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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.
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.