milrinone/pulm HTN ?
Started by amyl
Arch Guillotti
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We routinely use milrinone usually coming off pump. Usually use low dose epi as well.
We use milrinone as needed. Are you talking about undiagnosed PHTN or known PHTN? With known PHTN I don't think we have a limit, but I've used PA catheters in those patients (1 was listed for a heart transplant, RVSP 65 and found colon ca leading to hemicolectomy).
I'd say a patient with severe undiagnosed PHTN is not medically optimized.
I'd say a patient with severe undiagnosed PHTN is not medically optimized.
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I did a Hysterectomy last week on a lady with RVSP of 75 due to primary pulmonary hypertension.
We did it under epidural anesthesia with A line and a central line.
No PA catheter, and she did great.
as an intern, morning conference left me with some questions: here's the case if any are interested. woman in her 40s with pulm HTN secondary to pulm fibrosis as side effect of redux (weight loss drug). rvsp 100s. with viagra improved to 80s. bmi 47.
for resection of adrenal incidentaloma. family not aware pt is going for this surgery but pt is apparently adamant about surgery despite risks and ?benign nature of lesion seen.
debate with surgeons about open vs. lap. pre-op abg showed resp alkalosis with metabolic compensation. invasive monitoring (TEE vs. swan), open vs. lap, vent settings were all discussed. any insights you guys have would be greatly appreciated, the learning curve is steep ;-)
for resection of adrenal incidentaloma. family not aware pt is going for this surgery but pt is apparently adamant about surgery despite risks and ?benign nature of lesion seen.
debate with surgeons about open vs. lap. pre-op abg showed resp alkalosis with metabolic compensation. invasive monitoring (TEE vs. swan), open vs. lap, vent settings were all discussed. any insights you guys have would be greatly appreciated, the learning curve is steep ;-)
Get her to see a Vet
I am assuming you guys have already ruled out Pheochromocytoma, correct?
Now we have an adrenal mass in a patient with severe pulm htn and obese.
Of course the first thing to try is to convince her to wait a little bit and do repeat CT's because maybe she does not need surgery.
If surgery is decided then I would encourage the surgeon to do an open procedure under epidural anesthesia with an A line and an introducer in place (so you can drop a Swan if you need to). Dose the epidural gradually and you can also supplement it with a few intercostal blocks.
Keep a close eye on BP and CVP and replace volume aggressively.
If Bp is low you might need a pressor infusion in the background, I would start with phenylephrine.
If Laparoscopy is the way they decided then I would still place a thoracic epidura, I might just put the PA catheter in to get closer look on the PAP and Cardiac output.
Induce GA gently and maintain with combination of vapors + Epidural.
For laparoscopy you have to pay close attention to CO2 and ventilate aggressively.
Other than these measures make sure that post op pain is well controlled.
that's a LOT of
.
You can
all you want, and it's not going make a bit of difference.
This is a NON-modifiable risk...short of heart-lung transplant.
First decision tree: GO or NO-GO.
If you decide to go....all that pud wacking isn't going to help you....you tweak the patient once in the OR and try things to make it work.
And bottom line...if they're not hypoxic or hypotensive in the OR, they'll be fine.
Academics
You can
This is a NON-modifiable risk...short of heart-lung transplant.
First decision tree: GO or NO-GO.
If you decide to go....all that pud wacking isn't going to help you....you tweak the patient once in the OR and try things to make it work.
And bottom line...if they're not hypoxic or hypotensive in the OR, they'll be fine.
Academics
Viva Viagra.
Phenyl? I've also considered using phenyl to drive RV coronary perfusion pressure in PHT, but have been shot down on occasion because phenyl increases PVR. Intuitively to me, I'd rather marginally increase PVR and have decent RV coronary perfusion, because, you can bet your a*s that the RV coronary perfusion is shot to hell due to RV hypertrophy.
I found this in Anaesthesia 2002 57(1):9-14
The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension*
Y. L. Kwak, 1 C. S. Lee, 2 Y. H. Park 3 and Y. W. Hong 4
In this study the effect of phenylephrine and norepinephrine for the treatment of systemic hypotension were evaluated in patients with chronic pulmonary hypertension. When systemic hypotension (systolic arterial pressure < 100 mmHg) occurred following induction of anaesthesia, either phenylephrine or norepinephrine were infused in a random manner to raise the systolic blood pressure by 30% and 50% above baseline values. Norepinephrine decreased the ratio of pulmonary arterial pressure to systemic blood pressure without a change in cardiac index. However, phenylephrine did not increase arterial blood pressure by more than 30% from baseline in one-third of patients and decreased cardiac index without a significant decrease in ratio of pulmonary arterial pressure to systemic blood pressure. These vasoconstrictors showed different systemic and pulmonary haemodynamic effects in patients with chronic pulmonary hypertension as compared to acute pulmonary hypertension. Norepinephrine was considered to be preferable to phenylephrine for the treatment of hypotension in patients with chronic pulmonary hypertension.
