Division Corner

Feroze Mahmood, MD

Robina Matyal, MD

Shirin Saeed, MD

Case Scenario: Use of the SALVATION algorithm to manage perioperative hypoxia and hypotension

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: (Click here to view interactive case)

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