INSUFICIENTA CARDIACA

PERIOPERATORIE
 Heart failure (HF) is a risk factor for cardiac complications after
noncardiac surgery . After major surgery, chronic stable HF is associated
with two- to threefold higher 30-day mortality and hospital readmission
compared with coronary artery disease .
Minor procedures are also associated with somewhat increased
morbidity and mortality in patients with chronic stable HF .
Patients with new-onset, worsening, or acute decompensated HF are at
particularly high risk for perioperative morbidity and mortality

.
Heart failure (HF) is one of the most common conditions requiring evaluation and treatment in patients
undergoing noncardiac surgery. Ageing populations and progress in the treatment of chronic diseases
such as hypertension, diabetes, and coronary artery disease are increasing the prevalence of HF [1]. In
addition, elderly patients at risk for HF are undergoing noncardiac surgery at increasing rates. It is
estimated that HF is present in almost 20 percent of older adults undergoing common surgical
procedures in the United States [2]. HF is a major risk factor for adverse cardiac events, including death
following noncardiac surgery [3].
More than 20% of patients are expected to have acute
cardiovascular dysfunction in the perioperative period
of cardiac surgery
 ETIOLOGY OF HEART FAILURE
Systolic HF is characterized by increased ventricular volume
and reduced ejection fraction (EF)
Causes of systolic HF are ischemic heart disease, valvular
heart disease, idiopathic dilated cardiomyopathy, and
hypertension
Diastolic HF is a clinical syndrome in which patients have
symptoms and signs of HF with evidence of diastolic
dysfunction (eg, abnormal pattern of left ventricular [LV]
filling and elevated filling pressures), but normal or near
normal LVEF and LV volume
Causes of diastolic HF include ischemic heart disease,
hypertension, hypertrophic obstructive cardiomyopathy, and
restrictive cardiomyopathy. Many HF patients have both
systolic and diastolic dysfunction
A major cause of non-ischemic contractile
dysfunction is chronic volume overload due to
either severe mitral regurgitation or severe aortic
regurgitation. This leads to chamber dilation and
eccentric hypertrophy.
Pressure overload is a functional cause of diastolic
HF, where chronic hypertension or chronic aortic
stenosis lead to ventricular remodeling which
increases wall thickness
Acute Heart Failure
Definitions
CONGESTIVE HEART FAILURE (CHF): It is defined as the
inability of the heart to supply sufficient substrate to meet
the needs of the body.
CARDIOGENIC SHOCK (CS): It is end-stage CHF and is a
largely irreversible condition and as such is more often fatal
than not.
PULMONARY EDEMA: Accumulation of fluid in the
pulmonary air spaces and the interstitial spaces of the lungs,
which inhibits oxygen and carbon dioxide diffusion, leading
to impaired gas exchange and respiratory failure.
Acute decompensated HF may be precipitated
by:
Myocardial ischemia or infarction, worsening
of cardiac valve dysfunction, atrial fibrillation
and other arrhythmias, cardiotoxic agents,
stress-induced (Takotsubo) cardiomyopathy, or
rapid progression of underlying chronic HF.

Noncardiac precipitants include severe

hypertension, renal failure, and pulmonary
emboli.
"Flash" pulmonary edema is a dramatic form of
acute decompensated HF that may develop in
susceptible patients in certain clinical settings
(eg, hypertensive crisis, acute onset of severe
myocardial ischemia or cardiac valve
regurgitation).
The general approach to management of
perioperative heart failure includes :
Preoperative evaluation and risk assessment,
Decision making regarding whether and when
to proceed with surgery,
Pre-, intra-, and postoperative management.
The nature of the evaluation should be individualised to the
patient and the specific clinical scenario.

Patients presenting with an acute surgical emergency require

only a rapid preoperative assessment, with subsequent
management directed at preventing or minimising cardiac
morbidity and death. Such patients can often be more
thoroughly evaluated after surgery.

