Intraoperative hypotension with presumed left heart failure/dysfunction: Approach after initial assessment and management
Intraoperative hypotension with presumed left heart failure/dysfunction: Approach after initial assessment and management
This algorithm describes an approach to intraoperative hypotension with presumed left heart failure after initial assessment and management. Refer to the algorithm on the initial approach to intraoperative hypotension.
Hypotension is defined as an MAP <60 mmHg or SBP <100 mmHg when <90% of baseline SBP. Left heart failure is suggested by PCWP >18 mm Hg, CVP >10 mmHg and by TEE or TTE evidence of LV systolic and/or diastolic dysfunction.
Refer to UpToDate content on intraoperative hemodynamic monitoring and management.
For patients with persistent hypotension and/or acute heart failure, the risk/benefit of continuing, modifying or aborting the planned procedure is assessed.
LV: left ventricle; ACS: acute coronary syndrome; LVOT: left ventricular outflow tract; MCS: mechanical circulatory support (such as intra-aortic balloon pump [IABP] or left ventricular assist device [LVAD]); ECMO: extracorporeal membrane oxygenation; ICU: intensive care; MAP: mean arterial pressure; SBP: systolic blood pressure; PCWP: pulmonary capillary wedge pressure; CVP: central venous pressure; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; LVEF: left ventricular ejection fraction; RV: right ventricular. * LV systolic dysfunction sufficient to cause hypotension is generally associated with an LVEF <40%. ¶ Signs of ACS include ST segment elevation or depression, T wave changes, new regional LV and/or RV wall motion abnormalities. Δ Hypovolemia should be excluded prior to administration of an inotrope. Refer to UpToDate content on use of inotropes. ◊ Dynamic LVOT obstruction occurs in patients with hypertrophic cardiomyopathy and in other patients with left ventricular hypertrophy. It is generally worsened by inotropic agents and is improved with negative inotropes (such as beta blockers). § Refer to UpToDate content on MCS and ECMO. ¥ Refer to UpToDate content on valve disease including aortic valve stenosis.