So maybe phenyl not so good? Or does it depend on the cause of the PHT?
Still struggling to sort this out in my mind....
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From a practical point of view I think we are so good at using Phenylephrine and titrating it that it is in our hands a better option than norepinephrine to correct mild systemic hypotension in the context of epidural anesthesia.
If the patient is in acute RV failure I wouldn't use it though.
that's a LOT of.
You canall you want, and it's not going make a bit of difference.
This is a NON-modifiable risk...short of heart-lung transplant.
First decision tree: GO or NO-GO.
If you decide to go....all that pud wacking isn't going to help you....you tweak the patient once in the OR and try things to make it work.
And bottom line...if they're not hypoxic or hypotensive in the OR, they'll be fine.
Academics
Maybe so, Mil, but it's still good for us to hear the thought process as some of us will have to whack the pud in front of our oral board examiners in a few short years.
I don't imagine answering with "Whatever, Mr. Oral Board Pud-Whacker. I'll just push that Hippo into the OR and tweak that **** proper" will do much to get me board certified.
Your point is taken, though.
I didn't say they're wrong.....I'm just saying that they're whacking their pud.
What do I always say about my posts? ....it's just another point of view....from one whose whacked his pud longer and harder than 99% of you guys....and have know decided that whacking your pud doesn't make you $$$$$.
Doing anesthesia on a patient with severe pulmonary hypertension is challenging and requires a clear understanding of the possible complications with a preformulated plan of action.
It is very easy to kill these patients.
The most important piece of information is actually a good history taken from the patient and an accurate estimate of the severity of the symptoms. I actually find the information obtained from the patient more important than any other diagnostic study in this setting.
This is an anesthetic that requires a good anesthesiologist.
It is very easy to kill these patients.
The most important piece of information is actually a good history taken from the patient and an accurate estimate of the severity of the symptoms. I actually find the information obtained from the patient more important than any other diagnostic study in this setting.
This is an anesthetic that requires a good anesthesiologist.
we are a center for pulm htn so we see a lot of these pts. phenylephrine is our drug of choice to, as someone said, improve rv coronary perfusion and, therefore, contractility. I don't know if vaso has been looked at for this purpose, but supposedly there are no V1 receptors in the PA. if nitric oxide weren't so expensive, that would be an option on this intubated patient. our right-sided cardiologists seem to view the PA in these patients as lead pipes with no flexibility and so tend to be pessimistic about milrinone and instead focus almost exclusively on volume.
hahaha, thats one of the funniest posts I've read in a while
Arch Guillotti
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Agree. I posted somewhere else some time ago about a pt. w/pulm. htn who entered a death spiral during induction because of hypercarbia due to some difficulty ventilating and controlling the airway (and CO2 rise).
Vasopressin is a good pressor to use in pulmonary hypertension because as you said there are no V1 receptors in the pulmonary circulation, so theoretically it should not worsen the PAP.
There are several case reports about it's use during anesthesia on these patients but I am not sure if large studies exist.
Here is an example: http://www.anesthesia-analgesia.org/cgi/content/full/99/1/36
I would actually consider using Vaso before using norepi in these patients.
they did use vasopressin and phenylephrine in this case, eventually needing a levophed drip.... but it was the milrinone that broke rvsp spikes into the 140s on emergence.
they went lap with minimal insufflation (surgeon preference, promised it would be faster and less post op pain) with the understanding that if hypercarbia or high pressures developed they would open or cancel. swan was picked over TEE -- reason being that the positioning was left lateral recumbent with a slight prone inclination and that the images on TEE might not be the greatest in that position. baseline abg showed resp alk with met compensation. low bps were treated phenylephrine, then vasopressin, then levophed drip. intra op acidosis (but not too bad) developed despite vent settings to mimick her baseline and some bicarb (also controversial). on emergence rvsp spiked into 140s, which milrinone broke. decided to leave the tube in, to sicu, after prolonged intubation in sicu for a few days (pt had been adamant on no trach and no prolonged vent support) they woke her up, pulled the tube, she signed the papers and died a few hours later.
path report unfortunately showed a hematoma in adrenal gland in question, completely benign. too bad she had that random outpt CT.
they went lap with minimal insufflation (surgeon preference, promised it would be faster and less post op pain) with the understanding that if hypercarbia or high pressures developed they would open or cancel. swan was picked over TEE -- reason being that the positioning was left lateral recumbent with a slight prone inclination and that the images on TEE might not be the greatest in that position. baseline abg showed resp alk with met compensation. low bps were treated phenylephrine, then vasopressin, then levophed drip. intra op acidosis (but not too bad) developed despite vent settings to mimick her baseline and some bicarb (also controversial). on emergence rvsp spiked into 140s, which milrinone broke. decided to leave the tube in, to sicu, after prolonged intubation in sicu for a few days (pt had been adamant on no trach and no prolonged vent support) they woke her up, pulled the tube, she signed the papers and died a few hours later.
path report unfortunately showed a hematoma in adrenal gland in question, completely benign. too bad she had that random outpt CT.
that's a LOT of.
