Pulm HTN.jpg

Patient is in mid 70's, ~100kg, in for 3 vessel OPCAB. They have a Zenker's diverticulum so no TEE. Cath shows severe stenosis of LAD (>90%), and significant stenosis of left circumflex and RCA. EF of 20% and pre-existing pulmonary HTN. At this point the LIMA and RCA have been grafted and the heart is lifted/twisted to get to the last site. Before the lift & twist, we drew labs & ABG and corrected met acidosis as best we could, gave 1gm CaCl and had already repleted K. Hgb was 9.7 before getting a big cell-saver bolus. We're up about 3L of crystalloid. Drips are bicarb, levo, epi & amio (the latter is part of the surgeon's protocol) and requiring large boluses of neo and 2-4 unit bumps with vaso just to maintain this pressure - really not very responsive. The art-line was a bit dampened so we were kind of splitting the difference with the cuff but after this we couldn't really get the SBP >85 on the AL, cuff was 90-105.

The MDA I was working with knows his stuff but the neo/vaso combo didn't really seem to be working, but that's what he wanted to go with. Any other ideas on how to treat this scenario? The coronary artery has already been incised, so we can't drop the heart and its a hard to reach area so its taking forever.