by your fluids but more likely by prolonged intubation postop leading to PNA in this super obese pt and suboptimal icu management. Volume overload will definitely worsen outcomes in this scenario though. Good learning case for a resident
 
Eh I think the ARB/ACE is overreported. Yes they can get hypotensive but the majority still respond to neo. Very few need vaso (but this could be the case here).

Some of that depends on whether there is a beta blocker (almost always) and perhaps a CCB in addition to the ACE/ARB. It is not infrequent in my practice to have someone like that who is refractory to phenylephrine. I will say that raising the heart rate is a frequently over looked strategy in dealing with this situation. Some Robinul can make your phenylephrine a little more effective if you insist on infusion.
 
Eh I think the ARB/ACE is overreported. Yes they can get hypotensive but the majority still respond to neo. Very few need vaso (but this could be the case here). Are you a CA-2 ? I assume you are and should probably have asked your attn if it was a good idea to extubate or why? If you are running neo wide open that should give you a clue that either A) the pressor is doing minimal or B)Patient has significant blood loss/shock state etc aka something is not right. Probably should have replaced blood or done ABG's which I'm sure you were doing? Op yes in lung cases we try to minimize fluid but they also don't last 8 hours and loose >1L of blood! This is your garden variety academic surg who can't make it in the real world, but is allowed to butcher patients in the academic hospital.

I used to think the ACE/ARB HoTN was overrated, too, but didn't a recent study just come out and affirm it?
I also don't routinely transfuse for a HCT of 36, but to each his own, I guess. I understand viscosity affects BP, but HCT 36 is probably not enough to cause HoTN not fixed by wide open phenylephrine.
Lastly, I'm not gonna hate on him for attempting extubation. You've gotta take out the double lumen anyway. As long as you're prepared to reintubate, it's basically just a tube exchange.
 
I used to think the ACE/ARB HoTN was overrated, too, but didn't a recent study just come out and affirm it?
I also don't routinely transfuse for a HCT of 36, but to each his own, I guess. I understand viscosity affects BP, but HCT 36 is probably not enough to cause HoTN not fixed by wide open phenylephrine.
Lastly, I'm not gonna hate on him for attempting extubation. You've gotta take out the double lumen anyway. As long as you're prepared to reintubate, it's basically just a tube exchange.
One shouldn't transfuse by Hct, but by the body's compensation and response. A patient who's hypotensive secondary to blood loss needs 1-2 L of crystalloid at most, and then blood, or at least a colloid.

There is a component of SVR (and thus BP) that is frequently overlooked by physicians without a strong background in physics: viscosity. (That's why polycythemic patients are hypertensive.) One cannot replace massive blood losses with the equivalent volume of crystalloid and expect the same BP. This is one of the reasons why colloids are better at maintaining BP (not because they stay in the vessel much longer than crystalloids; they actually don't, especially in inflamed tissues).
 
  • Like
Reactions: 2 users
Lot of great points. Yes im a CA2. I started the case with one of our best ATTENDINGs. The length necessitated several attending changes by the end of the case. Should have been more vocal in advocating for extubation but our thoracic surgeons push hard for it and the whole department hears about the cases that go intubated to ICU through nasty emails.

Patient was on lisinopril. I didn't think of that intraop but a good learning point for me. Did give a little ephedrine here and there which she responded to well. Could have tried Vaso or Levophed. Only had peripheral access but most of out people are ok running these temporarily till we or the unit place a central line.

Interesting point about viscosity. Definitely learn something new everyday on here.

Curious on how you all approach ACE/ARB hypotension when do you make the call to try vasopressin? How do you dose it?
 
It's ok greg, i'm learning vicariously through you. Good post, hello from uthscsa, i'm a CA-1 here.
 
  • Like
Reactions: 1 user
Extubating at the end of this case sounds like a poor idea.
 
  • Like
Reactions: 1 users
Yes a hct of 36 by itself is usually not an indication to give blood but you have to go by the clinical situation and patient too.
 
It's obvious that the fluid management here was not the issue but the surgeon will claim it is, and his opinion will be heard much louder than anything you and your department might say.
This will happen frequently to you in the future and you will always be blamed when a surgeon needs someone else to blame. All you can do is defend your management objectively if this ends up in an M&M but don't expect to be able to escape the blame. After all you are "anesthesia" which means by definition "have no balls".

1) who will hear the surgeons opinion louder than anything you say? his other surgical colleagues? The hospital CEO? I mean he can complain to his buddies all he wants but I will equally complain to everybody I know about the horrible surgery.

