Here is the pt info:

65 y/o male here for nephrectomy & ureterectomy d/t renal Ca.

Hx: CAD, Mi in '97, angina (last time 30 days go), Pacemaker

Rx: beta blocker, ntg PRN, ASA (d/c 14 days prior)

Allx: none

Aline attempt X 3 people with no luck.

16 G IV and 18 G iv in left hand

After uneventful induction surgeon tells you that the pt previously had a minor urology procedure with GAETT where they required reintubation. Per surgeon, pt had a fluid overload and after getting to PACU resulting in a tube. Pt took 2 days to be extubated. Surgeon believes this is someone who has undiagnosed CHF.

H&H is 12/36 currently other labs are normal.

You are faced with a large case (3-4 hours) and potential major blood loss on a pt you dont have an aline for who appears to have major issues with fluid.

How do you manage this case?