SVR too low!!

[HeartRN80]

I have recently transfered to a CCU after doing ER nursing for 3 years. I had a fresh open heart patient the other night. The patient came back with a CO 14.6 and a CI 7.1 with an SVR 246, and a SBP in the 80's..... this was on 3 mcg of dopamine and 8 mcg of EPI. Throughout the night I had the pt up to 10 mcg of EPI, 200 mcg of NEO, 3 mcg of Dopamine, and 0.04 units an hr of Vassopressin....... To get me to an SVR of 496 and an SBP crashing in the 70's. Needless to say we did an emergent IABP at bedside.

Now for my questions.... why couldn't I get an SVR??? My white count actually decreased throughout the night going from 22 to 18, kinda ruling out sepsis. My patient was an emergent CABG so I if anything I would actually expect cardiogenic shock with a high SVR????

Just looking for some ideas from experienced CCU nurses...Thanks!!

Melissa

[aCRNAhopeful]

why would increasing volume increase your systemic vascular resistance? I can see increased volume increasing preload and thus increasing CO and BP but not SVR.

Very interesting about the vasoplegia. Ive had some bizarre hours of critically low SVR with my limited experience with OHs. I need to be less green before I take the fresh ones, and Ive always chalked it up to infection/sepsis because it happened to be concurrent.

I believe adding volume does increase your SVR. While it doesn't constrict your vessels like you typically think of an increased SVR it does add volume and pressure to those vessels and therefore resistance. But as you mentioned, adding volume may increase the CO driving the SVR equation down and/or increasing the MAP, driving the SVR up.

Just for review: SVR = MAP-CVP/CO x80

[tri-rn]

Unrelated to vasoplegic syndrome...was this patient acidotic? Maybe that was hindering the pressor's effectiveness?

[sunnycalifRN]

Aside from what you've mentioned, consider adreonocortical insufficiency, particularly in patients taking steroids preoperatively.

Absolutely! We always check cortisol level as soon as we get the patient from OR and often will give hydrocortisone before we even get results, esp when the SVR remains so low with all those pressors on board.

[WalkieTalkie, RN]

I had the same thing happen to me with a patient who'd gotten a heart transplant. He was on pump a long time and had vasoplegic syndrome. Giving him lots of Neo and Vaso helped.

[clementinern]

Was the pt an AVR in addition to CABG? Sometimes those pts are used to really high SVR's pre-op and the suddenly competent valve can have a hard time adapting to the decreased afterload.

I also find the addition of the IABP odd, even though it will help perfusion, yes, I'm not sure how it will help perfuse when the SVR is already SO low. Though your numbers did improve somewhat, so what do I know! :)

Was the pt febrile? As I'm sure you know that can also cause vasodilation.

A final thought, do you know if the pt had Tricuspid regurg and did you FICK the cardiac output at all? Sometimes CCO monitors can be inaccurate in a pt with MR and TR, but the numbers (CO) tend to be falsely low, not high.

Do you measure SVO2, and if so, what was it?

[clementinern]

Also i wonder why the docs would have you go up so high on Epi and add vasopressin without increasing Dopa or adding Levophed first? Vasopressin usually works in conjunction with Levo....seems like increasing the Dopa to alpha doses or adding Levo would have constricted you more.

[Always-Learning]

This is an interesting post. I've had similar problems in the past but none have had so little responce to such a large amount of pressors. I'm definatley interested in reading up more on vasoplegia syndrome.

[altusjg]

Although I appreciate a response to my question, I have to admit that I am rather offened by your tone and implications of my ER nursing background

I was seeking some supportive advice about a patients situation, not an assesment of my nursing skills.

I'll start by saying I'm truely sorry that you took my comment about your ER background out of context. You said that you had recently transfered from ER to CCU and gave no indication that you had a proper orientation/preceptorship. I've been in facilities that have put nurses in situations that they were not ready to handle and put the nurse and the pt at risk in doing so. Seeing as how this was not the case in your circumstance, you could have disregarded the comment as it did not pertain to you. I'm sure your ER experience has proven invaluable in your transition to becoming a CCU nurse and will continue to be. In reading your post i wrongly jumped to the conclusion that you were yet another unfortunate nurse who had been thrown into something they were not ready for. Again, i apologize.

Also you did not say that you had already tanked up the pt with volume and did not give a CVP in the initial post to indicate that you may have done so. I was going off of the limited information that i did have and did not mean to sound judgemental but was in my own way offering the supportive advice you were looking for. Sorry if i offended you.

As far as the questions asking why volume would increase SVR, I would refer you to aCRNAhopeful's post as his explanation is dead on. I have personally seen this work time and time again.

Great post on vasoplegic syndrome!! I definately intend to do some reading up on it.

[call1agent]

This one looks more like septic rather than cardiogenic. But not enough data. What's the PA and filling pressures? Is the patient dry (most likely not d/t high CO/CI). Also do you have an initial post-op ABG? Have they also ruled out correct placement of Swan Ganz? With those SVR and CO/CI numbers it did not make sense to me the addition of IABP as it could lower the afterload even more and increase CO/CI and may cause the BP to drop even more. I have seen this on prolonged exposure to heart and lung machine where they vasodilate badly and the addition of M. acidosis lowers the efficacy of your vasopressors. Given the nature of surgery and FLOD, I would have anticipated Methylene blue and addition of Levophed instead.

[offlabel]

Turn off the CCO monitor. Didn't seem to be helping here at all. More numbers don't help anything and you probably wouldn't be doing anything differently without it. Routine hearts don't need PA catheters, in fact the risk/benefit has made most CT surgeons to abandon them altogether except with bad PHTN.