Low BP in cardiac surgery patients

1st things first

• Zero all lines• Swingy arterial line• CVP• Urine output

– Beware osmotic diuretics

• Base excess• Are they warming up

• What inotropes ? escalating

BEFORE INOTROPES• Fluid

– Bolus– Legs up

• Rhythm– ECG, SR / AF, slow, fast, paced on ventricle, STs, ectopics

• Tamponade– CVP, BE, UO, temp, CXR, echo

• Bleeding– Drains, CXR, Hb

• Pneumothorax– CXR, examine, vent alarms

• Fight Ventilator– Paralyse, sedate or extubate

• If on ward what drugs– Beta blockers, ACE inhibitors, apha blockers, calcium channel blockers– Beware prostate alpha blockers and nicorandil for angina

What operation have they had?

• Any Valve – stuck leaflet, para valvular leak– Use stethoscope

• Mitral repair – ? Given way– Use stethoscope

• Aortic valve – adequate pre load, A-V synchrony, high SVR

• CABG – infarct, stunning, graft ok ? Re-graft ?IABP

Which Inotrope

• Ohms Law

• V=I x R

• BP=CO x SVR

• Simple terms• Low or high cardiac output, what is the PA pressure

• ARE THE ANKLE PULSES BOUNDING?

Inotropes• Atropine• Ca2+

• Adrenaline• Noradrenaline

• Dopamine• Dopexamine• Dobutamine• Isoprenaline• Enoximone• Aminophylline• Vasopressin• Methylene blue

What else

• IABP

• LVAD

• RVAD

• BVAD

Tamponade

Arterial Swing - Pulsus Paradoxus

Pneumothorax

Pleural effusion

Sinus bradycardia

Fast AF

Paced on ventricle

STs

Ectopics post inferior MI

Complete heart block