Patients undergoing an elective procedure with no surgical

urgency can undergo a more thorough preoperative
evaluation.
The main overall goals of assessment are to:

Identify patients at increased risk of an

adverse perioperative cardiac event

Identify patients with a poor long-term

prognosis due to cardiovascular disease. Even
though the risk at the time of non-cardiac
surgery may not be prohibitive, appropriate
treatment will affect long-term prognosis.
Goldman Cardiac Risk factors
Nine independent risk factors are evaluated on a point scale:

Third heart sound (S3) 11

Elevated jugulovenous pressure 11

Myocardial infarction in past 6 months 10

ECG: premature arterial contractions or any rhythm other than sinus 7

ECG shows >5 premature ventricular contractions per minute 7

Age >70 years 5

Emergency procedure 4

Intra-thoracic, intra-abdominal or aortic surgery 3

Poor general status, metabolic or bedridden 3

Patients with scores >25 had a 56% incidence of death, with a 22% incidence of severe cardiovascular complications.

Patients with scores <26 had a 4% incidence of death, with a 17% incidence of severe cardiovascular complications.

Patients with scores <6 had a 0.2% incidence of death, with a 0.7% incidence of severe cardiovascular complications.
Patient-Related Predictors for Risk of
Perioperative Cardiac Complications
Surgery-Related Predictors for Risk of
Perioperative Cardiac Complications
What is the stage and class of heart
failure?
 PREANESTHESIA CONSULTATION
Goals of the preanesthetic consultation include :
Evaluating the severity and stability of
symptoms in patients with known chronic heart
failure (HF).
Identifying patients with unsuspected HF by
careful history and physical examination.
Assessing the risk of cardiac morbidity and
mortality in patients with HF.
 History and physical examination
The history, including assessment of New York Heart
Association (NYHA) functional class, provides a
reasonable estimate of the severity of HF
Symptoms of HF include: decreased exercise tolerance,
paroxysmal nocturnal dyspnea, cough, orthopnea,
peripheral edema, and nocturia
Physical examination in patients with HF may reveal a
third heart sound (S3), elevated jugular venous
pressure, hepatomegaly, ascites, rales, wheezing,
diminished breath sounds, and a laterally-displaced
apical impulse
 What workup does this patient need
before surgery?
The patient with HF presents in one of three ways:

1)A noticeable onset of exertional dyspnea or decrease

in exercise tolerance;
2) Fluid retention;
3) With no symptoms or with symptoms of another cardiac
disorder or noncardiac disorder.

The complete history and physical exam will delineate cardiac versus
noncardiac causes of presentation. The routine ECG and chest X-ray
have low sensitivity and specificity for diagnosing a cardiac cause of HF,
but are useful in the general assessment of cardiac and pulmonary
pathology
 Preoperative testing
preoperative resting 12-lead except for those
undergoing low-risk surgery
a metabolic panel (sodium, potassium, chloride,
carbon dioxide, glucose, blood urea nitrogen,
creatinine)
A chest radiograph is not routinely recommended
in patients with chronic stable HF,
a chest radiograph should be obtained in patients
with acute decompensated HF to look for
evidence of pulmonary vascular congestion and
pulmonary edema
 Measurement of brain natriuretic peptide (BNP)
is not routinely recommended

