I promised to try to post some clinical issues and now I have one for your input.
Real Case Today: 43 year old female who lost 200 lbs post gastric bypass in 2003. She comes to us for a lower body lift, which includes abdominoplasty, bilateral lateral thigh and buttock lift. She is now 212 pounds and 6 feet tall. The surgeon removed 25 pounds (by scale) of body tissue, fat and skin. Surgery took 10+ hours. Minimum blood loss, estimated at 300 cc, but lots of tissue fluid loss--this was a big case in all respects.
How would you handle the fluid replacement?
Just curious to hear what you students and young CRNAs would do. This is NOT a question for non-anesthesia providers.
PS. The case was done in a plastic surgery facility with overnight capabilities and an excellent surgeon.
yoga - man...if you go on the numbers along - she would get a load of fluid - 130cc/hr is maint. based on weight (even though she is still about 30-40 lbs over weight)
an eight hour deficit -( which is more than likely a 10 or 12 hour deficit) - would give you a 1-1.5L loss.. 900cc to replace blood loss w/ crystalloid...
i would load her up in the first hour with 2L - i would then maint her at 150cc/hr and follow urine output.. i would likely use 500-1000cc of hespan to decrease the swelling that will ensue from the fluid we need to replace.
overall i can easily see giving her 5-6 L + 1000cc of hespan and give add'l fluid based on u/o and hemodynamics... for me it is one of those have to be there cases... i assume that otherwise she was healthy as she was done in an surgical center setting...
Last edit by athomas91 on Jun 5, '06
Quote from Tranman
, she should be extubate awake..
I don't extubate abdominoplasty patients awake, but actually quite deep. I deflate the cuff slowly, extubate and mask ventilate until awake. The reason--if they buck on the tube they can pop all of their deep muscle abdominal sutures. I had it happen once and you could actually hear the sutures popping. The patient had to be anesthetized again, opened and resutured. Once that happens, you never forget it.
I actually kept her dry fluid-wise. She had totally stable vital signs, urine output of about 35-40 ml/hr, no postural hypotension when put in the semi-sitting lawn chair position or when we turned her lateral to lateral for the thigh and buttocks lift. I gave her 5 liters of warmed crystalloid, which I thought was on the dry side, but had a hard time justifying pushing fluids if she didn't need them. Also, she had 2000 cc of tumescent fluid prior to the liposuction and only 600 cc aspirate.The surgeon asked that I not give hespan, because he has had a bad experience with increased bleeding after hespan use. The plastic surgeons really worry about bleeding. She did well, was awake in PACU with the same vitals as on admission. We will see how she does tonight. She is with our after-care RN, who also is an ICU nurse and who does a great job of taking care of these patients the first post-op night. I'll let you know how she does.
Thanks for the input.
Last edit by yoga crna on Jun 6, '06