2) If he wants to bring this up in some sort of interdepartmental M&M where you are invited, I'd ask what the median outcome is for morbidly obese 8 hour VATS lobectomies with massive blood loss? I mean is there a single anesthetic plan that creates a good outcome here? Because I don't see it. At minimum this dude is likely on the vent overnight and probably a CVP with possible pressors/inotropes and CVP monitoring.



This case f'in blows. There is no way to do the anesthetic and make it a perfect outcome. We can polish turds all day, but this one ain't gonna shine no matter how hard you try. Personally I'd have tried to stick a CVP in at some point during the case, although we all know how hard that is on their side under the drapes, especially when they are really big. If this surgeon wants to blame anesthesia, I'm pulling out a mirror and asking them to take a hard look.
 
  • Like
Reactions: 2 users
This case f'in blows. There is no way to do the anesthetic and make it a perfect outcome. We can polish turds all day, but this one ain't gonna shine no matter how hard you try. Personally I'd have tried to stick a CVP in at some point during the case, although we all know how hard that is on their side under the drapes, especially when they are really big. If this surgeon wants to blame anesthesia, I'm pulling out a mirror and asking them to take a hard look.
Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. - PubMed - NCBI . ;)
Paul Marik in Chest 2008 Jul said:
The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/DeltaCVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56+/-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21).
But please keep measuring the CVP. Also, don't forget to ask your astrologer.

I always love when the cardiac surgeon asks me how much fluid I have given when the CVP is high... from phenylephrine.

Also see the attachment, taken from here. And the full article quoted above, here.
 

Attachments

  • Capture.PNG
    Capture.PNG
    169.1 KB · Views: 81
Last edited by a moderator:
  • Like
Reactions: 1 users


Perhaps you could point out the part where I was planning on measuring a CVP to predict fluid responsiveness? Oh that's right, I didn't.

I'd stick a CVP in this guy because he's a train wreck going down the tubes and potentially in need of some medical therapies that don't go so well down a peripheral IV. While I was at it, I'd measure the CVP for giggles. And while CVP as an absolute number doesn't tell you anything, how it changes with fluid boluses does provide potentially useful information. Besides, at this point in a disaster (and let's be honest this is kind of a disaster), having an extra data point isn't going to hurt you even if you rightfully choose to ignore it. I consider it harmless. I'm already putting in the line, hooking it up to a transducer is not harming the patient.
 
  • Like
Reactions: 1 user
Perhaps you could point out the part where I was planning on measuring a CVP to predict fluid responsiveness? Oh that's right, I didn't.

I'd stick a CVP in this guy because he's a train wreck going down the tubes and potentially in need of some medical therapies that don't go so well down a peripheral IV. While I was at it, I'd measure the CVP for giggles. And while CVP as an absolute number doesn't tell you anything, how it changes with fluid boluses does provide potentially useful information. Besides, at this point in a disaster (and let's be honest this is kind of a disaster), having an extra data point isn't going to hurt you even if you rightfully choose to ignore it. I consider it harmless. I'm already putting in the line, hooking it up to a transducer is not harming the patient.
That's the part in the abstract that says "The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21)." ;)

The CVP is (mostly?) useless. The sooner we accept it, the sooner we'll stop reading coffee grounds.
 
Did give a little ephedrine here and there which she responded to well. Could have tried Vaso or Levophed. Only had peripheral access but most of out people are ok running these temporarily till we or the unit place a central line.

Curious on how you all approach ACE/ARB hypotension when do you make the call to try vasopressin? How do you dose it?

As I CA-3 I used to squirt 1-2 mg of norepi or 20-40 units vaso into a 40mg/250cc neo bag to add a little punch, assuming I had a solid 16 or 18g and was running the neo on an alaris with a separate carrier. I found the solution elegant as hell compared to making a new bag and trying to get another pump but I'd bet some of your attendings would frown on it.

The few cases of likely ACE hypotension I've had were extremely obvious. S/p standard prop induction, pt's BP is <80/50s. Give 100 of neo, nothing. Give 200 of neo, nothing. Turn down volatile and give 10mg ephedrine, HR comes up 5 and pressure is still in the toilet. Give 0.5-1u vaso, BP is now 130/80.
 
That's the part in the abstract that says "The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21)." ;)

The CVP is (mostly?) useless. The sooner we accept it, the sooner we'll stop reading coffee grounds.

Considering I've never used a CVP to solely determine fluid management, you are probably preaching to the wrong choir. I'd have had a Lidco hooked up to this patient at the start, but I'd still stick a CVP in during this crapfest and I'd still transduce it. And I'd still get some useful information out of it.
 
