elective case w/ severe pulm HTN

[behindthadeuce]

---

Members don't see this ad.

43 yr old female wants (needs) elective TAH for uterine fibroids. they are causing here severe pain and consistent bleeding.

patient has VSD and PDA which were never repaired, and now has Eisenmenger's physiology (R--> L shunt) with severe pulm HTN.

patient is otherwise healthy, but has 1 FOS exercise tolerance.

RA Sp02 84%. BP 84/49

Right heart cath: LPAP 98/59(71) RPAP 110/60(79) PCWP 12 bilat.


How do you do this case? regional or general? what monitors would you use (PAC and/or TEE)?? ICU post op?

 

[ssmallz]

I'm just a CA-1 so take this FWIW

Preop: A - line and CVP (could be done after induction if pt has adequate IV access), don't think a TEE is necessary

Induction: Midaz, Fentanyl, Etomidate, Roc, Tube, Sevo, go very slowly keep pressures stable.

Maintainance: Avoid hypercarbia and hypoxia, use neo maintaine BP and avoid overaggressive fluids

Extubation: Depends on how she's lookin at the end of the case, I would extubate her in the OR if she met the typical requirements.

Postop: Monitored floor is fine, don't see any reason why she would necessitate ICU care if she was extubated.

I'm sure someone will chime in that this could be done under epidural but if your OBs are anything like mine, its better for the patients not to know whats goin on.

 

[Jeff05]

send to interventional radiology as her prognosis is grim. but, if you had to...

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1880420&blobtype=pdf

Non- cardiac surgery carries a high mortality (19% - but old study)
http://www.annals.org/cgi/content/full/128/9/745#R88-8

However, this paper details a series of successful general anesthetics.
http://www.anesthesia-analgesia.org/cgi/content/abstract/56/4/543

Epidural anesthesia has also been described numerous times as in this article
http://linkinghub.elsevier.com/retrieve/pii/S0959289X01998899

 

[Jeff05]

you don't have to avoid hypoxia or hypercarbia - not for the sake of her pulmonary vasculature. as it is fixed at this stage of her dz.

I'm just a CA-1 so take this FWIW

Preop: A - line and CVP (could be done after induction if pt has adequate IV access), don't think a TEE is necessary

Induction: Midaz, Fentanyl, Etomidate, Roc, Tube, Sevo, go very slowly keep pressures stable.

Maintainance: Avoid hypercarbia and hypoxia, use neo maintaine BP and avoid overaggressive fluids

Extubation: Depends on how she's lookin at the end of the case, I would extubate her in the OR if she met the typical requirements.

Postop: Monitored floor is fine, don't see any reason why she would necessitate ICU care if she was extubated.

I'm sure someone will chime in that this could be done under epidural but if your OBs are anything like mine, its better for the patients not to know whats goin on.

 

[Planktonmd]

Place epidural for post op pain.
A line pre-induction
Induce gently and make sure you don't cause major hemodynamic changes, Narcotic induction might be a good idea here.
After induction insert introducer and PA catheter.
The name of the game here is maintain LV function intra-op and maintain SVR while trying to not allow the PVR to rise too much.
Nitric oxide if available might be good here.
Dobutamine is very attractive.
Many approaches can be successful.
This is a very difficult case and not for the faint of heart.
I would not attempt a pure regional anesthetic here although I am usually an advocate of regional.

 

[ssmallz]

Place epidural for post op pain.
A line pre-induction
Induce gently and make sure you don't cause major hemodynamic changes, Narcotic induction might be a good idea here.
After induction insert introducer and PA catheter.
The name of the game here is maintain LV function intra-op and maintain SVR while trying to not allow the PVR to rise too much.
Nitric oxide if available might be good here.
Dobutamine is very attractive.
Many approaches can be successful.
This is a very difficult case and not for the faint of heart.
I would not attempt a pure regional anesthetic here although I am usually an advocate of regional.

Why a PA catheter? How will that information alter your anesthesia plan? Given the inherent risks, do you see a true benefit?

