How would you manage this patient? Provide rationales for your actions
You are caring for a 68-year-old man who has had bilateral inguinal hernia repairs under a spinal blockade with sedation. His preoperative BP was 120/80 mmHg and his BP on arrival into the PACU was 105/85 mmHg. Your second blood pressure reading shows that his BP has fallen to 85/68 mmHg.
What will be an ideal response?
Answer:
Lay the patient flat with the legs elevated (not head down). This allows blood to be pumped more easily to the vital organs. The head down position is not appropriate, as the Trendelenburg causes the abdominal organs to fall on the base of the lungs, thus limiting expansion. The Trendelenburg is the most difficult position to uptake oxygen.
Provide supplemental oxygen (if not already in use).
Call for medical assistance and check the patient's peripheral return at the fingernail beds to assess whether peripheral shutdown has occurred, signalling compensation.
Follow the instructions from the treating anaesthetist.
Depending on the type and cause of hypotension, medical management may include fluid resuscitation therapy; in the case of misdistribution of circulation from an epidural or spinal injection of local anaesthetic, medications such as metaraminol (a potent sympathomimetic agent) may be used to provide some vasoconstriction to increase the BP.
If haemorrhage is the cause, commence resuscitation of the patient.
For unresolved haemorrhage, the patient may be returned to the operating room to find the cause of the bleeding and to initiate surgical haemostasis.
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