g/a for pulmonary hypertension pts

[chef]

what's the std care & protocol for sever pulmonary hypertension pts undergoing g/a ? (for liver transplant surgery for example)

i guess you'd limit i/v fluids during surgery, but what else? please elaborate and for each drug you'd use please state your reasoning.

btw pre-surgery tx w/ viagra and prostacyclin has not responded and pt suffered severe side effects.

also what's the usual prognosis for pulm h/p pts? do they die often?

thanks a ton and btw i'm an M2 and i find anesthesia absolutely fascinating. you guys seem to "OWN" physiology and know so many cool drugs!!

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[Gator05]

The journal Anesthesiology had an article recently about conducting a medically-indicated Ab on a woman w/ PPMTH. I'm pretty sure they moved to bypass/ECMO, but sadly the woman did not survive.

A couple of questions for the OP to investigate for fun and learning:

1. If this pt were older, why didn't the prostacyclin/iNO work as well as it might have in, say, a neonate?

2. On TEE, what might you expect to see on the cardiac exam?

3. What would be the baseline CVP values you would expect for this pt?

4. Aside from reducing IV fluids, which meds could you use to reduce preload for this patient? Reduce afterload?

I'm only an MSIII, so if anyone would like to chime in with more questions/answers, this seems like an excellent post to do so!

I'll post what I think are answers this afternoon.

 

[pasgasser]

I am replying from memory so do not take this as gospel and please post corrections if errors are made.

In your first question you asked about a pt with pulm. HTN for liver transplant. This is a non-issue because a pt with pulm. HTN is not a candidate to be a transplant recepient.

Several anesthesia drugs can cause problems in this pt population. Nitrous oxide and ketamine both increase pulm pressures and would be poor choices to use. Volatile anesthtics dilate pulm. vasculature. Oxygen is the greatest pulmonary vasodilator that is used routinely so run a high FiO2. On the O2 thought do not use any drug that can cause histamine release as these drugs can lead to bronchconstriction -> hypoxia -> worsened pulm HTN. Histamine releasing drugs include morphine, possible thiopental, and benzyl isoquinoline muscle relaxants with the exception of cisatricurium. Narcotics other than morphine do not effect pulm pressures. Also remember to keep the pt comfortable and calm, hypocarbia causes bronchoconstriction. A pulmonary artery catheter and arterial line are indicated in these pt's for nearly all procedures. Theses pt's should be closely monitored in the ICU post-op.

Any good anesthesia text book will cover this topic in depth.

 

[eddieberetta]

Originally posted by pasgasser
In your first question you asked about a pt with pulm. HTN for liver transplant. This is a non-issue because a pt with pulm. HTN is not a candidate to be a transplant recepient.

There are certain situations where this is not true. Secondary pulmonary hypertension can for example be due to intrahepatic AVMs (as is uncommonly seen in Osler-Weber-Rendu). Interventional radiological embolization of hepatic AVMs is unsafe; thus transplant is the only option. In fact, pulmonary hypertension/RVH would be the indication for transplant in these patients and usually occurs when the shunt exceeds 20% C.O.

 

[Tenesma]

a few things - pulm. htn is not an absolute contra-indication for transplant, especially if the transplant is designed at reducing the pulm. htn (ie: cardiac, liver or lung transplant)

you also mentioned hypocarbia re: bronchoconstriction, hypercarbia definitely leads to increased pulm. pressures - so normocarbia is ideal and actually i would push for some mild hypocarbia.

I have done/seen/been part of severe pulm. hypertension cases = and trust me, almost half of those patients went down the tubes (one of which passed away immediately post-op).... The key things are full invasive monitoring, dedicated post-op ICU bed, and playing things careful -

I hate to sound condescending, but at the M2/M3/M4/Intern level i think it is better to focus on truly understanding pulm. hypertension and its broad implications on the rest of the body - and not worry about the Anesthesia side of things (unless this is for a special project/paper) as this extra information will just bog you down but i am glad you are interested in anesthesia and i agree about what was said about us owning physiology.... I like to consider anesthesiologists as interventional physiologists/pharmacologists amongst other things. It is funny how many times we will get recommendations from Cardiologists/Pulmonologists (or even better from Internal Medicine) about how to manage patients physiology intra-operatively when they have no clue what happens intra-operatively or even immediately post-operatively...
my favorite lines include: "avoid severe hypotension" "keep PCWP between 16-18" [in a pt. w/ severe MR no less who doesn't have a PA catheter ] , etc...