Severe pulmonary hypertension for elective surgery.

[Chloroform4Life]

Pt is 73yo M with severe pulm htn scheduled for hernia repair.

Pt has hx of COPD, CAD, and a-fib. Heart cath from a month ago shows pulmonary artery pressure in the 60s and about 60% stenosis of LAD that did not meet criteria for intervention. Echo showed nl LV EF, moderate TR, and severe pulm HTN. Pt can climb a flight of stair, but occasionally uses 2L O2 at home.

Pt went to see cardiologist prior to procedure, who wrote a note saying patient is at high risk for general anesthesia and recommends a spinal for the case. Pt is now in your pre-op area.

Go!

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[deleted171991]

GA-LMA on PCV/PSV. Or propofol MAC + field block by surgeon.

Almost forgot: retrograde intubation.

 

[nimbus]

60's not bad. GA with 100% FiO2 is good for pulm htn. Proceed.

 

[psychbender]

As long as the pressure in the 60s isn't the PA diastolic, that's not so bad. GA, avoid all the usual things that increase pulmonary vascular resistance, have the surgeon localize well, and give some non-opioid analgesics to supplement and decrease his post-op opioid requirement.

 

[caligas]

Pt is 73yo M with severe pulm htn scheduled for hernia repair.

Pt has hx of COPD, CAD, and a-fib. Heart cath from a month ago shows pulmonary artery pressure in the 60s and about 60% stenosis of LAD that did not meet criteria for intervention. Echo showed nl LV EF, moderate TR, and severe pulm HTN. Pt can climb a flight of stair, but occasionally uses 2L O2 at home.

Pt went to see cardiologist prior to procedure, who wrote a note saying patient is at high risk for general anesthesia and recommends a spinal for the case. Pt is now in your pre-op area.

Go!

Agree with others.

If you have trouble, consider milrinone, nitric oxide if available

 

[deleted171991]

Agree with others.

If you have trouble, consider milrinone, nitric oxide if available

If you have trouble, first consider fixing hypoxia, hypercarbia, pain.

 

[sevodex1]

If you have trouble, first consider fixing hypoxia, hypercarbia, pain.

Why is a spinal/ epidural not an option here if patient was amenable?

 

[urge]

pent sux tube

 

[deleted171991]

Why is a spinal/ epidural not an option here if patient was amenable?

Because the last thing you need in pulmonary hypertension is a drop in preload or systemic hypotension, spinal is out. Carefully-dosed epidural should be fine.

 

[GravelRider]

We don't know where the hernia is? Open vs laparoscopic? How big is the hernia? I assume it's not strangulated given the patient had time to see a cardiologist. If this were truly a severe pulmonary hypertensive patient (like on Flolan or another vasodilator) then let's first make sure we are doing this procedure for the right reason because severe pulmonary hypertension is an end stage disease. If it's an open procedure and the hernia small enough, you could do local and a smidge of versed (again, assuming severe end stage pulmonary hypertension).

A lot of ways to do this, but I agree the pulmonary pressures are high, but not the worst I've ever seen and whatever way you do the procedure, just do things to avoid making the pulmonary pressures worse and maybe keep some milrinone handy to ward off the spirits.

 

[vector2]

What's the right heart look like on echo? If it's still banging, let him breathe a little sevo then 1/2 dose prop/sux/tube. Use a little bump of vaso here and there for hypotension. Multimodal opioid sparing analgesia for post-op. If right heart sucks, precedex/ketamine MAC and wide local infiltration by surgeon.

I can still remember a lap gastric sleeve I had a few months ago on a 375lb lady with primary pulm HTN (baseline pulm systolics 70-80s) who had a remodulin pump. Surgeons and cards said she had to have the sleeve for weight loss or she'd die cause her OSA was making her right heart that much worse. She had had a RHC the day before surgery and cards left the cordis in so we floated a swan preop. Her PA systolics got up to >110 during closing and she required multiple epi/vaso pushes along with milrinone load/infusion and nitric to keep her right and left pressures from equalizing and her right heart from failing. Woke her up in the OR with the tube still in on a whiff of precedex and extubated her in the unit 30 min later to 4L O2. If she can live through a laparascopic procedure then this guy is a chip shot.