Left ventricular (LV) function should be evaluated

preoperatively in patients with dyspnea of
unknown origin, worsening dyspnea, or other
change in functional clinical status
Echocardiography in patients with symptoms or
signs of new or worsening HF useful to establish
the etiology.
 Diagnostic utility of BNP and NT-proBNP B-
type natriuretic peptide (BNP) and N-terminal
pro-BNP (NT-proBNP) assays can supplement
clinical judgment when the cause of a
patient's dyspnea is uncertain, particularly
among patients with an intermediate
probability of HF
 Echocardiographic quantification of the severity
of both systolic and diastolic dysfunction may
guide perioperative management in patients with
symptomatic HF.
For example, if severe systolic dysfunction is
identified, then inotropic therapy might be
preferable to fluid administration for ensuring
end-organ perfusion, and anesthetic agents
causing myocardial depression might be avoided
or administered in low doses
 If severe diastolic dysfunction in a small non-
compliant LV is identified, then it is important to
maintain adequate preload.
Underfilling the LV may result in decreased
cardiac output and concomitant hypotension,
even if the LV ejection fraction is normal.
Decompensated heart failure In patients with
decompensated HF (NYHA Class IV, worsening, or
new-onset HF), surgery is postponed, if possible,
to allow treatment and stabilization of HF
symptoms . However, options may be limited in
patients requiring urgent or emergent surgery.
Cardiogenic shock For patients with cardiogenic
shock due to a recent myocardial infarction (MI),
unstable angina, decompensated heart failure (HF),
high-grade arrhythmias, or hemodynamically
important valvular heart disease such as aortic
stenosis, surgery is delayed if possible, because of a
high risk for postoperative complications (eg,
worsening of the MI and/or HF, ventricular
fibrillation, complete heart block, cardiac arrest,
cardiac death). If urgent or emergent surgery is
necessary, benefits and risks of timing strategies are
discussed among the cardiologist, surgeon, and
anesthesiologist
 If acute coronary syndrome is suspected,
serial ECGs and measurements of cardiac
enzymes should be performed and urgent
coronary angiography should be considered
when ischemia may be contributing to (rather
than a consequence of) HF
 PREOPERATIVE MANAGEMENT
Medications In patients already taking the following
medications for treatment of HF, considerations for
anesthetic care include:
Beta blockers Chronically administered beta blockers
are continued perioperatively.
Angiotensin converting enzyme inhibitors and
angiotensin receptor blockers Angiotensin converting
enzyme (ACE) inhibitors and angiotensin receptor
blockers (ARBs) are generally continued perioperatively
unless there is evidence of hemodynamic instability,
hypovolemia, or acute elevation of creatinine
 One observational study in patients undergoing
noncardiac surgery found that withholding an
ACE inhibitor or ARB for 24 hours was associated
with reduced risk of intraoperative hypotension
and adverse outcomes
Aldosterone antagonists In HF patients receiving
an aldosterone antagonist, hyperkalemia is the
most important potential adverse effect, especially
if aldosterone antagonists have been chronically
administered in combination with ACE inhibitors.
The preoperative potassium level should be
checked.
Diuretics Perioperative hypovolemia and
hypokalemia are the major physiologic effects of
concern in patients receiving chronic diuretic
therapy. Close attention to electrolytes is necessary.
Digoxin The role of digoxin in the perioperative
period is not well-defined. Although administration
of digoxin may decrease the incidence of
postoperative supraventricular arrhythmias, the
anesthesiologist must be prepared to treat other
digoxin-induced arrhythmias.
 Aldosterone antagonists (spironolactone),
digoxin, and longacting nitrates can be
continued on the day of surgery.
 PREOPERATIVE MANAGEMENT
In general, patients with a history of heart
failure (HF) who are asymptomatic at the time of
surgery should continue their current medical
regimen.
Patients with symptomatic HF prior to surgery
should receive medical therapy to optimize their
clinical status. There is little evidence on how to
manage HF in the preoperative period
The goals of optimization to achieve stability in
patients with preoperative HF are similar to those
of all patients with decompensated HF
Improve symptoms, especially congestion and
low-output symptoms
Restore normal oxygenation
Optimize volume status and improve end-organ
perfusion
Identify etiology
Identify and address precipitating factors
 Pacemaker interrogation
to determine whether a patients heart rhythm is
pacemaker dependent and if so, the device
should be re-programmed to asynchronous
demand pacing (e.g., VOO).
a magnet placed on the chest should convert a
pacemaker to VOO
If a biventricular pacemaker device has an ICD, a
magnet should inactivate the defibrillator but
may not change the pacemaker settings. To
prevent unnecessary shocks the ICD should be
inactivated
 Implantable cardioverter defibrillators and
pacemakers Patients with HF frequently
have a pacemaker and/or implantable
cardioverter defibrillator or a biventricular
pacemaker inserted to provide cardiac
resynchronization therapy
 INTRAOPERATIVE MANAGEMENT
Cardiac output is determined by heart rate,
preload, afterload, and contractility. These
factors can be manipulated intraoperatively by:
Control of heart rate and rhythm
Fluid replacement and diuretics
Vasopressor and vasodilator drugs
Administration of positive and negative
inotropic drugs
Monitoring
The aim of monitoring is the early detection of perioperative
cardiovascular dysfunction and assessment of the mechanism(s) leading to it

Volume status is ideally assessed by dynamic measures

of haemodynamic parameters before and after volume
challenge rather than single static measures

Heart function is first assessed by echocardiography

followed by pulmonary arterial pressure, especially in
the case of right heart dysfunction

