Hypotension
Differential Diagnosis
-
↓ preload:
-
Bleeding
-
Relative
-
-
↓ afterload/distributive shock:
-
Anaphylaxis
-
Sepsis/SIRS
-
Neurogenic
-
Blood transfusion reaction
-
Neuraxial
-
Drugs: anethetic overdose/drug swap
-
Endocrine: Addison's, myxedema, carcinoid
-
Metabolic: hypocalcemia, hypoglycemia
-
-
Obstructive shock:
-
Tension pneumothorax
-
Tamponade
-
Embolic events
-
Pulmonary hypertension
-
-
Cardiogenic shock:
-
Rate:
-
Bradycardia
-
Tachycardia
-
-
Arrhythmias
-
Contractility:
-
Ischemia
-
Drugs or toxins
-
-
RV failure/pulmonary hypertension
-
Acute valvular pathology
-
Management
-
Emergency situation requiring simultaneous diagnosis & management
-
Inform the surgeon
-
Call for help
-
↓ anesthetic & hand ventilate with 100% O2
-
Vasopressor bolus +/- IV fluid bolus:
-
Phenylephrine 100 mcg IV PRN
-
Norepinephrine 5 mcg IV PRN
-
Ephedrine 5-10 mg IV PRN
-
Epinephrine 1-10 mcg IV PRN
-
-
Cycle BP & scan monitors for HR, rhythm, ST changes, SaO2, EtCO2, PAP
-
Feel for a pulse:
-
If no pulse → ACLS as per protocol
-
-
Ensure crash cart in room:
-
If pulse present → targeted physical exam
-
Urticaria, flushing, angioedema
-
Tracheal deviation, jugular venous distention, subcutaneous crepitus, bilateral air entry
-
JVP (jugular venous pressure) / CVP (central venous pressure) / PCWP (pulmonary capillary wedge pressure)
-
↑ CVP / PCWP = obstructive or cardiogenic
-
↓ CVP / PCWP = hypovolemic or distributive
-
-
Peripheral perfusion (↑ in distributive, ↓ in others)
-
Look at surgical field (blood loss, IVC compression, pneumoperitoneum pressure)
-
Check IV fluids, vasopressors, blood products
-
-
-
Reassess differential diagnosis based on findings