I know we've talked about a similar scenario, but i'm looking for some input.

-51 y.o. male
-medical hx: ESRD (dialyzed 6L the day before), HTN (current pre-op BP 140s/60s, it's where he lives), CAD (no current/remote chest pain, 3 vessel CABG a few years back>>activity greater than 4 METS), PAF (currently on beta blockers with HR upper 40s to low 50s baseline).
-electrolytes within relatively normal levels
-not on ARBs or ACEIs
-meds taken day of procedure was metoprolol XL 50 mg
-no current edema and lung sounds clear

-gave 1 mg dilaudid and 1 mg versed in pre-op. head on over to OR, patient still awake and alert. time frame from pre-op to OR about 5-8 minutes when all's said and done.

-get patient to move himself onto OR table, usual non-invasive monitors applied. standard slow induction: 50 mcg fentanyl, slow IVP propofol (patient was still breathing on 100 mg) to a total induction dose of 130 mg. 40 mg rocuronium.

-after the tube was taped, and positioning done, prepped/draped, incision, BP was hanging around 80s. i gave ephedrine 10 mg first; little to no effect. tried 15 mg next. not much different. went to phenylephrine 80 mcg. little change, but didn't want to start a drip r/t HR and coronary perfusion/chronic beta blocker therapy. decided to start a low dose epi gtt (4 mcg/ml concentration), and got HR to stay around 58, and BP 100s-110s/50s-60s. i was ok with this, but wasn't completely sure this was the best therapy at the time. so, i decided to dilute vasopressin to 1 unit/ml. i turned off the epi gtt, and pressures resumed back to the 80s systolic. i then gave one unit vasopressin, waited, no effect. gave another about 2 minutes later. not much effect again. decided to give 2 units a few minutes later. now, mind you.. this guy has 'normal' EF and circulation time. anyway, not much effect. so, i decided to go back to the epi gtt. finished the case, turned off epi gtt, went to PACU, and all was well. also, the guy got about 1300 ml crystalloid for the 4 hour-ish procedure.

-aside from ?more crystalloid? or albumin, and assuming maybe that the patient was hypovolemic, would you guys have done something different? dopamine? would that be overkill?

anyway, thoughts appreciated.