Pulmonary Hypertension

[RxBoy]

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Interesting case of pulmonary htn:

60 something M for aortofem bypass with COPD and severe pulmonary HTN. Put swan preop, Awake PAP pressures 90/60 🙁

During case, PAP close to systemic pressures. Both aline and PAP tracing on same scale superimposed and at one point the PAP was equal to the systemic pressure. Did intraop TEE and moderate TR and huge RA and RV.

Long story short, I ran into a very vicious cycle for extubation...

Blow off CO2 and oxygenate well with vent -> get pt to breath on their own-> Pt gets light as anesthetic wears off-> PAP pressures increase, hypoxia and hypercarbia insue->PAP pressures skyrocket->Deepin pt, blow off CO2 and oxygenate with vent. Cycle repeats.

Tried some fentanyl, lidocaine down tube, even tried milronone drip, but no help for breaking cycle. After about 30 min, my attending got fed up and had me push push ativan. We shipped pt to ICU vented to "blow off the gas". Basically washing our hands clean of this mess. Have no idea how this dude was eventually extubated.

So my question: How would you guys approach this problem? I think pulling it deep would be out of the question considering how fast this dude desaturates.

 

[IlDestriero]

This case was a turd from the beginning. I hate pulm htn with a passion.
What meds was he on for it pre op?

 

[RxBoy]

This case was a turd from the beginning. I hate pulm htn with a passion.
What meds was he on for it pre op?

Didn't matter because he wasn't taking them. Pt told me he was prescribed inhalers at one point but doesn't think he needed them. EMR pulmonary consult says he was prescribed sildenafil at one point but he never filled it.

RA sat 88%. Has 120 pack year hx of smoking. 3 PPD since age 14. He only quit because it was too painful to walk to the store for smokes due to his claudication.

We actually wanted to cancel the case, but vascular agreed to note that the case was "emergent" due to critical ischemia.

We considered neuraxial. But this guy was an all star. Of all the meds this dude was supposed to take but didnt, the only one he does take is plavix.

 

[Arch Guillotti]

No way in the world I would pull it deep. Tough case, dude is lucky he made it through alive.

Sending them upstairs tubed to the ICU is the easy way out but sometimes patients just need to chill for a while before they are extubated. This is a big ass surgery on a sick ass dude.

Ideally you would go for something akin to a narcotic heavy/remifentanil type wakeup but it just may not be possible in a case like this.

 

[proman]

You need a pulmonary vasodilator like nitric or Flolan. Flolan is probably better because you can continue it post extubation by mask (iNO too but 24x the cost). I would assume his PVR isn't fixed because otherwise he wouldn't have gotten the sildenafil. These patients either fly immediately or linger on the vent for a couple of days.

 

[deleted126335]

No way in hell I would extubate no matter how quick and slick the surgery went. The decision was made the minute the PA catheter was floated. Only for a ditzel surgery would I think about extubating this patient. Certainly not major vascular. This is what critical care docs do for a living.

 

[Idiopathic]

this guys will own (not rent) his tube. the only way the anesthesiologist will kill him is on induction or re-induction (i.e. failed extubation).

keeping in mind that he will not tolerate unclamping well (when was your TEE in?), but I wouldnt expect to see baseline RV disfunction to that extent if the intraop care was optimized. maybe i underestimate how many people walk around with severe RV dysfunction.

any thought to dobutamine? its more forgiving, and the tachycardia can help R>>L flow without the degree of systemic hypotension offered by milrinone (dont let that RV get ischemic or its over), i probably would have taken him up on flolan and dobutamine/milrinone and let him rest for 24-48 hours getting those weaned off, make sure there is no rebound acidosis or severe pain control issues. i applaud you for trying. ive extubated someone with PAP of 90+ systolic after lap SBR, but completely uneventful case and PA was about 2/3 systemic, so I felt like there was a tiny bit of room.

NTG to offload the RV is not a bad idea, also, especially if your LV looks like its hurting, diastolic dysfunction of the LV? maybe the lusitropy of your inotrope will benefit there as well.

 

[RxBoy]

this guys will own (not rent) his tube. the only way the anesthesiologist will kill him is on induction or re-induction (i.e. failed extubation).

keeping in mind that he will not tolerate unclamping well (when was your TEE in?), but I wouldnt expect to see baseline RV disfunction to that extent if the intraop care was optimized. maybe i underestimate how many people walk around with severe RV dysfunction.

I tried to spare the details of the case because there were so many intraop issues and I figured I'd focus on the extubation but it was a pretty intersting case.

We prepared for the unclamp. We started a bicarb drip, hyperventilated and preloaded the pt. We had dobutamine/epi on standby. Vascular was nice and did a gradualy unclamp instead of the all or nothing technique most of them do. It was actually tolerated surprisingly well. I did question my attending why bicarb if we know it will cause CO2 buildup. He told me that its the pH that is worrisome in pulm HTN and controlling it is more important than the PaCO2. We never did use dobutamine.

However, it was actually shortly after incision where this guy almost died. His BP tanked bad. I honestly don't what caused it but I suspect it had something to do with increased PVR because the RV was hugging the LV like a sandwich. He needed a couple small boluses of epi and it got him back. Throughout the case, the TEE looked like the heart chambers were inverted because the RV was about the same size and thickness as the LV and very circular.

The main reason I was pushing for extubation was because surgery went pretty uneventful with minimal fluid shifts and EBL. Our ICU has so many extubation criteria protocols bull that it makes extubation slow and tedious. Plus our surgeons love trach'ing prolonged intubations.

 

[Idiopathic]

sounds like a good one. these are the cases that make you better.

 

[RxBoy]

.

 

[dhb]

Blow off CO2 and oxygenate well with vent -> get pt to breath on their own-> Pt gets light as anesthetic wears off-> PAP pressures increase, hypoxia and hypercarbia insue->PAP pressures skyrocket->Deepin pt, blow off CO2 and oxygenate with vent. Cycle repeats.

The problem here is that you are watching a PA tracing, the same probably happens to him every night when he sleeps.
Anyhow i would have done a good TAP block pre-inscision minimal opioids (i've done one with 10mcg of sufenta) and let him blow of the gas on pressure support in the PACU.

 

[RxBoy]

The problem here is that you are watching a PA tracing, the same probably happens to him every night when he sleeps.
Anyhow i would have done a good TAP block pre-inscision minimal opioids (i've done one with 10mcg of sufenta) and let him blow of the gas on pressure support in the PACU.

TAPblock, interesting never thought about it for vascular cases. It makes sense because there really isn't too much of a visceral component to the dissections. However I can imagine it will not cover the inferior aspects of the femoral cutdown incision.