Hypotension in the PACU

1
Hypotension in the PACU

• Orestes OBrien, M.D.
• Department of Anesthesia and Perioperative
  Medicine
• University of California, San Francisco

2
History

• 60 y.o. male presented to an outside hospital
  with chest pain, diaphoresis, nausea and vomiting
  and HTN. Diagnosed with an acute MI.
• While there, he complained of right flank pain.
  Abdominal CT revealed a 6cm adrenal mass.
• Urine epinephrine and metanephrine levels were
  elevated. Noted to have a Serum TSH, renin and
  aldosterone levels were normal.
• Diagnosed with pheochromocytoma.

3
History (continued)

• Echocardiogram at OSH initially revealed global
  hypokinesis. Nine days later repeat echo
  interpreted as normal.
• Developed rapid atrial fibrillation treated with
  Digoxin.
• Started on phenoxybenzamine and transferred to
  UCSF for further management.

4
History (continued)

• Here he got IV hydration and continued on
  phenoxybenzamine.
• Cardiology saw him.
• Repeat echo Normal LV function, EF 76.
• Cardiac cath Mild calcific left main stenosis
  and a 20 stenosis of the LAD.
• Scheduled for laparoscopic adrenalectomy 17 days
  after starting alpha blocking drugs.

5
Past Medical History

• Brittle diabetes mellitus requiring insulin
  pump.
• GERD
• Hypertension
• Hypothyroidism

6
Physical Exam and Lab Data

• Vital Signs BP 155/78, HR 84, 96 RA , wt.
  82 kg
• Chest clear
• Cardiac unremarkable except for a 2/6 Systolic
  murmur audible at the base.

• Hematocrit 27
• Na 136, glucose 197, Troponin I 0.3
• CXR normal

7
Intraoperative Course

• Premedicated with Midazolam 2mg.
• Pre-Induction vital signs BP 126/70, HR 56, SaO2
  100.
• Induction Fentanyl 500 mg, STP 200 mg,
  Rocuronium 70mg, Esmolol 50 mg.
• Maintenance Oxygen, Desflurane, Fentanyl
  (additional 250 mcg), Esmolol for periodic
  hypertension.
• Duration of Case 6 hours.

8
Intraoperative Course (continued)

• Total fluid 3800 ml.
• Urine output 600 ml.
• Est. blood loss 150 ml.
• Extubated awake, taken to PACU

9
PACU Course

• Initial pressure 80/60, pulse 70. Pt. awake and
  responsive and appropriate.
• Over next hour hypotention persists and responds
  poorly to fluid boluses.
• Patients mental status deteriorates.
• Dopamine, Epinephrine and Norepinephrine
  started. BP remains 70/30, HR 100.

10
Arrest

• Cardiac rhythm becomes bradycardia then asystole.
• CPR is initiated. Patient is re-intubated.
• Pt resuscitated with Atropine 1mg and Epinephrine
  48 mg and hydrocortisone 100 mg
• Trans-thoracic echo reveals global akinesis.
• After 20 minutes sinus tachycardia returns. Echo
  shows normal EF

11
Post Arrest

• Pt is transferred to ICU
• Pressers weaned off by post-operative day 1 and
  extubated.
• Tropinin I peaked at 1.3, creatinine increased to
  1.7 but resolved.
• Mental status was baseline by POD 1
• Discharged home POD 6