What would you do?
Patient is post-operative OPCABGX4, no control over HTN pre-op, smoker, and extreme HTN post-op despite multiple doses of IV lopressor, Hydralazine, OG Lisinopril, Clonidine, Lopressor, and a max dose of Nipride at 5mcgs/kg/min for the past 36 hrs. Nitro was removed in favor of trying to wean the Nipride (ha ha good luck). Blood Pressure ranges 180-250 systolic consistently. Pt. is actually tachycardic 110's. 02 sat is decreasing, and is 85-89% on 100% Fi02 on ventilator. RR is 20-35 w/ high Peak pressures. Pt. now has sub-q air in the left lung field (hey go figure!)
I know what I would do, and I think it is a no brainer, but maybe I am missing something. Let's see what you think.
Nov 16, '05
What kind of sedation is being administered?
Nov 16, '05
Has the pt been that hypertensive for 36 hrs? I agree about sedation indeed. Also, is Nicardipine not an option? Are there not other post-op complications?
Nov 17, '05
i am surprised he hasn't blown a graft...although is sounds like he blew a bleb....
i would up the diprivan, give morphine - turn the NTG back on...
do they have a swan in - what are the readings??
if he was and uncontrolled hypertensive pre-op - perhaps he needs a systolic of 180 due to an autoregulation curve shift...
pulmonary htn??? if so - i know there are 2 meds contraindicated - one is an ACEI (i think lisinopril) and the other is missing me right now...
what would you do pete??
Nov 17, '05
Pt. was getting versed 2mg q1-2hrs prn (shady doctor). My answer was simple diprivan for respiratory distress to let the lungs rest, sedation, and even for blood pressure, since it is so high, and other methods have been resistant. I thought it would be more of a priority to get his blood pressure down.
It turned out the patient had bilateral Pneumos. Chest tube insertion x2 was completed rather quickly. Pt. is still quite hypertensive, but did end up on a diprivan drip. it just took a while.
Swan was actually pulled today because pt's co/ci were great, 7/3 range. pulmonary pressures did not indicate any pulmonary hypertension, but that is in interesting point about contraindication. they did start lisinopril today actually.
also good point about the autoregulation curve. Since he was so poorly controlled pre-op, he's probably used to a high blood pressure. I kinda wondered if there was any other agent that could be used for blood pressure. Nipride is some pretty potent stuff.
Thanks for the info.
Nov 20, '05
Just thought I would update you. Right now, there investigating whether patient has a pheochromacytoma. That would explain that amount of hypertension that we saw.
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