Case Scenario: Use of the SALVATION Algorithm to Manage Perioperative Hypoxia and Hypotension
Robina Matyal, MD, Feroze Mahmood, MD, Shirin Saeed, MD
Published October 1, 2024 | Clinics in Medical Education
Issue 3 | Volume 1 | September 2024
Background
A 54-year-old male with a medical history of chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) underwent tracheomalacia repair surgery. Prior to surgery, a stent was placed. Anesthesia was maintained with propofol and remifentanil. Postoperatively, the patient was transferred to the post-anesthesia care unit (PACU), where Sugammadex was administered for neuromuscular reversal.
Complication
Approximately 30 minutes after arriving in the PACU, the patient experienced sudden desaturation from 98% to 88% and a drop in blood pressure to 80/50 mmHg. The anesthesia team responded using the SALVATION algorithm, a stepwise approach to managing perioperative hemodynamic instability. SALVATION (Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension Algorithm) Application:
Step 1: Contractility and Afterload Evaluation
The team begins by evaluating cardiac function using a focused transthoracic echocardiogram (TTE). The examination reveals a hyperdynamic left ventricle (LV), with no signs of major cardiac abnormalities, ruling out a primary cardiac cause for the hypotension.
No pericardial effusion or tamponade is noted, and the ventricular contractility appears stable.
However, increased afterload in the right ventricle (RV) is observed, pointing toward a possible pulmonary issue contributing to the patient’s instability.
Step 2: Preload Evaluation
Next, the team assesses the patient’s preload by performing an ultrasound evaluation of the inferior vena cava (IVC). The IVC is found to be distended with minimal respiratory variation, suggesting the patient is not hypovolemic. There is no evidence of fluid overload, and pericardial effusion is excluded as a potential cause of the hypotension.
Step 3: Hypoxia Evaluation
With preload and cardiac contractility deemed stable, the team turns its focus to the cause of hypoxia. A lung ultrasound is performed, showing absent lung sliding on the right side, along with prominent A-lines and absent B-lines. These findings, along with the identification of a lung point (the junction between normal lung sliding and absent sliding), confirm the diagnosis of a right-sided pneumothorax.
Intervention
The anesthesia team acts swiftly to treat the confirmed pneumothorax. They perform a needle decompression on the right side, followed by the placement of a chest tube to allow for continuous drainage. Following this intervention:
- The patient’s oxygen saturation quickly improves, rising from 88% back to 98%.
- Blood pressure stabilizes, increasing from 80/50 mmHg to 110/70 mmHg.
- Peak airway pressures, which had been elevated, return to normal limits, indicating relief of the pulmonary pressure from the pneumothorax.
The patient is transferred to the ICU for postoperative monitoring, with continued chest tube drainage. Special attention is given to the patient’s respiratory status due to his underlying COPD and the recent pneumothorax. He remains in the ICU for close observation to ensure stable breathing and to monitor for any recurrence of pneumothorax or other complications.
Conclusion
This case highlights the effectiveness of using the SALVATION algorithm to systematically evaluate postoperative complications. In this instance, early identification and intervention of a right-sided pneumothorax using the SALVATION approach helped prevent further deterioration in a patient with pre-existing COPD and coronary artery disease.
REFERENCES
1. Fatima H, Amador Y, Walsh DP, Qureshi NQ, Chaudhary O, Mufarrih SH, Bose RR, Mahmood F, Matyal R. Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal. J Cardiothorac Vasc Anesth. PMID: 34006466