You canall you want, and it's not going make a bit of difference.
And bottom line...if they're not hypoxic or hypotensive in the OR, they'll be fine.
Academics
yeah, but what were the chances that this lady wasn't going to be hypoxic or hypotensive?
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Our most miserable call in residency was to the heart/lung transplant icu for an intubation. Unfortunately it was a pretty common occurance for me. These folks were pre transplant and would have pa pressures that were not all that much lower than their systolics despite viagra and NO being given through a bipap machine along with 100% o2. After just about knocking one of these guys off, I starting giving 2-4 units of vasopressin after about 6 or 8 of etomidate. PA's didn't go up, bp's stayed relatively stable, tube put in as quickly as possible since their sats tended to drop like a stone. Usually worked out well, used it also in the OR for hypotension in pulm HTN pt's with similiar results.
Pd4
Pd4
yeah and what are you going to do...
yank your pud for a few hours then give oxygen and neo....or just do it..
Christ, you guys act like there are endless combinations of drugs that can be used for hypotension....
Epidural anesthesia with an open procedure would have been possibly a smoother approach.
The pressors were used in a sequence that makes sense to me: Neo then Vaso then Norepi.
The decision to go to surgery here was obviously the main issue and one wonders if this patient actually had a death wish.
Good case Amy.
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Good case Amy.
I would thing that the TEE imgaes would still be OK in this position. One of the more memorable cases I did in residency was a prone case on the ortho spine table using TEE.
I think that it was the oblique-ness, for lack of a better term, that made the quality of images come into question. left lateral recumbent with a prone inclination...was a weird position from their description.
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This would be a great ABA written exam question.
How much would TEE images be affected in the lateral recumbent position?
1.) a little bit
2.) not too much
3.) sort of
4.) partially
How much would TEE images be affected in the lateral recumbent position?
1.) a little bit
2.) not too much
3.) sort of
4.) partially
It is not surprising at all to see CRNA's applauding this type of logic.
ok then...you almight-monkey-spanking-fmg- moderator....what do you advise doing for the hypoxic / hypotensive patient who's RV ain't gonna stretch anymore???
My way...skip the self manipulations, and just give oxygen and vasoactive drugs.
Why would your recommendation be in this oooohhh so interesting consult???
You can go ahead and name off all those oooh so sexy inhaled/infused pulmonary vasodilators that will cost you the price of a Ferrari.....but face it, the reality is what I said.
Or is there some hocus pocus herbs that you FMG's know about that us US grads don't know about?
😀
Ok,
I am going to attempt to answer at your level although it is difficult for me to descend that low:
You little china man, navy trained 😱 , small genitalia little town Napoleon:
If I have to tell you at this stage of your career how to anesthetize a patient with severe Pulmonary hypertension then maybe one of the CA1 residents should explain that to you not me (I don't teach basic anesthesia on the internet).
I think you should start posting your questions on allnurses.com maybe one of the CRNA's will volunteer to explain the basics of nurse anesthesia to you.
By the way, don't get your feelings hurt now and open new accounts under new aliases to accuse me of racism.
😉
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You didn't answer the question.
What are YOU doing differently OTHER than playing with yourself and pretending to be smarter than me?
Once again...you haven't answered the question....
and JS , my assistant chief, does not think so.
Hello there JS, I can't believe you accept that little Napoleon calls you his assistant!
You are too good for this.
China man:
If you want answers you need to read my initial posts in this thread, I think I have adequately explained how I would approach this patient.
Read it, you might learn something.
Hello there JS, I can't believe you accept that little Napoleon calls you his assistant!
You are too good for this.
China man:
If you want answers you need to read my initial posts in this thread, I think I have adequately explained how I would approach this patient.
Read it, you might learn something.
Fine...
Obviously you're going to give oxygen and vasopressors like I said to do....
I'm done there, but I guess you need to mentally masturbate for a bit, pat yourself on your back a bunch, and then put down CRNAs.
That's fine if you feel that need to make yourself feel good, then fine.
Just so that we're clear....
PS...you can check the hospital website, it says that JS is my assistant ....she has no say about, I don't have any say about it....it's just the way it is.
yeah, and you STILL didn't answer the question...
You do know that your STOCK continues to drop with each of your juvenile insults in the eyes of this community.
You do know that your STOCK continues to drop with each of your juvenile insults in the eyes of this community.