 

[drmwvr]

milrinone shouldn't be casually entered into with a patient like this, imo. The half life and not unlikely requirement to support blood pressure is a hassle, especially in a patient that can be done under careful MAC or epidural. Better to not need it.

The surgeon needs to know that this is not a case to take his time on as well.

 

[GravelRider]

milrinone shouldn't be casually entered into with a patient like this, imo. The half life and not unlikely requirement to support blood pressure is a hassle, especially in a patient that can be done under careful MAC or epidural. Better to not need it.

The surgeon needs to know that this is not a case to take his time on as well.

I agree that milrinone is not to just be started without thought. That's what makes severe pulmonary HTN such a sh*tty disease. You often don't have good options when things go bad...especially if the RV starts to fail. We talk about inhaled nitric oxide, but the reality is that not every place has those capabilities and it is cumbersome and expensive to use.

 

[Ignatius J]

Propofol, LMA, Sudoku.

 

[Chloroform4Life]

Patient is adamant about having a spinal because his cardiologist told him general anesthesia is contraindicated due to his "pulmonary condition"

Cath report states pulmonary pressure in the 60s and did not specify systolic, diastolic, or MAP. Pt lives on second floor and displays >4 mets. Occasional O2 use is for COPD. Pt is on dabigatran for A fib and was told to stop it 48 hours prior to surgery by surgeon.

 

[Ignatius J]

Patient is adamant about having a spinal because his cardiologist told him general anesthesia is contraindicated due to his "pulmonary condition"

Cath report states pulmonary pressure in the 60s and did not specify systolic, diastolic, or MAP. Pt lives on second floor and displays >4 mets. Occasional O2 use is for COPD. Pt is on dabigatran for A fib and was told to stop it 48 hours prior to surgery by surgeon.

I give him the speech about spinals and how they last a good bit and not ideal for outpatient surgery because of their duration. Would need to look up the waiting period for dabigatran too.

 

[Mman]

If she can live through a laparascopic procedure then this guy is a chip shot.

Sort of. But with us it's all about odds. Just because a high risk patient survived a procedure doesn't mean a slightly lower risk patient will always survive. We take nearly dead people and get them through big procedures all the time, but occasionally bad things happen to even moderate risk patients (even if you do everything right).

For this case I agree a GA will probably go just fine. probably

 

[deleted171991]

Patient is adamant about having a spinal because his cardiologist told him general anesthesia is contraindicated due to his "pulmonary condition"

Cath report states pulmonary pressure in the 60s and did not specify systolic, diastolic, or MAP. Pt lives on second floor and displays >4 mets. Occasional O2 use is for COPD. Pt is on dabigatran for A fib and was told to stop it 48 hours prior to surgery by surgeon.

Patient can have his anesthesia performed by his cardiologist, if he wants, but he's not getting a spinal from me.

 

[GravelRider]

Pt is able to achieve >4 mets is a big piece of information. I see no contraindication to GA here.

 

[Chloroform4Life]

Here is another kicker...

An anesthesiologist in your group saw the patient, agreed to do spinal, but patient has to be off dabigatran a bit longer.

So patient went home, comes back 3 days later, and is now your patient.

 

[OB1🤙]

ASRA says 5 days for pradaxa, so GA it is.

 

[Chloroform4Life]

ASRA says 5 days for pradaxa, so GA it is.

3 plus he was already off for 2 so thats 5

 

[fakin' the funk]

Pt is 73yo M with severe pulm htn scheduled for hernia repair.

Pt has hx of COPD, CAD, and a-fib. Heart cath from a month ago shows pulmonary artery pressure in the 60s and about 60% stenosis of LAD that did not meet criteria for intervention. Echo showed nl LV EF, moderate TR, and severe pulm HTN. Pt can climb a flight of stair, but occasionally uses 2L O2 at home.

Pt went to see cardiologist prior to procedure, who wrote a note saying patient is at high risk for general anesthesia and recommends a spinal for the case. Pt is now in your pre-op area.

What is the RV systolic function?

What is this patient's normal systemic BP?

 

[OB1🤙]

3 plus he was already off for 2 so thats 5

Oh I didn't see your second post.

Yeah, would like to know the RV function and systemic BP at the time of the measurement of PASP.