Not disagreeing with your plan, just searching for knowledge

 

[Planktonmd]

Why a PA catheter? How will that information alter your anesthesia plan? Given the inherent risks, do you see a true benefit?

Not disagreeing with your plan, just searching for knowledge

In this specific case (Eisinmenger's syndrome) I think it is very important to know the PA pressure at all times because this will guide your usage of vaso-active drugs.
You need to keep the right to left shunt under control and I can't see how you can do that without monitoring the PA pressure.

 

[Jeff05]

the PA pressures are fixed in this end stage patient. the only variable effecting her shunts is the SVR.

there are also numerous complications reported from PAC placement in this (eisenmenger) population. this coupled with it's limited utility and its lack of influence on maternal outcome makes use of PAC a questionable practice (as it is for almost everything else, i suppose)
Outcome of Pulmonary Vascular Disease in Pregnancy: A Systematic
Overview From 1978 Through 1996
BRANKO M. WEISS, MD, LEA ZEMP, BURKHARDT SEIFERT, PHD, OTTO M. HESS, MD*

In this specific case (Eisinmenger's syndrome) I think it is very important to know the PA pressure at all times because this will guide your usage of vaso-active drugs.
You need to keep the right to left shunt under control and I can't see how you can do that without monitoring the PA pressure.

 

[Planktonmd]

the PA pressures are fixed in this end stage patient. the only variable effecting her shunts is the SVR.

there are also numerous complications reported from PAC placement in this (eisenmenger) population. this coupled with it's limited utility and its lack of influence on maternal outcome makes use of PAC a questionable practice (as it is for almost everything else, i suppose)
Outcome of Pulmonary Vascular Disease in Pregnancy: A Systematic
Overview From 1978 Through 1996
BRANKO M. WEISS, MD, LEA ZEMP, BURKHARDT SEIFERT, PHD, OTTO M. HESS, MD*

Where did you read that the patient was pregnant???
She is going for an elective TAH and they usually don't do that during pregnancy 😀
And although these days the cool thing to do is to criticize PA catheters at every occasion I still think that there are still certain situations where they can be useful.
The Pulmonary resistance only becomes "fixed" at the terminal stage of the disease when the patient is literally dying, but before that stage the PVR remains dynamic and affected by the usual factors (hypoxia,hypercarbia, vasoactive drugs...).
You might be able to predict the PVR and the cardiac output without any monitors but I don't have your degree of confidence and your experience and I feel that I need to use a terrible PA catheter to do that.

 

[cchoukal]

I agree with Jeff's point about the shunts. I think the SVR is the main contributor to the shunts here. I think this makes regional approaches a little dicey: spinal/epidural dropping SVR, R-to-L shunt increases, hypoxemia and ischemia ensue. On the other hand, intubation and PPV could decrease what is already likely to be a very low preload leading to R-sided coronary ischemia... So what to do...

1) It pays to ensure the patient is as optimized as she can be. We say that all the time, but when did this patient last see her cardiologist? Does she see a pulm HTN specialist, or just some community general cardiologist? Have disease modifiers (bosentan, Flolan, sildenafil) been considered/trialed?

2) In theory, an epidural could be the sole anesthetic for the case. Dose slowly and concomitant with a peripheral vasoconstrictor like phenylephrine or vasopressin. The increased SVR will improve R coronary filling which has the potential to improve R contractility (these patients tend to have baseline R ischemia 2/2 increased RV wall tension coupled with low systemic pressures)

The pulmonary circulation supposedly has few or no V receptors which, if you believe there's any reactivity left in her pulmonary circulation, might make vasopressin a better choice. I would have an a-line first, then the epidural. Sedation would have to be kept to a minimum to avoid whatever effect hypoventilation, hypoxia, and hypercania MIGHT have on her pulmonary circulation.

3) On the other hand, a slow, smooth IV induction with minimal hemodynamic swings (tachycardia and hypotension could be lethal) and spontaneous ventilation, with the aforementioned pre-induction a-line and perihperal vasoconstrictors, could also be done safely.

