Severe pulmonary hypertension for elective surgery.

[fakin' the funk]

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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.

Great post. Thanks for your input!

 

[OB1🤙]

I'll take this opportunity for my biannual public service announcement that patients with *true* horrendous pulm htn (not the patient in this case) do very well with carefully titrated spinal catheters.

 

[Noyac]

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.

Nice post. Thanks
My thoughts are that sometimes the pts with anaphylaxis may develope PHTN in the course of the reaction. What's your thoughts on this?

 

[partydoc]

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.

Not at my shop. They're some of the worst bc they think they know it all.

 

[bigtuna]

Nice post. Thanks
My thoughts are that sometimes the pts with anaphylaxis may develope PHTN in the course of the reaction. What's your thoughts on this?

Thats interesting. I believe that some of the mediators of anaphylaxis that are released from mast cells can cause increased PA pressures and that certainly would be poorly tolerated in someone with pre-existing pulm htn.

 

[GravelRider]

Thats interesting. I believe that some of the mediators of anaphylaxis that are released from mast cells can cause increased PA pressures and that certainly would be poorly tolerated in someone with pre-existing pulm htn.

So systemic vasodilation and pulmonary vasoconstriction by the same mediators or are there different mediators in the lung? I would think that there is some pre-existing condition in the patient that led to severe pulmonary hypertension in an anaphylactic reaction since you certainly don't see it in everyone. Or that it is a medication specific reaction like you can see with protamine. Either way, it seems to me that anaphylaxis with severe/sudden pulm htn would be a pretty bad downward spiral for the patient that would be difficult to reverse no matter how much epi you give.

 

[deleted171991]

Especially since epi is a pulmonary vasoconstrictor. 🙂

 

[GravelRider]

I dare you not to give epi in anaphylaxis 😉

 

[Arch Guillotti]

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.

Nice post, thanks!

 

[Arch Guillotti]

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.

Exactly, just do the case and keep it simple. the patient as described is a dime a dozen.

 

[anes121508]

So systemic vasodilation and pulmonary vasoconstriction by the same mediators or are there different mediators in the lung? I would think that there is some pre-existing condition in the patient that led to severe pulmonary hypertension in an anaphylactic reaction since you certainly don't see it in everyone. Or that it is a medication specific reaction like you can see with protamine. Either way, it seems to me that anaphylaxis with severe/sudden pulm htn would be a pretty bad downward spiral for the patient that would be difficult to reverse no matter how much epi you give.

Interesting you brought up the protamine thing, because that's exactly where my mind was heading...recently reading about type 3 protamine reactions being thromboxane A2 mediated causing severe pulmonary vasoconstriction. Wonder if it's similar

 

[Mman]

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.

I always greatly appreciate a person's primary doc (or specialist) that has a concern preop to come find me and chat or give me a call. You obviously know the patient better than I do and can provide me info that isn't as easy to glean from a chart. If I know everything about a patient, I can figure out an anesthetic plan that gives them the best chance to do well.