Hemodynamics Case 4

A 45 year old man is having a general anesthetic for fixation of a displaced fracture of the humerus. During the case his blood pressure is persistently low with systolic BP in the low 70s. There is some response to fluid and a high-dose vasopressors, (you are running 0.5mcg/kg/min of phenylephrine and 8 units an hour of vasopressin). However, you find that the saturation probe won’t read as his peripheries are mottled. Also he is not making any urine. You send a blood gas and he has a metabolic acidemia, with a pH of 7.10 and a base excess of -8. As the procedure continues you are unable to maintain his blood pressure above systolic BP of 80mmHg. You decide to do a TEE to investigate further.

What is your diagnosis?

How will you manage this?