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Anesth Analg 2006;102:650
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000190749.28151.A4

LETTER TO THE EDITOR

Appropriate Response to Hypotension

Evan G. Pivalizza, MD, Robert D. Warters, MD, and Peter Szmuk, MD

Department of Anesthesiology, University of Texas Medical School-Houston, Houston, TX, evan.g.pivalizza{at}uth.tmc.edu

To the Editor:

Luckner et al., reported transesophageal echocardiography (TEE) documented systolic anterior motion of the mitral valve and left ventricular outflow obstruction in 3 noncardiac surgical patients (1). We are concerned that, in their haste to insert the TEE, the authors have digressed from sound anesthesia care. Vigorous resuscitation with crystalloids, colloids, and vasoconstrictors are standard responses in the hypovolemic patient, and the TEE diagnoses did not alter logical management in any of the cases.

Case 1. The patient was hypertensive, elderly, with bilateral femur fractures, all associated with intravascular volume contraction, and received a large propofol dose (2.5 mg/kg). Resuscitation was with crystalloid only and an {alpha} + ß agonist. Only after TEE was colloid and phenylephrine (logical pure {alpha}-agonist) initiated.

Case 2. Extensive bleeding was diagnosed, with minimal crystalloid resuscitation. Only after TEE was colloid administered. A pure vasoconstrictor would also have been a logical simultaneous choice.

Case 3. This elderly, hypertensive patient received a large dose (2.5 mg/kg) of propofol. Hypotension would be anticipated and resuscitation with crystalloids, colloids, and phenylephrine would be appropriate choices, but were only initiated after TEE.

TEE may be of value in hypotensive noncardiac surgical patients, but insertion and focus on TEE images should not detract from logical clinical decisions. TEE-guided management in these cases should have been no different from that already instituted.

Reference

  1. Luckner G, Margreiter J, Jochberger S, et al. Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction: three cases of acute perioperative hypotension in noncardiac surgery. Anesth Analg 2005;100:1594-8.[Abstract/Free Full Text]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press