This is re: a s/p triple A patient last week in our unit. The anesthesia provider was a CRNA. Patient came out of the surgery intubated with just a cordis in place where all the IV drips were going. ...propofol, levophed. BP was unstable from SBP 60-220. He ordered Esmolol drip. HR- 101-112. HAd a clamped epidural cath, ordered to start epidural analgesia when patient starts to wake up and complains of pain. Patient was heavily sedated from OR, Propofol was 25 mcg/kg/min. He further ordered to keep the patient intubated through-out the night. Before he left he inserted a triple-lumen cath through the existing cordis. QUESTIONS:
1 - why do you think he ordered esmolol drip?hr- 112?even with low sbp.. (heard the surgeon saying," he is just a crna, not a doctor" re: this order)
2 - when the patient was heavily sedated, with propofol going - when is the best time to start the pcea pump?
3 - cvp - initially 3, went up to 6-9 after volume resuscitation. Still 30-60 cc/hr urine output. Lasix was given. ..cvp went down to 5-6. Do you think the patient was still dry?
4 - h & h - 14 & 42. after 8 hrs - was 7 & 30. Why the big drop ? Hemodilution ? thought the patient was on the dry side?
ahhhh.....can't stop figuring out this hemodynamics...
Dec 21, '03
What I learned about CVP was that CVP was an estimate of RVEDP. Because RVEDP is taken when the tricuspid valve is open, you get what can be assumed to be a open venous system, which can then be used to estimate ventricular pressures, which is then assumed to be related to volume in a normal heart. Obviously, there are a lot of assumptions in this and the result is something sort like a grey blob. I think if one has to resort to using CVP it would be best to use it in conjuction with stroke volume or, even better, stroke index, and like you said, watch the pattern rather than actual numbers.
As always, your post was greatly appreciated.
Last edit by Diprivan/Vented on Dec 21, '03