Honestly, PASP in the 60s doesn't worry me much, unless systemic pressure at the time is like 80-90. Assuming he's at least normotensive, you can do this case pretty much however you want. I would have no problem doing an isobaric bupi spinal on this guy, but I wouldn't do it just because some clown cardiologist thought I should.

GA/LMA/generous local/sudoku as mentioned previously sounds like a fine plan.

 

[GravelRider]

If the patient is hell bent on a spinal then explain the risks and benefits of all the options and have the patient decide. Explain that the point of the spinal is to avoid GA and that she will be pretty much awake for the majority of the procedure. Reassure the patient that GA is a perfectly safe option and I bet that once the patient hears "awake the whole time," she will change her mind.

 

[Chloroform4Life]

RV dilated, systolic function low normal. Systemic BP 140s/80s

 

[fakin' the funk]

All the R sided numbers and "severe pulm HTN" and the clinical picture don't really add up. With that sort of cardiac function, he ought to have better functional status.

It's almost like there's a pulmonary process going on too...

Any numbers on his COPD?

It kind of doesn't matter anyway.

Prop/LMA, sevo or des in O2/air, local by surgeon, next case

 

[Chloroform4Life]

So yeah, his functional status isn't as bad as I thought it would be with all the hoopla his cardiologist put him through.

He really wanted a spinal. The case is posted as a spinal, another anesthesiologist already okayed the spinal, his case has already been rescheduled so that he can be off his blood thinner long enough to have the spinal. So he got a spinal.

A line in pre-op. Diluted vasopressin and epinephrine ready in front shirt pocket. Spinal with 12.5mg 0.75% hyperbaric bupivacaine. Systolic BP decreased from 180s to 140s after spinal. No treatment for BP needed througout case. Patient was happy and discharged home later that day.


Although some anesthesiologists may consider severe pulm HTN a relative comtraindication to spinal, it is controversial and there is no good evidence to support or refute its use. There are case studies showing complications from it and case studies showing its safe use. There are also case studies showing complication from general anesthesia in patients with severe pulm HTN.

The fact that this guy had relatively good functional status made the decision to comply with everyone else's plan easier to swallow. If he had poor functional status, I would have done a bilateral TAP block.

 

[deleted162650]

The classic teachings of "contraindications to spinal" for AS, pHTN, etc. are pretty stupid in my mind. It's not the spinal that's contraindicated, it's the potential HD changes (pre-load and SVR drop) associated with a spinal which present with induction of GA as well. Pre-Op A-line and pressors either in line already or in the shirt pocket can damn near completely mitigate the HD changes associated with a spinal. Time to start using our brains and the tools at our disposal, and not cling to dinosaur era teachings.

 

[deleted9493]

I was going to say, TAP is a great option but with this information, I wouldn't feel badly about neuraxial or GA.

 

[deleted171991]

Whoever approved this, for spinal, should have done it. I would have just switched rooms/cases.

@SaltyDog , the problem with the "classic" teachings is exactly that they are classic, as in standard of care. In another country, I would swim against the current, and take risks; here it's just not worth it.

The problem is also that patients lie all the time (about their exercise tolerance, NPO status etc.) especially when they know that telling the truth will not get them what they want. So I would take those 4 METs with a lot of salt, unless he climbs a flight of stairs in my presence. There was recently a case in the forum about a patient who lied about his recent chest pains, and had a periop MI.

 

[deleted162650]

I was going to say, TAP is a great option but with this information, I wouldn't feel badly about neuraxial or GA.

I don't like the TAP idea as a surgical anesthetic. I think it's a great idea for post-op pain and minimizing opioids both intra and post-op, but I just don't find them to be reliable enough to hang my hat on as a surgical anesthetic. I would really hate to be forced into a position where the TAP is painfully inadequate (pun intended), and now you have to convert to a GA under less than ideal conditions.

Especially when you want to keep sedation minimal as to not risk elevated CO2, the TAP is no bueno in my book.



Or maybe I just really suck at TAPs??

 

[Noyac]

As long as the pressure in the 60s isn't the PA diastolic, that's not so bad. GA, avoid all the usual things that increase pulmonary vascular resistance, have the surgeon localize well, and give some non-opioid analgesics to supplement and decrease his post-op opioid requirement.

