Hypotension - Anesthesia Early post-operative care

Hypotension

Differential diagnosis

·           Inadequate preload

– Inadequate fluid resuscitation

– Continued hemorrhage

– Venodilation due to medications or sympathetic blockade

– Pericardial tamponade

– Pulmonary embolism

– Increased intra-abdominal pressure, e.g., big uterus pressing on vena cava

– Increased intra-thoracic pressure, e.g., tension pneumothorax

·           Poor contractility

– Residual anesthetics

– Myocardial ischemia

– Fluid overload (“far-side” of the Starling Curve)

– Pre-existing cardiac dysfunction

– Electrolyte disturbance

– Hypothermia

·           Inadequate afterload

– Sepsis

– Vasodilation due to medications or sympathetic blockade, e.g., neuraxialanesthetic

– Anaphylaxis

·           Arrhythmias

– Bradycardia

– Loss of atrial kick

Atrial fibrillation/flutter AV dissociation

– Electrolyte disturbance

Management

·           Physical examination (especially chest auscultation)

·           ECG (at least 5-lead strip) to detect arrhythmias and ischemia ACLS protocol if abnormal rhythm

·           Hemoglobin level

·           Intravascular fluid resuscitation +/− blood transfusion Supplemental oxygen

·           Elevate legs to enhance venous return Consider transthoracic echo

·           Consider chest radiograph

·           Consider invasive monitoring

·           Check electrolytes, especially Ca2+ for inotropy and K+ , Mg2+ for arrhythmias