If both volaemia and heart function are in the normal

range, cardiovascular dysfunction is very likely related
to vascular dysfunction
With regard to managing perioperative HF, the four crucial components remain
measurements of heart rate, volaemia, myocardial function and vessel tone.
 Monitors
ACCF/AHA guidelines recommend invasive
hemodynamic monitoring in HF patients
whose fluid status, perfusion, or systemic or
pulmonary vascular resistance is uncertain;
whose systolic pressure remains low, or is
associated with symptoms, despite initial
therapy; whose renal function is worsening
with therapy; or those who require parenteral
vasoactive agents
Hemodynamic monitoring Hemodynamic
monitoring in patients with ventricular
dysfunction depends on patient-specific and
surgery-specific factors
Electrocardiography (ECG) Continuous ECG
monitoring is necessary to detect arrhythmias
and/or myocardial ischemia;computerized ST-
segment trending
Intraarterial catheter Invasive measurement
of arterial blood pressure (BP) is used when
moment-to-moment BP changes are anticipated
and rapid detection is vital. An intra-arterial
catheter is also useful for guiding management
of vasoactive drugs, including vasopressors,
vasodilators, and inotropic agents, as well as
facilitating the anesthesiologist's ability to
obtain frequent arterial blood gas
measurements.
If possible, the intra-arterial catheter is inserted
prior to induction of anesthesia
Central venous catheter The decision to place a
central venous catheter (CVC) is based on the
potential for significant blood loss and/or large fluid
shifts, likelihood of administration of continuous
infusions of vasoactive drugs, and challenges in
obtaining reliable intravascular access.
Monitoring the trend in CVP values may be
helpful to avoid extremes to enable maintenance
of adequate preload while preventing volume
overload, particularly in patients with right-sided
heart failure
Measurement of central mixed venous oxygen
saturation (ScvO2) in blood drawn from the
distal port of a CVC to serve as a surrogate for
adequacy of CO if a pulmonary artery catheter
(PAC) is not available
SCVO2>70 percent is considered to be a good
target during resuscitation efforts.
Pulmonary artery catheter (PAC) PAC
monitoring is not routinely recommended for
monitoring patients with cardiovascular disease.
 However, many clinicians insert a PAC for
patients with severe right ventricular (RV)
dysfunction, pulmonary hypertension, or
cardiogenic shock due to acute valvular
disease.
Hemodynamic measurements such as CO (and
cardiac index), systemic vascular resistance (SVR),
pulmonary artery pressures, pulmonary artery
occlusion pressure (PAOP), CVP, and pulmonary
vascular resistance (PVR)
Mixed venous oxygen saturation values in blood
drawn from the pulmonary arterial port (SvO2).
This blood includes drainage from the coronary
sinus which has a low saturation; thus, SvO2 will be
slightly lower than ScvO2 .
 The intrathoracic thermodilution method
utilizes a central venous line for injection of
iced saline, and a thermodilution catheter in a
proximal artery (i.e., femoral or axillary) to
sense the temperature change from the cold
saline injection
estimates stroke volume and intrathoracic
blood volume and global end-diastolic volume
without dependence on the respiratory cycle
Intermittent blood sampling to measure arterial
blood gases, pH, base deficit, serum lactate,
hemoglobin, electrolytes, glucose, and activated
clotting time (ACT). Additional tests of hemostasis
are obtained if there is evidence of coagulopathy or
significant bleeding
The most useful diagnostic test is echocardiography
to address three main questions:
1)ejection fraction;
2) left ventricular structure, dimension, wall
motion;
3) non-left ventricular abnormalities (i.e., valve,
pericardium, right ventricle).
Additional echocardiography indices will
include atrial size and pressure, characteristics of
LV filling, and pulmonary arterial pressure.
Transesophageal echocardiography (TEE)
Emergency use of intraoperative or perioperative
TEE is indicated to determine the cause of any
unexplained persistent or life-threatening
hemodynamic instability ("rescue echo") when
equipment and expertise are available
TEE may identify hypovolemia, Left ventricular
(LV) and/or right ventricular (RV) dysfunction,
pericardial effusion or tamponade,
intrapulmonary emboli, valvular regurgitation, or
LV outflow tract obstruction
 Even with minimal user training,
transesophageal echocardiography (TEE)
provides real-time image estimates of end-
diastolic ventricular volume, and global and
regional ventricular contractile function
TEE is often considered the monitor of choice
to differentiate between cardiogenic,
hypovolemic, and vasodilatory causes of shock
 The most critical aspect of intraoperative and
postoperative monitoring for HF patients
involves careful fluid management.
Static variables are those that estimate cardiac
filling pressure or cardiac filling volume (as an
estimate of end-diastolic volume, or preload)
CVP, PAP, PCWP
Will not discriminate between changes in
ventricular dysfunction and volume overload
 Dynamic variables estimate changes in
intravascular volume based on characteristics
of the arterial waveform that vary with the
respiratory cycle
A regular rhythm is also necessary
Hypovolemia is suggested when systolic
pressure variation is greater than 10 mmHg.
Similarly, pulse pressure (PP) will vary over the
respiratory cycle in accord with hypovolemia.
 SVV or PPV >10% suggests that the patient is fluid
responsiveness as indicates that stroke volume is
sensitive to fluctuations in preload caused by the
respiratory cycle
CONDITIONS AND CAVEATS
The patient must be in volume controlled ventilation,
without spontaneous breathing
Tidal volume must be at least 8 ml/Kg
If using SVV the SV must be measured beat to beat
Shouldt be used on a patient with an arrhythmia, right
heart failure or pulmonary hypertension, as those will
lead to an increased variation
Module on the arterial line that analyzes the pulse
contour to estimate SV
 CAUSES OF INCREASED SYSTOLIC PRESSURE VARIATION

