The patient appears to have post-
operative low output syndrome. Her heart
is no longer responding to volume re-
placement and she may now be on the
descending limb of the Starling curve.
It is vital to aggressively treat this
patient and to follow the results of
therapy as it progresses. You should be
at the bedside looking at the data as
well as examining the patient frequently
for signs of adequate peripheral
perfusion. Such findings as pedal
pulses, temperature, color, venous
refill and capillary refill are as
important as the calculated SVR.

The patient needs sequential treatment.
Start with an inotrope which does not
cause peripheral vasoconstriction such
as dobutamine and give an amount known
to raise cardiac index (10-15 mcg/kg/
min). Then add dopamine in a renal
dosage (5 mcg/kg/min) to increase urine
output. Lidocaine should be used to keep
the PVC's under 3/min. Furosemide should
be used only in small doses to maintain
urine output above 30 cc/hr. Too much
may make the patient hypovolemic.


As these medications are titrated,
frequent observations of the effects on
vital signs, filling pressures and
resistances are necessary in order to
assess the response. As the BP rises
with inotropic stimulation, the patient
is now ready for very careful attempts
at afterload reduction with nitro-
prusside. When this therapy is started,
have volume (blood if HCT<35, colloid if
HCT>35) available, attached to the IV
for possible rapid infusion. Often when
the patient begins to vasodilate he
requires more volume in order to
maintain blood pressure.