On Physical examination: 60 inches, 50 kg weight. BP 150/78 mm of Hg, RR 14/minute, Pulse 90/minute. Important labs: BUN/Cr 30/1.8, Hct 27, BNP 300pg/l, Chest Xray normal lung and cardiac silhouette.

Perioperative management: Preop: 1. Large IVs 2. A-line 3. Epidural INR 1.5 what other options for multimodal analgesia? For example, rectus sheath block, TAP block, ketamine

Intraoperative:

1. GA with maintaining hemodynamic stability
2. Central line for CVP monitoring
3. Non-invasive monitoring LIDCO for SVV, CO and SVR
4. TEE or TTE depends on the expertise
5. Nitroglycerine and phenylephrine on the pump
6. Consider renal protection strategies

Management:

1. Goal directed fluid management is the protocolized use of cardiac output and related parameters as end points for fluid and/or inotropic therapy administration.
2. Goal directed coagulation management (TEG, ACT, platelets, INR when needed)
3. Goal directed resuscitation (baseline blood gas and afterwards every hour or half an hour depending on the stage of surgery, SVV, end systolic and end diastolic diameter, PPV for fluid management.)
4. Starting from clamping the aorta, goal directed volume with blood, balanced crystalloids (plasmalyte), and albumin. Consider FFP, platelet depending on the amount and time period of blood loss.
5. Will you consider Cell Saver?
6. Anticipate hemodynamic changes with cross clamping and release of cross clamping (aggressive preload and tone support).
7. Frequent labs for acidosis and ischemia reperfusion injury evaluation.
8. Appropriate temperature management and avoid hypothermia and at the same time hyperthermia to the legs during cross clamp.

Reasons when to consider Cell Saver

1. When anticipated blood loss is >1 L or 20% of the patient’s estimated blood volume (EBV).
2. In patients with a low hemoglobin concentration or who are at increased risk of bleeding.
3. In patients with multiple antibodies or rare blood types (cross-match compatible blood is unobtainable).
4. In patients who are unwilling to accept allogeneic blood (e.g. Jehovah’s Witnesses).

Cell saver is the process of collecting blood from the operative field, which is then anticoagulated, centrifuged, filtered, washed and finally re-suspended in saline. Coagulation factors and platelets are entirely removed by the cell saver. Salvaged red cells can then be transfused to the patient during or after the surgery as required (within 6 h). According to a recent Cochrane review, cell saver is associated with a 38% reduction of allogeneic blood transfusion, without significant safety concerns being raised.

End of surgery: Surgery finished uneventfully, you gave 650 cc from the cell saver, 2 packed RBC, three liters of plasmalyte. Total EBL 1.8 liters. Urine output 200 cc. PPV 8, CO 4.0 l/minute. End diastolic diameter is 11cm. Blood gas Lactate is 1.5 to 5.5 soon after the infrarenal clamp. Base deficit is -2, Hct 28. The incision site looks dry. You are asked to give protamine. Fixed protamine dose regimen-1-1.3mg of protamine for each100IU of heparin. For this patient 30 mg of protamine is given slowly after test dose. Suddenly, patient became hypotensive with systolic pressure in 50/30 mm of Hg.