Case 9: Intraoperative Hypotension in a Patient Receiving Chronic Steroids

Abstract

A 4-year-old boy (12 kg) presents for surgical excision of a kidney tumor. His history includes severe asthma that is treated with prednisone, 2 mg per day. Two days before surgery, he was given bronchodilator therapy to optimize pulmonary function. The patient is anesthetized by an inhalation induction with sevoflurane. An intravenous (IV) line is inserted, and vecuronium and hydrocortisone 50 mg are given. Endotracheal intubation is performed uneventfully. Anesthesia is maintained with fentanyl and isoflurane in an oxygen-air mixture. Surgical resection of the kidney proves difficult, and surgical bleeding ensues. Blood loss (1,000 ml) is replaced. The internal jugular vein and right radial lines are cannulated. Bleeding continues (blood loss now 1,500 ml). Blood and crystalloid are given. A moderate acidosis (base excess 7) and a low serum calcium are corrected. Eventually the bleeding is under control and the central venous pressure (CVP) is 10 mmHg, but the blood pressure (BP) decreases precipitously, despite multiple IV doses of ephedrine, phenylephrine, epinephrine, and dopamine infusion to support the BP.