- The decision was made to place a
pulmonary artery catheter to evaluate cardiac
filling pressures in myocardial performance. The
catheter was floated with ease via the right
internal jugular vein. The initial readings were
as follows:
- central venous pressure (CVP), 5
- systemic blood-pressure (BP),
95/60; mean, 72
- pulmonary artery pressure (PAP),
18/9 (Low)
- pulmonary capillary wedge
pressure (PCW), 6
- heart rate, 55 bpm
- cardiac output, 8 liters per
minute
- The calculated systemic vascular
resistance (SVR) was 670 (normal range
800-1900)
 The initial reading support the
diagnosis of significant sympathetic blockade
secondary to the patients metoprolol and
verapamil and exacerbated by the epidural:
 The low SVR suggests than the
vasculature is markedly dilated in spite
of the dopamine infusion.- Treatment modalities include
the administration of fluids to fill the
dilated vessels, using a different
sympathetic agonist with more
alpha-receptor activity or do nothing.
- The
original premise for treatment was to maintain
the patients BP close to his normal range to
enhance cerebral perfusion and to maintain
perfusion across atherosclerotic plaques
throughout the arterial system:
 The original
premise has not changed.
- Consequently, the decision
was made to continue treatment by
changing the agonist. An infusion of
epinephrine was begun and the low-dose of
1 ug/minute or 0.01 ug/kg/min. Within ten
minutes the hemodynamics changed to the
following:
- CVP, 8; BP 120/70
(mean 87), PAP 20/11, PCW 9,
heart rate, 65 bpm, and cardiac
output, 7 liters per minute
- The dopamine was titrated
off without hemodynamic change.
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- One
could argue the choice of epinephrine as the next
agonist administer.
- Some would review
the data include that only a pure alpha
adrenergic receptor agonist, e.g.
phenylephrine, to constrict the
vasculature was needed.
- The cardiac output
of 8 liters per minute suggests that the
myocardium is performing well and the
beta-agonist activity of epinephrine was
not needed
- Others may have
chosen norepinephrine over epinephrine
for its alpha activity.
- It is not uncommon for drugs
to be chosen with individual and
institutional bias.
- Over the next hour the
patient's vital signs remain stable.
- The sedation was
waned in the patient was extubated
without incident.
- The patient denied
incisional pain.
- Over the next
hour, the patients blood-pressure
continued to rise in the epinephrine
infusion was titrated off.
- Three and 1/2 hours had
passed from the intraoperative re-dosing
of the epidural catheter.
- The patient was
transferred to the surgical intensive care unit
for overnight observation. The pulmonary artery
catheter was removed after six hours of stable
hemodynamics.
- The patient remained pain
free for the first 36 hours
postoperatively and then required
acetaminophen with codeine for analgesia.
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