Pressors; Q; or Volume?

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Editor’s Note:

Well I was surfing the perfusio.com FB perfusion group, when I came across a continuing dialogue on when and why to adjust pressure using flow, vasopressors, or volume…

So it seemed to be a pretty advanced thread- and I thought I would share it to see if anyone else wanted to join in?

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Pressors; Q; or Volume?

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Good evening guys… i’m a jnr perfusionist.. i want to know your opinion about the advantanges n disadvantanges of using vasopressor like phenylephi during cpb… answer with mercy please hahaha… thank you..

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  • 2 people like this.
  • Wong Martin Phenylephi is short acting. If the patient is hypotension. What I do is to increase the pump flow rate to make sure the patient is adequate perfusion by observe the on line monitoring device especially the SVO2. But bear in mind that at the time you have enough venous return in your reservoir. If venous return in the reservoir is insufferient , do not add fluid for the flow increasing. Even there got enough venous return , I will increase my pump flow rate 10% above the optimal flow .If the mean aterial pressure does not rise. I will give drug. But need to concern on the dosage that going to be given . Otherwise the mean arterial pressure runs up the arterial line pressure also runs up.
    3 hrs · Like · 2
  • Jennifer Brown Neo is short acting and works on the alpha receptors so it acts primarily on the arterial side. It is good and safe to give always with keeping SVR in mind. There are times where the PT needs flow. Neo can also cause vasospams and decrease venous return when femorally cannulated
  • Ahmad Fais Ok.. the actual senario is like this.. during my pump case this evening.. patient for cabg, k/c/o DM, HTN.. during cpb pt MAP around 35-45, i already increase pump flow 20% above the optimal flow.. MAP goes up to >50 then goes down after a while.. i gave the phnylepih but MAP was labile… the SVO2 was around 90-95… blood gases (before rewarm) showed lactate 4.0+, hct 25, gases are good.. volume was suficient.. last resort i gave noradrenalin infusion 0.4 mcg/kg/hr… i want to know how u guys mnage blood pressure for this kind of case( i will use as reference in future)
  • Michael Harmon I have found that if your pt. Has a Hx of taking alpha hypertensives you will need vaso. Neo for all others due to short acting needs.
    2 hrs · Like · 1
  • Wong Martin Are the MAP correlated to the arterial line pressure. Are both on the low side or else the areterial line pressure is on the high side and the MAP is on the low side. Other may be the drug effect since the patient is HTN. Having taken hypotensive drug for a long time . If the SVO2 is so high during cooling, the petfusion is adequate. How about the serum K is it high or not. If it is hemolysis, the serum K is high and lactate is also high
    2 hrs · Like · 1
  • Ahmad Fais Arterial line pressure is on the high side n map in on the low side.. serum K is high.. but pt urine showed no haematuria
  • Wong Martin Do you add a lot of crystalloid fluid causing hypotonic and make the cell rupture. Which will give you high serum K and High lactate reading .From my point of view for the low MAP. I will consider may be damping of the pressure other is the drug effect. Check what hypertensive drug the patient is taking. I do not worry if the SVO2 is high enough. Normally greater then 70% is alright.
    2 hrs · Like · 1
  • Ahmad Fais I added 300mls of gelafundin during bypass… thank you very much for your opinion Wong Martin.. it’s very usefull for me
  • Wong Martin How much you have in the reservoir except the 300 ml. Gela.
  • Ahmad Fais Around 600mls before going off cpb.. my level sensor is at 150mls
  • Wong Martin That means totally 900ml. What is the age and how about the Albumin level
  • Ahmad Fais 56 yrs old,male, chinese..
  • Wong Martin The albumin low or high
  • Wong Martin The priming fluid is all crystalloid?
  • Ahmad Fais Crystalloid n colloid
  • Ahmad Fais We dont monitor serum albumin during cpb at our center..
  • Ahmad Fais Sorry i didnt view pt previous serum albumin.. didnt have a chance to review it
  • Wong Martin What is ratio of the crystalloid and collid . I am sorry, I mean the preoperative albumin reading
  • Wong Martin What collid you are using ,is human Albumin 25% or 5%
Circuit Surfers Calculate your SVR first before deciding on pressors versus volume versus Q rate.
  • Circuit Surfers BTW- after a certain point of using neo- your radial art line is going to be so constricted that your pressure wave form will be dampened. At that point when coming off bypass- confirm the discrepency by measuring your aortic root pressure via your transduce aortic cannula. You might have to commit to a femoral art line
    • Kirill Chasovskiy Do you use ultrafiltration during cpb? You may increase Hct up to 30% and arterial preasure will arise also. I am doing perfusion in pediatric population but we never use vasopressors during perfusion. Only vasodilators depending ob tge case. Regards.
      3 hrs · Edited · Like · 3
    • Diana Ruas Fragozo Hi Guys
      In the scene of normal SVR, normal CO and MAP <50 mmHg. I have observed that serum lactate is going up so, I want your opinion about that; What do you think is the opinion:
      1. Volumen up or