Hypovolaemia
Tamponade
Constrictive pericarditis
LV dysfunction
Massive PE
Bronchospasm
Dynamic hyperinflation
Pneumothorax
Raised intrathoracic pressure
Raised intraabdominal pressure
 FLUID RESPONSIVENESS
SVV and PPV are not indicators of actual preload
but of relative preload responsiveness.
Also, just because a patient is fluid responsive
does not mean they actually need fluid.
SVV has a very high sensitivity and specificity
when compared to traditional indicators of
volume status (HR, MAP, CVP, PAD, PAOP), and
their ability to determine fluid responsiveness.
 Commercial modules exist that determine
variability in the amplitude of the pulse
oximetry waveform. The variability in pulse
oximeter plethysmography waveform (POP)
is calculated as the maximal minus minimal
plethysmographic amplitude, divided by the
maximal amplitude. This too can be
determined over one respiratory cycle
 Cardiac output monitors Determining
whether a patient has a low or high CO state is
helpful to guide intraoperative resuscitative
efforts. Several invasive and noninvasive
technologies have been developed to measure
CO, including arterial pulse waveform analysis,
thoracic electrical bioimpedance, aortic
Doppler, point-of-care echocardiography, and
carbon dioxide rebreathing
 How should I care for this patient
during and after surgery?

Induction and maintenance of anesthesia

An awake arterial catheter prior to induction is
helpful for any patient in acute or
decompensated HF presenting for emergency
surgery, for any HF patient in a higher
functional class or stage of HF and for any HF
patient with severe systolic or diastolic
dysfunction, pulmonary hypertension, or
significant valvular disease.
 Rapid atrial fibrillation in a HF patient would also
indicate arterial line placement, with aggressive
attempts to adequately stabilize ventricular rate
control prior to surgery.
Propofol or thiopental have the potential to cause
profound hypotension in the HF patient because
of the chronically elevated sympathetic nervous
system activity
can be given simultaneously with pressor
administration
 Etomidate and ketamine have less effect on
sympathetic-mediated maintenance of blood
pressure
Maintenance of anesthesia in HF patients is
generally dependent on the surgical
procedure, the expected duration of
procedure, blood loss, fluid shifts, and the
need for additional monitoring techniques
 Maintenance Anesthetic agents for
maintenance of anesthesia are selected with
consideration of dose-dependent
cardiovascular effects. In most cases, a volatile
inhalation anesthetic agent is initiated at a
lower concentration than in healthy patients,
with titration to maintain anesthesia while
avoiding a further decrease in end-organ
perfusion
Intraoperative resuscitation target values
include systolic BP 90 mmHg or mean arterial
pressure (MAP) 65 mmHg, urine output 0.5
mL/kg per hour, and decreasing serum lactate
levels.
Hemodynamic supportive infusions for
perioperative management
Decompensated heart failure

