Scribd Logo
Upload

Welcome to Scribd!

  • 29 views

    Pulmonary Hypertension

    Uploaded by

    Kirk Louie Amandoron
    This case report describes the anesthetic management of a 28-year-old pregnant patient with severe pulmonary hypertension undergoing emergency cesarean section. Preoperatively, the patient was optimized on medications for pulmonary hypertension and invasive monitoring was placed. During surgery, hemodynamic stability was maintained using epidural anesthesia, low-dose vasopressors, and inodilators. Postoperatively, the patient required temporary oxygen and resumed pulmonary hypertension medications with an ultimately improved condition after readmissions for exacerbations. The report reviews pulmonary hypertension pathophysiology, diagnosis, management, and perioperative risks, emphasizing hemodynamic stability and avoidance of increased pulmonary vascular resistance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Pulmonary Hypertension

    Uploaded by

    Kirk Louie Amandoron
    29 views32 pages
    This case report describes the anesthetic management of a 28-year-old pregnant patient with severe pulmonary hypertension undergoing emergency cesarean section. Preoperatively, the patient was optimized on medications for pulmonary hypertension and invasive monitoring was placed. During surgery, hemodynamic stability was maintained using epidural anesthesia, low-dose vasopressors, and inodilators. Postoperatively, the patient required temporary oxygen and resumed pulmonary hypertension medications with an ultimately improved condition after readmissions for exacerbations. The report reviews pulmonary hypertension pathophysiology, diagnosis, management, and perioperative risks, emphasizing hemodynamic stability and avoidance of increased pulmonary vascular resistance.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This case report describes the anesthetic management of a 28-year-old pregnant patient with severe pulmonary hypertension undergoing emergency cesarean section. Preoperatively, the patient was optimized on medications for pulmonary hypertension and invasive monitoring was placed. During surgery, hemodynamic stability was maintained using epidural anesthesia, low-dose vasopressors, and inodilators. Postoperatively, the patient required temporary oxygen and resumed pulmonary hypertension medications with an ultimately improved condition after readmissions for exacerbations. The report reviews pulmonary hypertension pathophysiology, diagnosis, management, and perioperative risks, emphasizing hemodynamic stability and avoidance of increased pulmonary vascular resistance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views32 pages

    Pulmonary Hypertension

    Uploaded by

    Kirk Louie Amandoron
    This case report describes the anesthetic management of a 28-year-old pregnant patient with severe pulmonary hypertension undergoing emergency cesarean section. Preoperatively, the patient was optimized on medications for pulmonary hypertension and invasive monitoring was placed. During surgery, hemodynamic stability was maintained using epidural anesthesia, low-dose vasopressors, and inodilators. Postoperatively, the patient required temporary oxygen and resumed pulmonary hypertension medications with an ultimately improved condition after readmissions for exacerbations. The report reviews pulmonary hypertension pathophysiology, diagnosis, management, and perioperative risks, emphasizing hemodynamic stability and avoidance of increased pulmonary vascular resistance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 32

    A CASE REPORT ON A

    PATIENT WITH SEVERE


    PULMONARY
    HYPERTENSION
    UNDERGOING NON-
    CARDIAC SURGERY
    Dr. Kirk Louie Amandoron
    Third Year Resident
    Department of Anesthesiology
    OBJECTIVES
    ● To present a case of MY, with severe pulmonary hypertension,
    who underwent emergency cesarean section
    ● To review the pathophysiology, diagnosis and treatment
    options of pulmonary hypertension
    ● To discuss the perioperative management of pulmonary
    hypertension
    PATIENT PROFILE