      2. Vasopresors or
      3. CO up or
      4. Hct up
    • Kirill Chasovskiy My choice: 1. Increase CO; 2. Increase Hct; 3. Vasopresors
    • Saleh Al Harthy Ahmad Fais,
      We are using vasopressin once phenylphrine is no more useful.. Vasoplegia is one of the cause of that.. If all techniques don’t work then vasopressin is the choice..
    • Saleh Al Harthy Diana, high lactate doesn’t always mean low perfusion. It also means good perfusion.. If lactate keeps going up, then check the difference btwn PO2v – PO2a
      It should be less than 6.. If it’s more than 6 I would suggest to increase CO n do ZBF
    • Diana Ruas Fragozo Saleh Al Harthy Difference btwn O2 or CO2 A-V?
      4 hrs · Like · 1
    • Kirill Chasovskiy Saleh Al Harthy would you be so kind to explain how high lactate represent a good perfusion. In my understanding high lactate is caused hypoxemia ( e.g. hypoperfusion).
      4 hrs · Like · 1
    • Saleh Al Harthy Diana, sorry by mistake I wrote Po2 it’s in fact Pco2 difference
    • Saleh Al Harthy (V-A) pco2
    • Saleh Al Harthy Kirill, before going on CPB, most of the pts experience hypoxic state at capillary level due to many reasons.. Good perfusion will flush all lactate which stayed in tissues and circulate it in the plasma. So in ABG we see lactate level high though all parameters are good..
    • Kirill Chasovskiy Saleh, would you be so kind to provide for me any reference which confirms your sugestion. Because I can not agree with that. But I can change my mind. Regards
    • Kirill Chasovskiy And also about (v-a) pco2 difference and its importance on assesment of perfusion. Thanks
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Pressure Management & Hemodilution

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i want to know about the pressure management during cpb.in some of my experiences pressures shortly after the institution of cpb were low by the help of phenyl epinephrine pressures were back.but we cannot give too much support so what should be the management ? and causes of low pressures.
thank you

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  • Bijender Singh Bali Because of sudden hemodilution your pressures drop.make sure u make mixeture of collidal as well as crystolliod sol in prime.keep hb around 10 on cpb
    11 hrs · Like · 3
  • Tony Shackelford Do you RAP?
    11 hrs · Like · 1
  • Nour El Ezzedine Al-Qassam What i do is, i ensure to maximise overflow once i take over fully. Normally line pressure around 180-190mmhg (around 20-30% overflow) but not all the time, on
    Y during initiation. Normally i dont need phenyleph. However, it depends on the starting hct and the hct just b4 going on cpb (dilution due to anes gv volume preop). If its >40, easier. <40, consider givg packed cell once start the cpb. And if too much vol, consider lasix or hemoconcentrtn.

    Remember, dont simply gv phenyleph b4 increasing your flow and maximising ur hct.

    This is my humble opinion. . Happy pumping.
    11 hrs · Like · 4
  • Tony Shackelford Retrograde autologous prime? This will keep hct higher, minimize dilution/preserve viscosity, and reduce dilution of Catecholamines. Once on CPB keep systemic vascular resistance between 900-1300 dynes/sec/cm-5 via vasocontrictor/vasodilation. That is assuming hct >21. MAP should be such that urine output is >1cc/kg/min of CPB. SvO2 >65-75% via flow, assuming normal resistance. If metabolic acidic with all parameters in line, check level of anesthesia. When respiratory acidosis occurs increase gas flow accordingly. That is perfusion in a nutshell.
    11 hrs · Edited · Like · 1
  • Towfiq Shahriar Islam Khan i think just after going on bypass, pressure will reduce, its logical. if we establish bypass slowly (not all on a sudden, clamps off & start giving flow) in this way gradually if we give flow and removing clamps off, then we can overcome this sudden pressure drop. in this way once you are satisfied with venous return and adequate flow, within few minutes pressure will be satisfactory. its my own experience. if then also pressure is not up to the mark then we can use medicines
    11 hrs · Edited · Like · 7
  • Ericson Kilonzo Immediately after cpb initiation, pressure is expected to go low because its only the crystallized going back to patient, its always advisable to slowly keep on flows until the patient starts getting his/her own blood back  and the pressure will normalize. 
    10 hrs · Like · 5
  • Ericson Kilonzo Good discussion though,, issues with hemodilution will make bp low,, thats the reason, how to manage: slowly initiate bypass and i hope all will be well, if not well, then consider pheny.. my opinion too
    10 hrs · Like · 2
  • Khan Zaman Slowly start draining the patient and keep increasing the flow. Maintain full flow before complete drainage. It will help to maintain pressure.
    10 hrs · Like · 3
  • Raghav Dungriyal In starting ur pressure will be low coz of hemodilution our harmons diluted but slowly ur pressure will cm up no need to give anything but in thyroid pt. ur pressure will low n its excepted
  • Saleh Al Harthy I think the q is answered by the participates.. I would add the SIRS plays good role in hypotension once you go on CPB.. Inflammatory mediators are released as soon as blood gets contact with tubes..
    8 hrs · Like · 2
  • 7 hrs · Like · 1
  • Khan Zaman Welcome
  • Wong Martin The circulating catecholamines levels are decresaed at the onset of bypass due to dilution and the arterial pressure may experience a transient drop. What I do is I will gradually on bypass ,not in a rush. I will gradually increase the pump flow rate bSee More
    4 hrs · Like · 2
  • Don Nieter All good answers. In addition, many prime with Mannitol which can cause potent (but transient) vasodilation, particularly in skeletal muscles vascular beds.
  • Paul DiGregorio After 35 years of practice I can say this is not a big deal unless it persists. All the suggestions here are great and relevant. My advice to you is don’t sweat it.
    3 hrs · Like · 1
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