 

[Noyac]

I agree with Jeff's point about the shunts. I think the SVR is the main contributor to the shunts here. I think this makes regional approaches a little dicey: spinal/epidural dropping SVR, R-to-L shunt increases, hypoxemia and ischemia ensue. On the other hand, intubation and PPV could decrease what is already likely to be a very low preload leading to R-sided coronary ischemia... So what to do...

1) It pays to ensure the patient is as optimized as she can be. We say that all the time, but when did this patient last see her cardiologist? Does she see a pulm HTN specialist, or just some community general cardiologist? Have disease modifiers (bosentan, Flolan, sildenafil) been considered/trialed?

2) In theory, an epidural could be the sole anesthetic for the case. Dose slowly and concomitant with a peripheral vasoconstrictor like phenylephrine or vasopressin. The increased SVR will improve R coronary filling which has the potential to improve R contractility (these patients tend to have baseline R ischemia 2/2 increased RV wall tension coupled with low systemic pressures)

The pulmonary circulation supposedly has few or no V receptors which, if you believe there's any reactivity left in her pulmonary circulation, might make vasopressin a better choice. I would have an a-line first, then the epidural. Sedation would have to be kept to a minimum to avoid whatever effect hypoventilation, hypoxia, and hypercania MIGHT have on her pulmonary circulation.

3) On the other hand, a slow, smooth IV induction with minimal hemodynamic swings (tachycardia and hypotension could be lethal) and spontaneous ventilation, with the aforementioned pre-induction a-line and perihperal vasoconstrictors, could also be done safely.

I like #3. But an epidural would work as well. I would have this person spontaneously breathing asap as long as it doesn't interfere with the surgery.

Anyone like milrinone in this case?

 

[DrDre']

Pick your plan, pick your complications!

I would perform a GA. I would not want a conscious pt who I am concerned about how ventilation will affect their hemodynamics. To me, this would preclude sedation.

If the SVR will change the shunt, milrinone would not be my 1st choice unless combined with AVP.


No matter what anesthetic plan, I would do an awake AL. Turn on a pressor (phenyl or AVP) then titrate in etomidate for induction


I thought anesthesia was all prop-sux-tube, or Anesthesia on...

I like #3. But an epidural would work as well. I would have this person spontaneously breathing asap as long as it doesn't interfere with the surgery.

Anyone like milrinone in this case?

 

[sweetalkr]

I am McSleepy.
gas on
bzzzzzzzzzzzzz
gas offf
bzzzzzzz

 

[periopdoc]

I am with Plank on this one. She buys a PA catheter. However, I disagree with him that the LV is the concern here. Long before you can overload that system the RV will have crapped out. (but that is just semantics)

the PA pressures are fixed in this end stage patient. the only variable effecting her shunts is the SVR.

The concept of a "fixed" PVR is just that, a concept. The reality is that the PVR is fixed at an elevated level with a blunted range of reactivity. It may not decrease much with proper maintenance of PO2 and PCO2, but is will certainly increase if they are poorly managed. It will increase when you give her phenylephrine and when you initiate PPV. With nitric oxide, sildenafil, and volatile inhaleds etc you may be able to decrease her PVR a little bit, or at least ward off an increase in PVR due to other anesthetic issues.

The PA catheter is much maligned because it is hard to integrate all the information appropriately to derive a benefit from it relative to the risks. In this case you are going to focus on one number (the PA pressure) and tweak everything you can to minimize it in relationship to the systemic pressure. Therefore, the benefit can be enormous. I can think of three PA complications that are increased in this scenario; malposition (due to R --> L shunt), arrhythmia, and thrombotic complications.

Remember that you cannot get CO from your thermodilution PAC because of the R-->L shunt fraction.

I think the most important thing that people forget about managing PA HTN in general is that they are typically polycythemic and prone to thrombosis. Obviously even small pulmonary embolism is poorly tolerated in this population so meticulous attention must be given to anticoagulation and avoidance of air injected into the IV.

My plan (basically)...

• Preop optimization by a pulmonary hypertension specialist.
  
• Heparin 5000 bid starting the morning of surgery.
  
• Preoperative a-line and PAC.
  