    Patient MY
    28 years old
    G4P2(1112) PU, 37 weeks
    AOG, cephalic
    CC: water vaginal discharge
    PREVIOUS MEDICAL HISTORY
    • Subclinical Hypothyroidism
    Maintained on Levothyroxine 75mcg OD
    Currently euthyroid
    • Severe Pulmonary Hypertension
    NYHA Class IIC
    Maintained on Sildenafil 25mg OD
    2D ECHO (Taken 1 month PTA)
    • Concentric Left Ventricular Remodeling with Segmental Wall
    Motion Abnormality but preserved LV systolic function (68%)
    and normal filling pressures
    • Dilated RV with Normal Systolic Pressures with signs of
    Pressure and Volume overload
    • Dilated RA
    • MVP with Mild MR
    • Mild AR, TR, PR
    • High Probability for Pulmonary Hypertension, probably pre-
    capillary
    PHYSICAL EXAMINATION
    • Awake, coherent, able to lie flat, not in respiratory distress with
    pre-operative vital signs of: BP-120/60, HR – 92bpm, RR – 22,
    O2 sat – 99% at 2lpm via NC
    • No cyanosis, pink palpebral conjunctivae, no neck vein
    distention
    • Clear breath sounds, distinct heart sounds
    • Strong peripheral pulses
    • Airway: Mallampati 2 with adequate mouth opening and
    thyromental distance and no history of obstructive sleep apnea
    LABORATORY EXAMINATIONS
    • CBC
    Hb 11.3, Hct 37, WBC 15, PLT 320
    • Bleeding Parameters
    PT 92%, INR 0.98
    • Creatinine – 0.8
    PRE-OPERATIVE PLAN
    • Maintain on NPO
    • Double line
    • Premeds: Pantoprazole, Metoclopramide
    • Secure 1 unit pRBC
    • Plan: CSEA
    • Dobutamine drip
    • Additional monitors: Arterial line
    INTRAOPERATIVE COURSE
    • Spinal anesthesia with 2.5mg bupivacaine (H) with subsequent
    administration of 16mg bupivacaine (I) via epidural catheter
    • Stable BP range at 110-140/70-80 mmHg maintained on
    dobutamine drip at 3 to 5mkm
    • No desaturations while maintained on O2 at 2lpm via NC
    • Adequate urine output
    • S/P Primary Cesarean Section with Bilateral Salpingectomy
    POST-OPERATIVE COURSE
    • Post operative medications: epidural morphine, paracetamol,
    tramadol+paracetamol
    • Dobutamine was weaned off
    • O2 support was maintained at 2lpm via NC
    • Repeat CBC: Hb 9.9, Hct 31.4
    • Sildenafil resumed at postoperative day 2
    TWO WEEKS LATER
    • Readmission due to episodes of dyspnea
    • Exacerbation of pulmonary Hypertension
    • Underwent TEE under sedation
    • Discharged with improved condition
    ONE MONTH AFTER
    • Readmission due to episodes of dyspnea again
    • Managed as a case of CAP-MR
    • Discharged after 9 days with improved condition
    PULMONARY
    HYPERTENSION
    PULMONARY HYPERTENSION
    • Heterogeneous disease that may be a pulmonary or a left sided
    heart problem
    • Mean pulmonary Artery pressure of more than or equal to 20
    mmHg
    PULMONARY HYPERTENSION
    PATHOPHYSIOLOGY
    PATHOPHYSIOLOGY
    DIAGNOSIS
    • Symptoms: Dyspnea, fatigue
    • Signs: Venous congestion, split S2, tricuspid regurgitant
    murmurs
    • Labs: ECG, echocardiogram, Chest x-ray, Right heart
    catheterization, pulmonary function test, sleep studies, CT
    angiography
    PHARMACOLOGIC MANAGEMENT
    • Prostanoids: Epoprostanol,
    Treprostinil, Selexipag
    • Endothelin Antagonists: Bosentan,
    Macitetan, Ambrisentan
    • Nitric Oxide Pathway Effectors:
    Sildenafil, Tadalafil, Riociguat
    PERI-OPERATIVE RISKS
    • Four fold increase in major peri-operative cardiovascular events
    • Risk factors: Elevated RAP (>7mmHg), decreased 6-min
    walking distance, use of pressors
    PRE-OPERATIVE ASSESMENT
    • Patient-Related Factors: Severity of PAH, RV dysfunction,
    OSA, Low exercise capacity, ASA of 2 or more
    • Procedure-Related Factors: emergency surgery, high and
    intermediate risk surgery, need for vasopressors, prolonged
    surgery of more than 3 hours
    PATIENT OPTIMIZATION
    • Pre-surgery visit 2 to 4 weeks prior for disease stratification
    • Repeat laboratory assessment
    • Assess the need for diuresis, advanced PH therapeutics,
    afterload reduction, arrhythmia management, inotropes
    • Pulmonary optimization
    • Medications should be taken on the morning of the day of
    surgery
    INTRA-OPERATIVE GOALS
    • Main Goal: prevent acute RV dysfunction and maintain cardiac
    index to ensure adequate end –organ perfusion
    • Avoid hypotension (MAP >60)
    • Maintain normal sinus rhythm
    • Avoid factors that mitigate increase PVR (hypoxia, hypercarbia,
    acidosis, pain, hypothermia)
    • Avoid high airway pressures
    • Maintain baseline RV loading conditions
    INTRA-OPERATIVE GOALS
    • Use of Diuretics and PAH directed therapies to optimize central
    venous pressures
    • Use of inotropes and pulmonary vasodilating agents
    ANESTHESIA MANAGEMENT
    • Main goal: maintenance of hemodynamic stability
    • Choice of technique depends on each case
    • Consider type of surgery
    GENERAL ANESTHESIA
    • Induction Agents: Etomidate, propofol, opioids
    • Do not use ketamine
    • Muscle relaxant: Succinylcholine or Rocuronium
    • Minimizing response to intubation: lidocaine, fentanyl
    REGIONAL ANESTHESIA
    • Avoid single shot spinal anesthesia
    • Epidural is a better choice
    • Standby vasopressors
    OBSTETRIC ANESTHESIA
    • Generally discouraged
    • Endothelin antagonist – category X, prostacyclins and PDE5
    inhibitors – Category B
    • Invasive monitoring, Low dose vasopressors, inodilators
    • Epidural anesthesia is recommended
    • Cesarean Section vs Vaginal Delivery
    • Critical period: post-partum
    VASOPRESSORS
    • Norepinephrine and vasopressin (0.08 – 0.1 units/min)
    • Avoid phenylephrine and epinephrine
    • Inodilators: Milrinone (0.25 to 0.75 mkm) or dobutamine (2.5 to
    10 mkm)
    REFERENCES
    • Evaluation and Management of Pulmonary Hypertension in
    Noncardiac Surgery: A Scientific Statement From the American
    Heart Association
    • Harrison’s Internal Medicine Chapter 283 Pulmonary
    Hypertension
    • Focused Review of Perioperative Care of Patients with
    Pulmonary Hypertension and Proposal of a Perioperative
    Pathway
    THANKS!

    You might also like