A lobectomy shouldn't bleed 1200ml and take 8 hrs. There is obviously a surgical issue going on.

I would disregard the concern about fluid. I think he is trying to divert attention from his botched surgery.

What was the urine output?

A case that long at the minimum would get 2L of crystalloid. Add 1200 for blood loss not even giving 3:1 back and you are already over 3L. You are not far off. It was a bad surgery.

X2.
Surgeon sucks. That's it. A lobectomy is usually a relatively short and straightforward case. He ****ed up, should have gone open and wants to blame someone else. 8 hours? WTF was he doing? Not controlling the blood loss and ****ing around in the dark, that's what. Your attending should have been advocating for sanity. Watch out for him in the future, he's a danger to your career.
PS It sounds like you DID run her dry. And that was a truckload of Neo. Maybe tweak your anesthetic down by 20, 30% (?) or so next time, or change pressors.
PPS give some blood, albumin and or FFP.


--
Il Destriero
 
Last edited:
  • Like
Reactions: 2 users
Considering I've never used a CVP to solely determine fluid management, you are probably preaching to the wrong choir. I'd have had a Lidco hooked up to this patient at the start, but I'd still stick a CVP in during this crapfest and I'd still transduce it. And I'd still get some useful information out of it.
Please tell me the useful information it gives you, besides ScvO2.

Even a bad clock shows the right time twice a day. So does (Delta)CVP. Use the A-line SPV/PPV, all much more reliable (as long as one knows and satisfies the prerequisites).

P.S. Not trying to change your practice, just to educate future generations.
 
Last edited by a moderator:
1) who will hear the surgeons opinion louder than anything you say? his other surgical colleagues? The hospital CEO? I mean he can complain to his buddies all he wants but I will equally complain to everybody I know about the horrible surgery.

2) If he wants to bring this up in some sort of interdepartmental M&M where you are invited, I'd ask what the median outcome is for morbidly obese 8 hour VATS lobectomies with massive blood loss? I mean is there a single anesthetic plan that creates a good outcome here? Because I don't see it. At minimum this dude is likely on the vent overnight and probably a CVP with possible pressors/inotropes and CVP monitoring.



This case f'in blows. There is no way to do the anesthetic and make it a perfect outcome. We can polish turds all day, but this one ain't gonna shine no matter how hard you try. Personally I'd have tried to stick a CVP in at some point during the case, although we all know how hard that is on their side under the drapes, especially when they are really big. If this surgeon wants to blame anesthesia, I'm pulling out a mirror and asking them to take a hard look.
I agree with your general sentiment of prejudice towards this surgery but I am not sure I share you enthusiasm for CVP and it's value.
 
  • Like
Reactions: 1 user
Curious on how you all approach ACE/ARB hypotension when do you make the call to try vasopressin? How do you dose it?

Give some crystalloid, raise the HR with glyco, for infusion maintenance start with NE. Rarely is vasopressin needed. Half unit bolus and half to about 2 u/hr if really refractory.
 
1) who will hear the surgeons opinion louder than anything you say? his other surgical colleagues? The hospital CEO? I mean he can complain to his buddies all he wants but I will equally complain to everybody I know about the horrible surgery.

2) If he wants to bring this up in some sort of interdepartmental M&M where you are invited, I'd ask what the median outcome is for morbidly obese 8 hour VATS lobectomies with massive blood loss? I mean is there a single anesthetic plan that creates a good outcome here? Because I don't see it. At minimum this dude is likely on the vent overnight and probably a CVP with possible pressors/inotropes and CVP monitoring.



This case f'in blows. There is no way to do the anesthetic and make it a perfect outcome. We can polish turds all day, but this one ain't gonna shine no matter how hard you try. Personally I'd have tried to stick a CVP in at some point during the case, although we all know how hard that is on their side under the drapes, especially when they are really big. If this surgeon wants to blame anesthesia, I'm pulling out a mirror and asking them to take a hard look.

what he said

@Planktonmd I'd LOVE for this case to go to M&M. How's a surgeon defend an 8hr VATS with 1.2 L EBL? I'm just curious..would he go 10 hrs? 12 hrs? 14hrs? Holy crap, at what point do you pull the freaking trigger and just open the damn chest? How's an anesthesiologist defend extubating the morbidly obese COPD'er OD'd on phenylephrine for 8 hours? I don't mean to be overly critical, but that case sucked all around.
 