• Thoracic epidural placed in the OR with vasopressin infusion connected and ready to go at the push of a button. (for postop pain management). Alternatively, it could be placed in preop and tested when in the OR.
  
• fentanyl, etomidate, panc induction.
  
• Intraoperative nitric oxide. Vasopressin to treat hypotension. Strict attention to fluid balance.
  
• Postop to the ICU intubated.

I might toss in a TEE just so that I can watch the right heart die a slow and agonizing death. It would be interesting to quantify the shunt and see how it changes with variations in anesthetic management.

I am curious what others would do regarding transfusion in this patient. How would you determine your transfusion threshold? I have some ideas, but I am curious what others would do.

- pod

 

[proman]

I think this is a time when we need to be physicians. Talk first with the GYN, describe the risk (5-25% mortality). That alone should dissuade them from proceeding. At least they should exhaust all other options (such as IR embolization, endometrial ablation). The patient also needs to understand that the risk of death could be 25% (never know what complication will happen intraop that turns this minor procedure into a major vascular bloodbath). If they're dead-set on proceeding, I would use a very slowly titrated lumbar epidural, a line, central line for an inotrope (dobutamine I think is a great choice) and agree with vasopressin. No opioid. I doubt a PA cath would give much more useful info than a CVP. Plus, the risk of the PA cath and large VSD outweighs the benefit. Post-op ICU of course. Oh, and this isn't a teaching case. Operative time needs to minimized, so GYN attending with 4th year resident only.

Bottom line, I think it's a bad idea to operate on this patient for an elective procedure with alternatives.

Reg Anesth Pain Med. 2002 Sep-Oct;27(5):509-13. Links
Safety of regional anesthesia in Eisenmenger's syndrome.

Martin JT, Tautz TJ, Antognini JF.
Department of Anesthesiology and Pain Medicine, University of California, Davis, California 95616, USA.
BACKGROUND AND OBJECTIVES: Eisenmenger's syndrome is characterized by right-to-left or bidirectional shunting and pulmonary hypertension. Perioperative risk is high for noncardiac surgery, and many clinicians avoid regional anesthesia because of the potential deleterious hemodynamic effects. We determined perioperative mortality based on published reports describing anesthetic management in patients with Eisenmenger's syndrome. METHODS: A literature search identified 57 articles describing 103 anesthetics in patients with Eisenmenger's syndrome. An additional 21 anesthetics were identified in patients receiving regional anesthesia for labor. RESULTS: Overall perioperative mortality was 14%; patients receiving regional anesthesia had a mortality of 5%, whereas those receiving general anesthesia had a mortality of 18%. This trend favored the use of regional anesthesia but was not statistically significant. A better predictor of outcome was the nature of the surgery (and presumably the surgical disease). Patients requiring major surgery had mortality of 24%, whereas those requiring minor surgery had mortality of 5% (P <.05). Patients in labor receiving regional anesthesia had a mortality rate of 24%, and most of these occurred several hours after delivery. CONCLUSIONS: This review of anesthesia and surgery in patients with Eisenmenger's syndrome reveals that most deaths probably occurred as a result of the surgical procedure and disease and not anesthesia. Although perioperative and peripartum mortalities are high, many anesthetic agents and techniques have been used with success.

 

[Planktonmd]

To those who keep saying that a PA catheter is not appropriate here:
I am not an advocate of placing PA catheters left and right but this patient has the following:
Severe Pulm HTN, she has a severe R to L shunt, She is hypotensive and severely hypoxic pre-op.
I am not sure how you intend to administer vasoactive drugs intraop when she (inevitably) becomes severely hypotensive and her shunt increases without having a clear idea of what the PA pressure is, what is the cardiac out-put and what is the SVR.
You need to know when to treat the PA pressure and when to give vaso-pressors or positive inotropes.
If this case does not warrant a PA catheter then what case does?
All that stuff they are teaching today about the risks of PA catheters is great but we can't become PA Catheter haters.
I feel that the subject of PA catheters has become a taboo for the residents almost comparable to the taboo of doing C Sections under GA.