Patients at increased risk for development of acute

HF in the immediate postoperative period include those with
a history of chronic left or right HF, as well as those with
diastolic HF (also called HF with preserved ejection fraction).
This is due to intraoperative factors such as fluid
overload resulting from fluid shifts during major surgery,
anemia, myocardial ischemia, severe hypertension, stress-
induced (Takotsubo) cardiomyopathy, or prolonged
unfavorable surgical positioning (eg, supine positioning of a
patient who cannot tolerate this position while awake).
Acute HF typically manifests as respiratory distress
with or without overt pulmonary edema. Respiratory distress
may be accompanied by hypertension due to hypervolemia
or hypotension due to cardiogenic shock or excess
vasodilator use.
TREATMENT GOALS FOR ACUTE VERSUS CHRONIC HF
It is important to distinguish the management of acute
decompensated heart failure (ADHF) from that of chronic HF.
The treatment of chronic HF, particularly when due to
systolic dysfunction, is built around therapies that have been
shown to reduce long-term mortality and improve symptoms
(eg, angiotensin converting enzyme inhibitors and beta
blockers).
In contrast, the goals of the initial management of ADHF are
hemodynamic stabilization, support of oxygenation and
ventilation, and symptom relief . Some of the cornerstones of
chronic HF therapy should not be added or should be used
with caution in ADHF (eg, beta blockers), particularly during
the period of initial stabilization. Such therapies may be
initiated or titrated upward later in a patient's course.
Treatment for acute decompensated HF incudes :

Administration of supplemental O2.

For persistent respiratory distress, respiratory acidosis, and/or hypoxia
despite oxygen therapy, initiation of noninvasive ventilation (NIV) or
endotracheal intubation and mechanical ventilation, as indicated.
Administration of intravenous (IV) diuretics to relieve pulmonary
congestion or fluid overload .
Initiation of vasodilator therapy in the following settings: early
IV nitroglycerin as a component of therapy in patients with refractory HF
(eg, inadequate response to diuretics and/or low cardiac output), or
IV nitroprusside as arterial vasodilator therapy to reduce afterload in
patients with severe hypertension .
Initiation of an inotropic infusion (eg, milrinone or dobutamine) in
patients with known systolic HF and signs of cardiogenic shock, in
combination with a vasopressor (eg, norepinephrine) if necessary to
maintain systemic BP.
Acute decompensated heart failure Left,
right, or biventricular heart failure may cause
cardiogenic shock.
Left-sided heart failure In general, goals
during the intraoperative period are to reduce
preload and afterload, maintain sinus rhythm
and a normal to high heart rate (HR) of 80 to
100 beats per minute, and improve contractility
 Because decompensated left-sided heart
failure is often associated with pulmonary
edema, appropriate levels of positive end-
expiratory pressure (PEEP; eg, 5 to 10 cmH2O)
are employed to improve oxygenation.
However, high PEEP >10 cmH2O is generally
avoided, as this may deleteriously reduce
venous return and CO.
Right-sided heart failure Perioperative right-
sided cardiogenic shock is aggressively treated since
it rapidly leads to multiorgan system failure
Infusion of an inodilator agent such as milrinone or
dobutamine is usually indicated.
Concomitant use of a vasopressor infusion such as
norepinephrine or vasopressin is typically required
to maintain adequate coronary perfusion
 Pulmonary vascular resistance (PVR) should be
minimized by maintaining normal PaCO2,
PaO2, and pH levels. Excessive tidal volumes,
excessive PEEP, and atelectasis should be
avoided.
It is also important to maintain normothermia.
If necessary, inhaled nitric oxide or
prostanoids (eg, epoprostenol) may be
administered to reduce PVR
Pharmacological treatment of left ventricular
dysfunction after cardiac surgery

In case of myocardial dysfunction, consider the following three options either alone or
combined:
Among catecholamines, consider low-to-moderate doses of dobutamine and
epinephrine: they both improve stoke volume and increase heart rate while PCWP is
moderately decreased; catecholamines increase myocardial oxygen consumption
Milrinone decreases PCWP and SVR while increasing stoke volume; milrinone causes
less tachycardia than dobutamine
Levosimendan, a calcium sensitizer, increases stoke volume and heart rate and
decreases SVR
Norepinephrine should be used in case of low blood pressure due to vasoplegia to
maintain an adequate perfusion pressure. Volaemia should be repeatedly assessed to
ensure that the patient is not hypovolaemic while under vasopressors
Optimal use of inotropes or vasopressors in the perioperative period of cardiac surgery
is still controversial and needs further large multinational studies
Va multumesc !