Anesthesia

Management for
Pulmonary
Hypertension
Patients
Ali Nasrallah – Med III
Anesthesiology Clinical Clerkship 2018-2019
American University of Beirut
 Elevated mean pulmonary arterial
pressure (PAP) >20 mmHg at rest

Classification based on 1) function and

2) etiology
What is
Symptoms:
PH?
• Dyspnea, fatigue
• Exertional chest pain, syncope, edema (RV
failure)
• Anorexia, abdominal pain (hepatic congestion)
• Arrhythmias
• Hoarseness
What is the most common cause
of PH?
A. Left heart disease
B. COPD
C. Hereditary
D. Idiopathic pulmonary fibrosis
 Mortality in non-emergent non-cardiac surgery
increased by 2-10%
•Higher rates in emergency surgeries

Acute RHF

Respiratory failure
Risk?
Arrhythmias

CHF

Severe hypoxemia  end organ damage

Pre-Op
Assessment
Pre-Op Assessment
Targeted to assess severity of PH, functional
ability, and modifiable risk factors

Ensure that surgery is necessary by

consulting with surgery and cardiac teams

Ensure all risks are explained to patient

by surgical and cardiac teams
H&P Focus
• Functional Classification

• NYHA class

• Identify comorbidities

• Look for signs of LHF and

RHF

• Worsening or stable status?

 With consulting cardio and pulmo teams

ECG, CXR, Echo, BNP, Stress testing

Pre-
Compare to baseline
Operative
Testing
Screen for OSA

Right-heart catheterization gives an

accurate depiction of severity
• CVP, PAP, PCWP, PVR, CO, MVO2
Optimizing Pre-Operative
Condition
1. Chronic Medications
• Meds for PH generally continued
• Prostacyclin pathway agonists (epoprostenol, treprostinil, iloprost)
• Endothelin receptor antagonists (bosentan, macitentan, ambrisentan)
• Nitric oxide-cGMP enhancers (PDE-5 inhibitors sildenafil and
tadalafil, or guanylate cyclase activator riociguat).

2. Intravascular volume status

• Narrow pre-load window (diuresis but not too much)
• Intraoperative invasive monitoring is typically employed
Optimizing Pre-Operative
Condition
3. Control exacerbating factors
• Continuous oxygen administration.
• Treatment of exacerbations (bronchodilators, inhaled and systemic steroids,
respiratory support)
• Treatment of OSA
• Lifestyle modifications (exercise, cessation of smoking)
• Mechanical circulatory support during the perioperative period in rare case

4. Preoperative sedation
• May be useful to attenuate increases in sympathetic tone due to
pain and/or anxiety (Midazolam, opioids…)
Intraoperative
Management
Anesthetic Management Goals

Avoid increases in Pulmonary Vascular Resistance

Maintain optimal preload and afterload

RV oxygen supply + minimize oxygen demand

Maximize • Keep low PAP
Monitoring
Standard Monitoring
• ECG, SpO2, NIBP, FiO2 ….

Intra-arterial catheter
• Continuous arterial BP monitoring
• Evaluation of respirophasic variations
• Intermittent blood sampling for arterial blood gas measurement
Central venous catheter
• Conduit for administration of vasopressor, inotropes, or pulmonary vasodilators
• Ability to monitor CVP  regulate preload
Induction

Use of a short acting hypnotic (e.g etomidate)

Moderate dose of opioid (fentanyl 1 to 2 mcg/kg)

And/or lidocaine (50 to 100 mg)

To blunt increases in sympathetic tone during airway manipulation

• Muscle relaxant with rapid onset
Maintenance

A balanced regimen is typically

preferred

Infusions of a sedative-hypnotic
component + and opioid
• eg, propofol 50 to 150 mcg/kg per minute +
fentanyl 1 to 2 mcg/kg per hour
Ventilation
Balance oxygenation and ventilation

Avoid lung overdistention

Hypoxemia, hypercarbia, acidosis  worsen PVR

Pressure-control ventilation is typically selected

Optimal level of PEEP to minimize atelectasis

High inspiratory pressures and auto-PEEP are avoided

Post-Operative Care (PACU)
Pain, preload, heart rate, systemic blood pressure,
ventilation, and temperature

Regimen for treatment of PH should be reinstated as soon

as feasible

Selected patients may require ICU monitoring

• Significant intra-op hemodynamic instability, hypoxemia or hypercarbia

• Ongoing infusion or inhalation of a pulmonary vasodilator agent