😀
This thread was not about what you would do intra-op when the RV fails and the patient gets hypoxic and hypotensive, this is just a technicality.
This thread is about how to approach a patient with severe pulmonary hypertension undergoing retro-peritoneal surgery, it's about pre-op, intra op and post op.
These residents are going to have to take the oral boards and they need to know how to think methodically and formulate a plan.
To answer their question: give pressors and oxygen is a CRNA level technical approach and this is not insulting to CRNA's.
Actually when I said that you (supposedly an anesthesiologist) should ask a CRNA to teach you how o do this anesthetic this is not insulting to CRNA's in my opinion, do you think it is?
I apologize to Amy for hijacking her thread.
testosterone again ;-).
like plank, i initially wondered about epidural and if the results of this case might have been different. any thoughts about going regional instead of GA in this case?
like plank, i initially wondered about epidural and if the results of this case might have been different. any thoughts about going regional instead of GA in this case?
No difference...
PRCT has been done in high risk patients (AAA) ...although not PH...the concept is the same....alleviating the "stress response"....NO DIFFERENCE....
Plank's approach....typical of the CRNA's that I work with.......no offense to the CRNA's....just that they aren't familiar with the literature....sort of like Plank.
Silly Plank...thinking that an epidural would make a difference.
Like I said....masturbate all you want....and think that you are smart....but the reality is:
-give oxygen
- support pressure...
end of story.
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Sorry to say this but since achieving moderator status your attacks have become pretty lame 👎.
MMD is way ahead in the count... like he said O2 pressure end of story.
whats PRCT stand for?
did you mean epidural in addition to GA or instead of GA?
The suggestion of regional came up but was quickly dismissed and I couldn't hear the reasoning.
p.s. like it or not you guys do teach anesthesiology on the web ;-) but us newbies to the field really do appreciate it
did you mean epidural in addition to GA or instead of GA?
The suggestion of regional came up but was quickly dismissed and I couldn't hear the reasoning.
p.s. like it or not you guys do teach anesthesiology on the web ;-) but us newbies to the field really do appreciate it
Are you serious? How - why would you ever even consider uttering such drivel? Havent you ever engaged in a debate? Yes, you do your homework on the issue - and yes - you have passion and data to support your case - but you NEVER, ever want to become narrowminded.
Use your vocabulary to articulate without name calling.
Being pig-headed is one thing - but being narrowminded? Is a sign of insecurity and weakness.
To think that someone actually allows you at the helm is alarming.
I hope you have the ability to hypothesize your mistakes. (Dubious).
I do regional anesthesia everytime I can because regional anesthesia in MY hands makes a huge difference.
If you could do this case without having to intubate the patient and alter the hemodynamics by adding positive pressure ventilation then you might be able to get this patient out of the OR without major complications.
In my experience, the people who keep attacking regional anesthesia are the ones who are not very good at it like MMD, and they are as well the people who keep bringing up that silly literature about outcome in AAA.
Regional anesthesia IN THE RIGHT HANDS does make a huge difference, believe me.
I think you are MMD under a new name for the third time!
In the unlikely event that you are not MMD I find it interesting that you started posting today and the only thing that attracted your attention from all the wealth of information on the forum was this.
Maybe you should attempt to learn something rather than providing opinions on my posting style.
I did not attack anyone I just decided to not let this guy run this forum and spread misinformation left and right.
And I will continue to do that regardless of being a moderator or not.
For once someone is responding at the same level, and facing his racism and and bigotry with an equivalent "lame" logic.
It might be lame but you can't be cool when you are addressing racists and bigots.
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prospective randomized controlled trial.
in AAA surgery....4 arms w/ and w/o epidural intra op and w/ and w/o post op epidural pain control.
no difference in outcome...
the only significant difference was a few hours less of post op vent time in the epidural group.
yeah...different patient population, but the concept is the same.
yup, I hear that alot.
Poorly trained folks who don't know the literature, who only do a few cases who say :
"I don't like having evidence to confuse me from what I'm doing"
Typical - your accusatory style.
Nope, Im not MMD. I am simply an observer and loyal follower of SDN.
Im a female and just entering MS - but it doesnt take a person that is well versed in medicine to perceive that you can be a jerk.
I actually think that you are very bright - but honestly some of your remarks are so inane!
I was simply stating that it wasnt necessary and, in fact, down right "ghetto" to be name calling.
What happen to professionalism - do you converse with your partners in that manner? (Rhetorical)
Perhaps you should heed to the advice of others and learn to think before you speak (or type as the case may be).
Im not going to capitulate to your method of retaliation - The "Hitler" syndrome.
Go to a regional anesthesia seminar, the AANA is organizing them now where they will teach you regional in ONE WEEKEND, isn't that wonderful?
It's sad for your patients that you deprive them of such a great thing because of your personal inabilities.
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