TSRA Content:
Author: Aakash M. Shah, MD
This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by a collaboration of authors, Xiaoying Lou, MD, Elizabeth H. Stephens, MD, Kevin Beers, MD, Brendan Dewan, MD, Vakhtang Tchantchaleishvili, MD, and Panos Vardas, MD
Hypotension = (<100 mmHg systolic)
Etiology
Hypovolemia, bleeding, sepsis, acute MI, medications (sedatives, antihypertensives, opioids, diuretics, nitrates), arrhythmias, tamponade, tension pneumothorax, cardiomyopathy, vasoplegia, pulmonary embolism
Initial work-up should include:
- History: dizziness, altered mental status, syncope, blurry vision, fatigue,
- Physical exam: HR (>90), BP (orthostatics), UOP (typically 0.5cc/hr/kg), O2, peripheral edema, perfusion of extremities (cold, clammy, pale skin), weak pulse, CVP, capillary refill
- Elevate legs (150-300 cc bolus) to see response in HR
- Check to see if new VS differ from baseline (CHF and liver patients are baseline hypotensive)
- Labs: ABG, lactic acid, BNP, BUN, creatinine
- Imaging: EKG, CXR, Echo, Ultrasound of IVC
- Treatment: Start with bolus 1L isotonic fluid (0.9NS, LR)-ONLY IF THEY DO NOT HAVE CHF, SEVERE VALVE DISEASE, AND/OR LIVER DISEASE
- If have CHF, heart disease, liver disease – consider 250 cc of 5% albumin, 100 cc of 25% albumin or Lasix (this should only be considered after consulting an upper level)
- Provide supplemental oxygen if poor saturation
Notes:
Usually the cause is hypovolemia, but must be watchful for bleeding, early sepsis, acute MI, pulmonary embolism
• Pulse is often not a good indicator of volume status – UOP is much more helpful
- If UOP is declining post-op and not responding to IVF, may be bleeding – check CBC
- If UOP is declining post-op, and patient is tachycardic, hypotensive, febrile, maybe sepsis – hydrate aggressively, start antibiotics, call Upper-Level
• If chest pain, tachycardia, hypotensive, may be MI – start MI w/up, call Upper-Level
• If you suspect arrhythmia (A fib w/wo RVR, other), get EKG, call Upper-Level
• Opioids can significantly drop blood pressure – if patient is asymptomatic, assess pain control and decrease dose if possible.
If the patient is not responding to fluids alone, your upper level should have already been made aware, and you will need to transfer the patient to the ICU and consider initiating vasopressors/inotropes (generally an attending-level decision). Which drug to choose and what dose to start are largely attending- and institution-dependent; however, the summary chart below may be helpful to consider.