Focused Review of Perioperative Care of Patients with Pulmonary Hypertension and Proposal of a Perioperative Pathway

Abstract

Morbidity and mortality risk increase considerably for patients with pulmonary hypertension (PH) undergoing non-cardiac surgery. Unfortunately, there are no comprehensive, evidence-based guidelines for perioperative evaluation and management of these patients. We present a brief review of the literature on perioperative outcomes for patients with PH and describe the implementation of a collaborative perioperative management program for these high-risk patients at a tertiary academic center.

Perioperative anesthetic considerations in patients with pulmonary hypertension undergoing non-cardiac and non-obstetric surgeries

“…The most important requirement for the management of pulmonary hypertensive crisis (intraoperative increased PAP) is to avoid anything that could increase RV afterload or decrease RV contractility [38,42]. Hence, we should try to treat and prevent hypoxia, hypoxemia, hypercarbia (due to sedation, analgesia, poor mask seal, and delayed intubation), acidosis (secondary to hypovolemia, infection, and decreased CO), hypothermia, atelectasis, hyperinflation (due to inadequate tidal volume or PEEP), and catecholamine release (due to pain, inadequate anesthesia, anxiety, and histamine release drugs) [3].…”

“…pressure [43][44][45][46]. Indeed, low-dose vasopressin (0.04 U/min) and dobutamine (2-5 mg/kg/min) restore coronary blood flow to the RV by increasing SVR [3,47]. However, dobutamine, being an inotrope, exacerbates systemic hypotension due to anesthetic (inhaled or intravenous)-induced systemic vasodilation [3].…”

“…Indeed, low-dose vasopressin (0.04 U/min) and dobutamine (2-5 mg/kg/min) restore coronary blood flow to the RV by increasing SVR [3,47]. However, dobutamine, being an inotrope, exacerbates systemic hypotension due to anesthetic (inhaled or intravenous)-induced systemic vasodilation [3]. Therefore, norepinephrine, which has both vasopressor and inotropic properties, is frequently preferred for intraoperative administration in patients with acute RV failure due to PH [26,48].…”

“…Patients with severe compensated PH might undergo minor surgery on an outpatient basis, while those undergoing major surgery should be cared for in an ICU by staff experienced in managing postoperative PH [3,16,49]. However, the general principle for postoperative management is that the patient should be fully monitored in the ICU and pressures should be maintained with the judicious use of vasopressors and inotropes, along with blood volume replacement to maintain a hemoglobin level ≥10 g/dL if needed [13].…”

“…The perioperative management of patients with PH requires a multidisciplinary approach, which is aimed at carefully optimizing hemodynamics (right ventricular [RV] preload, afterload, and contractility), minimizing risk factors, and aggressively treating complications [2]. However, there is lack of comprehensive evidence-based guidelines, applicable risk assessment, and perioperative management of patients with PH with respect to anesthetic management [3,4]. In fact, most recommendations are based on expert opinions or case series rather than well-designed randomwww.embse.org ized controlled trials.…”