Let me know what you would do.


Patient is post-operative ascending aortic root replacement. Only history is a little hypertension. The patient did have a descending aortic aneurysm as well as an ascending aneurysm. Only the ascending aneurysm was repaired. Descending repair would have required too long of a circ. Arrest. The patient's aorta was replaced via circ arrest for 36 minutes. The patient came back to the CVSU with swan, art line intact like usual. drips up are .25mcgs of NTG, dopa at 5mcgs, nipride at .3 mcgs/kg.

Typically these patients need coupious amounts of volume post operatively. CO/CI upon arrival to CVSU is approx. 2.4/1.2. B.p. is right about 100 systolic, and PAD is changed from 17 to 22 after 3 bottles of albumin. CO/CI only up to 2.7/1.6 approx. SVR is 2200. This went on for about 2 hours. Called the surgeon 3 times. Surgeon wants more nipride to decrease SVR, but blood pressure on .7 mcgs of nipride (about 13cc's) is in the 70's. surgeon finally came and stood by and we watched b.p. stay that way for at least 15 minutes, just to get SVR down. Only 1 more bottle of albumin. Surgeon did end up giving 2 of FFP, and then FINALLY started dobutamine, and then added more dopamine (up to 10mcgs)

I understand the physiology, but why not add dobutamine, thus increasing your co/ci and prob. b.p. faster and allowing you to go higher on your nipride to get your svr down? I was really worried about the patient?s post op neuro status with that low of a b.p, and being post op circulatory arrest. Anybody have any ideas?


PETE495

Is there a concern about too greatly increasing dP/dT with the dobutamine and putting the unrepaired descending aneurysm at risk for further dissection/rupture? Plus with dobutamine you do get a vasodilatory effect in conjunction with the increased stroke volume and so perhaps there was a concern about further decreases in BP?

I don't know, how did the patient do??

Sounds to me like this pt could have used a little Primacor to get that SVR down and some Levophed for the bp. Was he bleeding? He could have used some blood as well. We use Dopamine but usually no more than 3 mcgs. The Primacor would have dropped the SVR and increased the CI. The Levo would help with the low bp, as I am sure you know. We also use a lot of Primacor it works really good! How did the guy do?

We too use primacor, but only after dobutamine is innefective, we call it "refractory treatment", and a dobutamine trial usually occurs first. Levophed doesn't affect the HR like dopamine so we use that first, save the dopamine for that (futile) renal dose, that so much literature is proving against, surgeons not sold on that theory yet.

We don't use Levo that often; vasopressin or Neo would be our drug of choice for the BP. Primacor (milrinone) would have been a good choice, I think.

What was the MAP?