Just curious, why are you so interested in decreasing opiod requirements? Are you concerned with deceased respiratory drive leading to increased CO2 followed by increased PVR?
My thoughts are that this is a hernia. I can not remember doing a hernia repair that required more than a minimal amount of fentanyl and some local. I am even doing Tap blocks for some of these now. But they are not really that necessary.
We do pts like this one every day. PAP of 60+ is now routine. I wouldn't even worry about giving him 100% O2. It's not necessary but it's fine to do.
I'd place an LMA as usual and let the pt breath as usual. No support. Not needed. Just don't drive their CO2 up above 50ish.
My $.02

 

[Noyac]

Agree with others.

If you have trouble, consider milrinone, nitric oxide if available

It's a hernia!

 

[Noyac]

Why is a spinal/ epidural not an option here if patient was amenable?

Because it's stupid. Stupid because it's overkill.

 

[Noyac]

Because the last thing you need in pulmonary hypertension is a drop in preload or systemic hypotension, spinal is out. Carefully-dosed epidural should be fine.

Do spinals all the time in these pts but for different cases. No big deal. Just don't be stupid.

 

[PainDrain]

I agree with others in that I would probably opt for GA. Not so much out of fear of the spinal leading to a death spiral but because it's pretty standard to avoid in severe pulm HTN. The other thing I am curious about is the root cause of his pulmonary Hypertension? Seems like he has a good functional status and not all "pulmonary hypertension" behaves the same.

Another option that is well described is paravertebral blocks for hernia repair. It avoids hypotension one may see after traditional neuraxial blocks.

 

[nimbus]

As a dinosaur who still routinely uses pa catheters for pump cases, I've seen PA pressures drop from 60 to 35 with a little deepening of the anesthetic, eg 2ml of fentanyl or increasing the forane from 0.5 to 1%. Maybe the patient was nervous during his right heart Cath. I wonder what 30mg of propofol would have done to that number.

 

[Noyac]

This pt only occasionally uses O2. Does this concern anyone?

 

[fakin' the funk]

Pt went to see cardiologist prior to procedure, who wrote a note saying patient is at high risk for general anesthesia and recommends a spinal for the case.

I know this is new to no one on this forum, but it continues to amuse me that consultants make recommendations about one course of therapy or another when they have ZERO BASIS ON WHICH TO MAKE THE RECOMMENDATION. Amazing. A cardiologist literally has no idea how a spinal vs general affects preload, afterload, SVR, PVR, CO2-ventilation relationship, pulmonary mechanics, etc, etc.

 

[fakin' the funk]

60% stenosis of LAD that did not meet criteria for intervention.

Teaching point not previously mentioned: the fact that it's the LAD that is diseased (and NOT the RCA, which perfuses the RV) is somewhat encouraging.

 

[deleted59964]

GA - LMA - tap block - letter to cardiologist - stfu

 

[deleted59964]

I don't like the TAP idea as a surgical anesthetic. I think it's a great idea for post-op pain and minimizing opioids both intra and post-op, but I just don't find them to be reliable enough to hang my hat on as a surgical anesthetic. I would really hate to be forced into a position where the TAP is painfully inadequate (pun intended), and now you have to convert to a GA under less than ideal conditions.

Especially when you want to keep sedation minimal as to not risk elevated CO2, the TAP is no bueno in my book.



Or maybe I just really suck at TAPs??

Tap works on the abdominal wall not the viscera

 

[Mman]

GA - LMA - tap block - letter to cardiologist - stfu

I actually did email a cardiologist once about their consult. I can't recall all the details, but it was reasonably done. Didn't tell me how to do the anesthetic, just commented on the patient and their risk factors and what not. Last line at the end said this patient should continue on their beta blocker throughout the periop period. Only problem was the patient was never on a beta blocker at any point. They weren't on one day of surgery. The med list on the cardiologist note also didn't list a beta blocker. I mean if you think they need to be on one, start it. If you think they don't, they don't. But when you tell me to make sure we continue a therapy the patient was never on I kinda got a small problem.

