Intraoperative Management

Before the patient undergoes induction of anesthesia, appropriate pharmacologic agents must be available. Adequate peripheral access plus a radial arterial catheter, in addition to a urinaiy catheter, is routinely utilized and, rarely a Swan-Ganz catheter may be placed if indicated on the basis of cardiac disease or other problem. Sodium nitroprusside (Nipride) was previously the intraoperative agent of choice for rapid control of acute hypertension. It is a powerful direct-acting vasodilator that can deliver profound hypotension immediately after its infusion. In contrast to the bolus effect of phentolamine (Regitine), it has the advantage that within seconds of discontinuing the infusion, the hypotensive effect ends, allowing nearly second-by-second blood pressure control. However, in the last 10 years, Nipride has been used only on rare occasion, replaced by intermittent small doses of esmolol (Brevibloc). Dopamine was the agent previously used to treat hypotension coincident with tumor excision. It has been replaced by short bolus administration of ephedrine or phenylephrine. Blood infusion to replace hemorrhagic loss as well as to fill the dilated vascular tree after tumor removal was much more commonly needed previously than in current practice. Lidocaine is rarely necessary initially as a bolus followed by a constant infusion if ventricular arrhythmias persist.

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