Table 1 Protocol-specified intraoperative and postoperative interventions for maintenance of hemodynamic and anesthetic stability, and correction of low urinary output
Tachycardia* | ||
Before ECC | HR > 90 beats/min | Esmolol in increments of 0.5 mg/kg i.v. |
After ECC | HR > 110 beats/min | As above |
In the ICU | HR > 120 beats/min | Esmolol 0.5 mg/kg i.v. If HR decreased < 120 beats/min, give metoprolol 1-5 mg i.v. |
Bradycardia | ||
Before ECC | HR < 40 beats/min | Glycopyrrolate 0.2 mg i.v. |
After ECC | HR < 70 beats/min | As above |
In the ICU | HR < 60 beats/min | Pacing at 70 beats/min |
Hypertension** | ||
Before ECC | SAP > 150 mmHg | Increase ET-IF by 0.4% and administer 50 μg i.v. bolus of glyceryl trinitrate. If response not adequate within 4 min, increase ET-IF a further 0.4% and give 5 μg/kg i.v. bolus of fentanyl. If still not adequate, increase ET-IF by 0.4% and give 50 μg i.v. bolus of glyceryl trinitrate. Taper isoflurane (to 0.2% ET-IF) when SAP and HR have reached predetermined values with no clinical signs of insufficient anaesthesia. If SAP or HR rises again, increase ET-IF by 0.4% and give 50 μg i.v. glyceryl trinitrate. |
During ECC | MAP > 80 mmHg | As above |
After ECC | SAP > 130 mmHg | As above |
In the ICU | SAP > 150 mmHg | Start glyceryl trinitrate infusion to effect. |
Hypotension | ||
Before ECC | SAP < 90 mmHg | Reduce ET-IF 0.4% per 4 min until ET-IF 0.2%. If not sufficient to restore SAP, administer ephedrine 2.5 mg i.v. bolus. If SAP response still not adequate repeat ephedrine bolus plus 250 ml i.v. bolus of hydroxyethylstarch (or 500 ml of Ringer's acetate). If necessary, repeat this intervention once, 4 min after first administration. If SAP response still not adequate, start epinephrine infusion at 0.03 μg · kg-1 · min-1; titrate to maximum of 0.3 μg · kg-1 · h-1. Taper epinephrine when SAP remains within protocol-specified values. |
During ECC | MAP < 30 mmHg | i.v. bolus doses of phenylephrine (0.2 mg) |
After ECC | SAP < 80 mmHg | As for 'Before ECC' |
In the ICU | SAP < 90 mmHg | 250 ml i.v. bolus of hydroxyethylstarch (or 500 ml of Ringer's acetate) over 10 min. If effective, repeat. Otherwise start epinephrine at a rate of 3 μg · kg-1 · min-1 |
Clinical signs of light anaesthesia | E.g. bucking, lacrimation, sweating, movement, eye opening, grimacing | As for management of hypertension |
Low urinary output | ||
Before ECC | Urinary output < 1 ml · kg-1 · h-1 during a 30 min period, when SAP above threshold for hypotension | 250 ml i.v. bolus of hydroxyethylstarch (or 500 ml of Ringer's acetate) over 10 min. If response not sufficient, repeat twice. If response not sufficient 15 min after third bolus, administer furosemide 5 mg i.v. every 30 min until effect is produced |
During ECC | Urinary output < 1 ml · kg-1 · h-1 during a 30 min period, MAP > 30 mmHg | Phenylephrine 0.2 mg i.v. bolus dose, repeated up to 3 times until MAP ≥ 50 mmHg. If urinary response not sufficient despite MAP ≥ 50 mmHg for 30 min, administer furosemide 5 mg i.v. every 30 min until effect is produced |
After ECC | As for 'Before ECC' | As for 'Before ECC' |
In the ICU | Urinary output < 1 ml · kg-1 · h-1 | 250 ml i.v. bolus of hydroxyethylstarch (or 500 ml of Ringer's acetate) over 10 min. If response not sufficient, give furosemide 5 mg i.v. at 30 min intervals |