The use of a somatostatin analog in the treatment of refractory hypotension after cardiopulmonary bypass

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The patient was a 59-year-old male status post-prior mitral valve replacement (MVR) for mitral regurgitation (MR) and coronary artery bypass grafting (CABG) 6 months previously. He presented with recurrent MR due to endocarditis and a perivalvular leak, and was admitted with congestive heart failure (CHF) and shaking chills. Blood cultures were positive for Staphylococcus epidermidis. He had undergone 14 days of treatment with intravenous (IV) antibiotics, including vancomycin, gentamycin, and rifampin, which was associated with cessation of fevers and chills. His past medical history included hypertension, prior inferior myocardial infarction, and peripheral vascular disease. Additional medications included IV heparin, 1,000 u/h, and nitropaste, 2 inches every 6 hours. Laboratory values included a white blood cel1 count of 8,400 without bands, platelet count of 170,000/cc3, and a hematocrit of 29.7%. Cardiac catheterization revealed patent grafts, an enlarged left atrium (LA) and ventricle (LV), inferior and posterior hypokinesis, 3+ MR due to a perivalvular leak and a large LA vegetation. The patient was scheduled for a redo-MVR and debridement of his atrial vegetation. The patient was brought to the operating room where initial hemodynamics included a bloed pressure (BP) of 135165 mmHg, heart rate (HR) 65 beatsimin, centra1 venous pressure (CVP) 10 mmHg, pulmonary artery pressure (PAP) 43120 mmHg, pulmonary capillary wedge pressure (PCWP) 21 mmHg, with V waves to 38 mmHg, cardiac output (CO) of 5.0 Limin, systemic vascular resistance (SVR) of 1,200 dynes sec. cmes, and mixed venous oxygen saturation (SvOz) of 74%. Induction of anesthesia was carried out with 500 ug of sufentanil and 10 mg of pancuronium. After adequate relaxation, the trachea was intubated and mechanica1 ventilation was initiated with 100% oxygen. Maintenance of anesthesia was accomplished with sufentanil, pancuronium, and lorazepam (total sufentanil dose 1.5 mg, total lorazepam dose 4 mg). His antibiotics were continued in the operating room. The prebypass hemodynamics ranged from systolic bloed pressures (SBP) of 100-120 mmHg, HR 60-70 beatsimin, CVP 10-12 mmHg, PAP 35-40115-20 mmHg, CO 4-4.5 Limin, SVR of 1,300 dynes sec cmm5, and SvO2 68% to 80%.