Intraoperative Management and Hemodynamic Support
Intraoperative control and support
The Intraoperative Management and Hemodynamic Support domain tests continuous assessment, fluid and blood management, vasoactive drugs, positioning and temperature. The exam asks for cause-based treatment, not reflexive numbers.
- Routine monitoring: ECG, NIBP or arterial line, SpO2, capnography, temperature, urine output, inspired and expired gases, neuromuscular block.
- Hypotension: check depth, rhythm, bleeding, volume status, anaphylaxis, tension pneumothorax, high neuraxial block and drug effects. Treat the cause.
- Fluids: isotonic crystalloid for maintenance and losses; avoid indiscriminate boluses in heart failure. Goal-directed therapy uses dynamic measures where available.
- Transfusion: restrictive threshold around 7–8 g/dL for most stable patients; higher threshold for active ischemia or ongoing massive hemorrhage. Confirm with labs and coagulopathy.
- Vasopressors: ephedrine 5–10 mg for vasodilation with bradycardia; phenylephrine 40–100 mcg for vasodilation with tachycardia; norepinephrine infusion for refractory vasoplegia.
- Positioning: protect pressure points, eyes and nerves; avoid extreme neck rotation; document.
Worked example
Five minutes after propofol induction, BP falls from 130/80 to 80/45 mm Hg with HR 95 and normal ETCO2. The reasoning: vasodilation and reduced preload from induction are likely. Give a crystalloid bolus and ephedrine 5–10 mg, reassess; if no response, look for bleeding, anaphylaxis or pneumothorax. Do not simply deepen anesthesia.
Traps that cost marks
Do not treat hypotension without checking the blood pressure cuff and ECG. Do not ignore oliguria or rising lactate. Do not over-transfuse based on a single hemoglobin value.