I had a case today that went just a little bit odd and I think it had to do with the patient's fluid status. I've been thinking about it all afternoon and would like some feedback.

72F, 41kg. In for removal of hip hardware (from an ORIF of intertrochanteric fx about 9 months ago) and THA. Pt has hx of hypertension (from H&P - pt and husband deny), COPD, chronic anemia, edema and a smattering of other minor stuff. Per pt "I sometimes wake up with my eyes about swollen shut" for which she takes prn aldactone and diuril. No further cardiac workup besides EKG which was not abnormal. Pt has continued pain from nonunion of the ORIF, so can't get a good bead on exercise tolerance. Pt on a few different anti-anxiety meds, some of which were not listed on the med rec, so there's a degree of loopiness to the interview. H&H 14.5/43, creatinine 1.0, lytes wnl except mild hypokalemia, coags normal. Preop bp 140's/90's. Pt claims at home SBP typically in the 90's.

This surgeon is notoriously slow so we opt for a general. Easy induction, but she takes a bit to go down - still quite chatty on 2 & 2 of versed and fentanyl. First couple of hours are pretty normal - a bit of hypotension on induction that corrects easily, foley gets about 200 of dilute urine upon insertion. Maintains HR in low 60's (not beta-blocked) and BP 110-120's, u/o ok, running on about 0.6-0.7 MAC of des with fentanyl bumps here and there. Surgeon finally gets the hardware out, lot more suctioning going on. HR trends up into 70's, bp down into the 90's. Finish the first bag of LR as well as 450 of various antibiotics, hang some hextend. This evens things out for a bit, but the reaming and drilling and hemming and hawing and pointless xraying and even more bloody suctioning continues. Blood loss around 400, run a hemicube Hgb is 8.9. CRNA thinks its probably ok, I'm thinking cardiac status is a gray area and what the hell is up with that weird edema? MDA wants to transfuse, so we give 2 units over about an hour. I'm thinking this will even things about a bit, but it doesn't make a bit of difference. Blood loss is now around 850-900. Hgb after the units is 11.9. HR trends up into the 90's, bp labile from 90-120's. We went up on the gas some to make sure she wasn't light and continued to titrate in fentanyl in small boluses, LR is still flowing in at a good clip, u/o is minimal. We start talking about trying to bring that HR down when I'm dismissed for the day - I had to leave at that point, otherwise would have stayed to finish the case. They are allegedly within vicinity of closing at this point, but with this guy, that could still be another hour or two.

I'm thinking most of her HR and BP issues were related to volume and blood loss, but I don't understand why the blood, hextend and crystalloid we gave her didn't improve her status even in the short term. In the absence of a central line or a-line, what are some good ways to determine a patient's fluid status intra-op? Was she still dry even after the 2 units? Was I too cautious in worrying about her cardiac status? Is there anything else I should have done or looked for? All help is greatly appreciated.