Hypotention in CSICU

we have a patient with hypotention in first hour after his operation (CABG 3v graft).

that petient had 10 years Case History in hypertention and treated by atenolol 50 mg Bid & captopril 12.5 mg Tid

his preasure depend on dopamin to 8-10 h

EF in post OR Echocardiography =45% & haven't cardiac tamponade

CVP = 12-15 cm H2O

HR = 90 - 110 bpm

BP sys = 60 - 80 mmHg ( with infusion of 10 miq/kg/min of dopamin )

IV Fluid: ser ringer 500cc stat

ser ringer 100cc/h

albumine 20% 50cc

what is your idea about this kind of hypotention ?

what is the best treatments ?

Was the patient an RCA graft??? Sounds like Right Ventricular failure, ???able graft shut-down. There are also a variety of things you can do depending on how your surgeons do surgery. If you have pacing wires, you can pace the patient over his intrinsic rate to see if you can improve cardiac output. I see rate of 90-110, is the patient in A-fib??? If he is, you can atrial pace a-fib by decreasing atrial sensitivity until you are capturining above the fibrillation threshhold if you follow me. The CVP indicates you have plenty of fluid on board, probably too much, but in a RV disfunction, you can't really have too much fluid, until you drown the patient. You also would benefit from a TEE vs. a normal Echo, as it would give you a little better idea of what the post. wall is doing. The albumin WILL NOT HELP, as the patient has plenty of volume, but not enough contractility. Most likely the only thing that would help this patient is a Balloon Pump, emergent re-vascularization, or a Bi-VAD.

A close friend's father was in this almost exact scenario about 5yrs. ago and may have had a better outcome had a "Bi-VAD" been available, but it wasn't and as a result he had an occipital lobe stroke, and can now only see shadows or silhouettes.

What happened???

Doug

what's the wedge, i mean cvp around 12 that's pretty tanked especially for an open heart patient, i guess what u can do is start inotropes first and foremost before baloon placement, and if there's no swan then it warrants insertion of it, i'd get the fellow to redo a stat 2decho to make sure the ef is still adequate, stat cxr r/o pulm edema, though pt's tachycardic and hypotensive which can suggest hypovolemia on any other patient but if the pt's going into cardiogenic shock, then ur interventions would be different. keep the dopa at 10 mcg, start dobutrex and shoot c.o. just to make sure, to be safe at least. so many different things can be going on.

I am not a CSICU RN but I am learning a lot from your critical thinking!

Keep up threads like that.

That's what I am talking about! :kiss

Let's network, learn from each another, sharing pearls and tricks, making us smart and competent.

As opposed to some firm (like mine, who does not even require ACLS for ICU RN's! and is very stingy on education money, by March, there is nothing left for seminars!), and some MD who would like us as dumb as could be to pass us a quick one or just dominate us. (Well, few MD's are generous enough to share their knowledge). :loveya: :heartbeat :thankya: