Expert: Dr Ian Jackson - please note UK based - 11/14/2008

Question
During a 2 hour lap chol operation, what is an acceptable drop in blood pressure during the operation. How quickly after the operation should the blood pressure rise/return to normal?

Look at the chart below oga 74 year old healthy man (except has glaucoma - controlled by Betagan/Levobutnolol) weighing 64kg:
Is the bp of concern during the operation?
Should the patient have been transferred to recovery with such hypotension?
If not, at what bp would be reasonable to send to recovery?

Any comments?

Time              BP      Pulse
09:00      110/70   70
09:05      100/58   60
09:10      90/52   53  Operation started
09:15      80/48   48
09:20      92/59   52
09:25      92/52   51
09:30      100/50   52  First cut
09:35      120/69   51
09:40      140/82   53
09:45      130/78   53
09:50      140/80   54
09:55      140/80   52
10:00      132/74   50
10:05      131/72   51
10:10      138/68   52
10:15      130/65   53
10:20      122/58   54
10:25      110/55   52
10:30      110/54   52
10:35      110/54   58
10:40      110/54   60
10:45      110/56   59
10:50      120/58   58
10:55      120/58   55
11:00      120/62   60
11:05      111/59   60
11:10      113/50   60
11:15      112/50   60
11:20      90/47   56
11:25      80/32   54
11:30      80/32   54  Operation ended
11:35      92/40   60
11:40      88/38   66
11:50   LEFT THEATRE      HYPOTENSIVE
  
11:55      62/41   61  IN recovery
12:00      74/44   58
12:06      76/51   57
12:10      100/58   59
12:15      85/53   60
12:20      90/54   61
12:25      83/61   66
12:30      92/66   64
12:35      99/61   65
12:45      114/68   70
13:00      99/66   68
13:10      70/48   70
13:20      72/52   75
13:40      65/39   72
13:50      88/59   82
14:20      62/34   88
14:25      51/34   86
14:30      60/46   99


Answer
Mark
Questions like this are always relative to the fitness of the patient etc. Current drug therapy is also important.
I am not qualified as an expert witness and will make some general comments about the readings you have sent.
The first thing is that things started well with only minor drop in BP at start of anaesthetic. Given a start time for the op at 0930 it appears that the op didn't finish for 2 hours. this implies difficulties were experienced by the surgeon. An easy lap chole can be done in 30 minutes by an experienced surgeon. The hypotension started only in the last 15 minutes of the op and so in the UK we would have been happy to take the patient to our Recovery Unit provided that there was no evidence of continuing blood loss.
I would be concerned about any patient of mine (and esp someone aged 74) if they remained hypotensive and would have treated this aggressively. It appears from chart that hypotension continued for another 2 hours and gradually became worse, but with some readings being a bit better. I suspect some form of treatment was taking place (most likely fluid challenge).
I can't comment much further than that - we look after hypotensive patients in our Recovery Unit on a fairly regular basis in the UK. The Recovery is often a better place to be than the theatre unless the patient needs further surgery to control bleeding.
Kind regards
Dr Ian Jackson