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Postoperative Hemodynamic Instability
Case Synopsis
A 90-kg, 75-year-old man (body mass index 35) with a history of smoking, well-controlled hypertension, and chemotherapy in the distant past for lung cancer is transported to the postanesthesia care unit (PACU) and intubated after a complex, 6-hour hand surgery. Preoperative medications include metoprolol and hydrochlorothiazide. Intraoperative urine output is 300 mL. An arterial line is in place. In the PACU he receives a 2-mg dose of morphine and a 1-g dose of acetaminophen intravenously. Noninvasive blood pressure (BP) then reads 70/40 mm Hg. Heart rate is 80 beats per minute and regular. Oxygen saturation is 92% on Fi o 2 of 0.6 and positive end-expiratory pressure (PEEP) of 5 cm H 2 O. End-tidal CO 2 is 50 mm Hg.
Problem Analysis
Definition
As surgical volumes continue to grow to an estimated more than 312 million operations worldwide, so do postoperative complications. In a subset of nearly 2 million procedures from Medicare beneficiaries, including cases such as the one we present, major complications were observed in 24% to 50% of the cases, with “failure to rescue”—as defined by the National Quality Forum Initiative as a lack of recognition of an adverse event leading to worsening outcome—ranging from 4% to 41%.
Recognition
Avoidance of failure to rescue a patient from crisis requires the patient’s caregivers to recognize that the patient is in crisis and institute effective action. Heart rate and rhythm and BP, as generic indicators of afterload, preload, and left and right ventricular function, all need rapid evaluation in the context of the clinical picture and recent surgery.
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