Eh I think the ARB/ACE is overreported. Yes they can get hypotensive but the majority still respond to neo. Very few need vaso (but this could be the case here). Are you a CA-2 ? I assume you are and should probably have asked your attn if it was a good idea to extubate or why? If you are running neo wide open that should give you a clue that either A) the pressor is doing minimal or B)Patient has significant blood loss/shock state etc aka something is not right. Probably should have replaced blood or done ABG's which I'm sure you were doing? Op yes in lung cases we try to minimize fluid but they also don't last 8 hours and loose >1L of blood! This is your garden variety academic surg who can't make it in the real world, but is allowed to butcher patients in the academic hospital.

I have hypotension w minimal response to phenylephrine in >50% of the patients who took their ACEI/ARB... it's very common to me at least. Sure they 'respond' to phenylephrine but i'd be blosing like 400mcg at a time and be out of phenylephrine in like 10 minutes.
 
what he said

@Planktonmd I'd LOVE for this case to go to M&M. How's a surgeon defend an 8hr VATS with 1.2 L EBL? I'm just curious..would he go 10 hrs? 12 hrs? 14hrs? Holy crap, at what point do you pull the freaking trigger and just open the damn chest? How's an anesthesiologist defend extubating the morbidly obese COPD'er OD'd on phenylephrine for 8 hours? I don't mean to be overly critical, but that case sucked all around.
The case has many interesting points and we should all be thankful that the OP posted it.
The issues here are :
1- Surgeon who over estimates his abilities and is unwilling to admit that maybe his technique was to blame
2- Surgeon thinks (maybe sincerely) that he could do no harm, and if harm was done it must be someone else's fault, most likely anesthesia
3- An anesthesiology team who made it easy for that surgeon to blame them
The clinical aspects of the case are definitely good teaching points but in my opinion the real issue here is a typical surgeon versus anesthesia conflict that we all are familiar with, and in most instances it is won by the surgeon because he is seen as the real doctor by the hospital administrators, other specialists and the whole system.
 
Give some crystalloid, raise the HR with glyco, for infusion maintenance start with NE. Rarely is vasopressin needed. Half unit bolus and half to about 2 u/hr if really refractory.

I asked this of one of our residents the other day from the adult hospital. They said that they order vasopressin for everyone on it. Seems like overkill.


--
Il Destriero
 
I'd be interested in knowing what the creatinine did over the following days.
 
I see patients with ace's all the time and it's not 50% that require vaso :/
 
I agree with your general sentiment of prejudice towards this surgery but I am not sure I share you enthusiasm for CVP and it's value.

I'm not exactly "enthusiastic" about CVP, but in this type of surgery and this type of patient, I'm at least going to hook it up and look at it. Seeing if it is 2 or if it is 34 gives you a piece of information that you can use as you like. Seeing what exactly the waveform looks like provides additional information.
 
I'm not exactly "enthusiastic" about CVP, but in this type of surgery and this type of patient, I'm at least going to hook it up and look at it. Seeing if it is 2 or if it is 34 gives you a piece of information that you can use as you like. Seeing what exactly the waveform looks like provides additional information.
In the lateral position and on one lung ventilation the interpretation of the numbers might be a bit tricky though.
 
  • Like
Reactions: 1 user
In the lateral position and on one lung ventilation the interpretation of the numbers might be a bit tricky though.

sure, but if I've already gone through the trouble of putting it in for other reasons I'm still going to look at it
 
I dunno. If I have a hypotensive paralyzed intubated patient with a CVP of -2 vs a CVP of 12, it means something to me. I don't know about everyone else. Maybe I've become a dinosaur.
 
  • Like
Reactions: 2 users
I simply make the Vaso 2 units/ml, give a couple cc's and see if it we get a decent response before adding it as an infusion.
 
As one more piece of information, the CVP (RAP) has some benefit. People here feel very strongly against that notion which seems an odd place to put that much emotion, but as an indicator of impediment to venous return and therefore cardiac output, it has its place. Especially when the chest is open and PPV/SVV indices are not valid. I'll grant that the circumstances where the information gained is meaningful are not as common in many practices, it is for mine and I'll continue to use it in those specific circumstances.
 
I pretty much agree with everyone here. But my question is what was the starting Hct? I'm guessing this pt likely had a high Hct but lowest Hct of 36, with >1L blood loss, tons of alpha agonist, and PPV for 8 hours point to more volume to me, though I'd have added some albumin.

I will also say outside of an echo there really isn't a great monitor to assess fluid status here. CVP is barely useful as a trend....maybe, but doesn't predict responsiveness. UOP? No. And lateral position, and OLV (plus pressor) basically makes any of the minimally invasive pretend CO/SVV/PPV monitors equally worthless. But increasing pressor requirement is usually volume.
 
Top