 

[psychbender]

Just curious, why are you so interested in decreasing opiod requirements? Are you concerned with deceased respiratory drive leading to increased CO2 followed by increased PVR?
My thoughts are that this is a hernia. I can not remember doing a hernia repair that required more than a minimal amount of fentanyl and some local. I am even doing Tap blocks for some of these now. But they are not really that necessary.
We do pts like this one every day. PAP of 60+ is now routine. I wouldn't even worry about giving him 100% O2. It's not necessary but it's fine to do.
I'd place an LMA as usual and let the pt breath as usual. No support. Not needed. Just don't drive their CO2 up above 50ish.
My $.02

I mention it solely because some of the people with whom I work are real winners, who, unless I specifically told them not to do it, would give 2mg dilaudid and 250mcg fentanyl as soon as I stepped out to see the next patient, be dumbfounded that the pt stopped breathing, and let the pt sit apneic for several minutes to let the CO2 rise to restart spontaneous ventilation. We also had some PACU nurses that thought orders were suggestions, and they could just give however much of the drug they wanted, but the worst offender was transferred out after an incident with a hospital VIP.

 

[Noyac]

Teaching point not previously mentioned: the fact that it's the LAD that is diseased (and NOT the RCA, which perfuses the RV) is somewhat encouraging.

Good point.

 

[Noyac]

I mention it solely because some of the people with whom I work are real winners, who, unless I specifically told them not to do it, would give 2mg dilaudid and 250mcg fentanyl as soon as I stepped out to see the next patient, be dumbfounded that the pt stopped breathing, and let the pt sit apneic for several minutes to let the CO2 rise to restart spontaneous ventilation. We also had some PACU nurses that thought orders were suggestions, and they could just give however much of the drug they wanted, but the worst offender was transferred out after an incident with a hospital VIP.

I guess I forget how dumb some nurses can be. It so nice not having to work with these people.

 

[GravelRider]

It's a hernia!

This is the best point. It's a freakin' hernia and she can achieve >4 METS. She'll do fine unless you do something to actively try to kill her. Getting all fancy with non-routine techniques without good reasons is likely to do more harm than good.

As a former internist, I can tell you that they have really no idea about different anesthetic techniques. We had a vague sense that it can cause hypotension from ICU experiences, but beyond that it is really completely out of the scope of practice for any internist or subspecialist to determine anesthetic technique.

 

[bigtuna]

Non anesthesiologist here. I'm an intensivist and run a pulmonary hypertension service. It seems like one of my PH patients is getting a procedure/surgery that requires some form of anesthesia every few weeks.

As previously mentioned, this is a way different beast than a patient with bad pulmonary arterial hypertension with an RV thats on the edge of failing. When my patients that are on prostanoid infusion need general anesthesia I almost always bring them into the ICU a day or two ahead of time to get a central line in place, optimize hemodynamics, possibly start dobutamine or milrinone. Patients that are on other meds may need to be converted to IV prostanoid before going to the OR.

My experience is that these patients generally tolerate general, spinal, epidural, MAC pretty well if the condition is well characterized going into the procedure. The rockiest time is usually 24-72 hours post op when they start mobilizing all that fluid they got in the OR. For a big surgery like a bowel resection or something I sometimes (not always) like to keep them intubated until we are past that point.

I am very careful not to request a certain mode of anesthesia but I do try to discuss things at length with the anesthesiologist and have been asked to come into the OR on multiple occasions (including all deliveries by pregnant women with PAH). The general consensus over the years is that spinal is best avoided in the sickest patients but every situation is different.

One amusing tidbit is that I have come across at least 5 patients over the years that have been labeled as having anaphylaxis to induction agents or paralytics because they coded/crashed after anesthesia induction. Only later were they diagnosed with PAH that I am fairly certain was the cause of their instability after induction.

 

[vector2]

This is the best point. It's a freakin' hernia and she can achieve >4 METS. She'll do fine unless you do something to actively try to kill her. Getting all fancy with non-routine techniques without good reasons is likely to do more harm than good.

As a former internist, I can tell you that they have really no idea about different anesthetic techniques. We had a vague sense that it can cause hypotension from ICU experiences, but beyond that it is really completely out of the scope of practice for any internist or subspecialist to determine anesthetic technique.

It's amusing how many specialties other than anesthesia (ranging from med to surgery to peds to ob) think they're intimately familiar with anesthesia despite never having performed an anesthetic in their lives. The only specialty I trust with their anesthetic opinion regarding a sick pt are ACS/trauma/surg critical care guys. They at least have half a brain.