PULMONARY

HYPERTENSION
& ANESTHESIA
Dr. wesam farid Mousa
Dr. Salwa hassan khalil
Anesthesia & Surgical ICU Department
Faculty of Medicine
Tanta University

objectives

Definition.
Classification.
Pathogenesis.
Diagnosis and treatment of PH.
Peri-operative management of PH
crisis.
PH in special situations.

Pulmonary circulation is a high flow, low resistance

circuit capable of accommodating the entire right
ventricular output at one-fifth the pressure of the
systemic circulation.

DEFINITION
PH is defined as a mean pulmonary artery pressure greater
than 25 mmHg at rest based upon right heart
catheterization measurements .
A mean pulmonary artery pressure of 8 to 20 mmHg at rest
is considered normal,.

Cor pulmonale
RV enlargement
secondary to any
underlying cardiac or
pulmonary disease.

Pulmonary hypertension
is the most common
cause of cor pulmonale.

Epidemiology
An estimated 15 to 52 people in 1 million
have PAH world wide.
Armin Sablotzki1, Hans-Juergen SeyfarthJochen Gille1, Stefan Gerlach1, Michael Malcharek1 and Elke Czeslick.

Critical Care and Pain Medicine, Klinikum St. Georg gGmbH,

Germany Department of Pneumology, Universittsklinikum Leipzig AR, Germany
Clinic for Anesthesiology and Critical Care Medicine, Martin-Luther-University of Halle-Wittenberg, Germany2015

CLASSIFICATION

A distinction between
pre-capillary and post capillary PH is
fundamental to understand the vascular
and hemodynamic changes present in
patients with PH.

Pulmonary Hypertension: Define Lesion

Post-Capillary PH
(PCWP>15 mmHg; PVR nl)
PAH
Respiratory
Diseases
PE

VC

RA

RV

PA

Atrial Myxoma
Cor TriatriatumMV Disease

PC

PV

LA

PCWP<15 mmHg
PVR > 3 Wu

Ao

LVEDP

PV
compression
PVOD

Pre-capillary PH

LV

Systemic HTN
AoV Disease

Myocardial Disease

DCM,HCM,ischemic
CM
RCM,Obesity , others

CLASIFICATION
Degree of disease
Mild
Moderate
Severe

Mean PAP (mmHg)

40 - 25
55 - 41
55<

Pathogenesis of Pulmonary Arterial

Hypertension

NORMAL

REVERSIBLE DISEASE

IRREVERSIBLE
DISEASE

DIAGNOSIS OF PH
Symptoms of PH

Dyspnea
60%
Fatigue
19%
Near syncope/syncope
13%
Chest pain
7%
Palpitations
5%
Leg edema
3%

PHYSICAL EXAMINATION

Loud pulmonary component of the 2nd heart

sound P2 (increases PAP)
Left parasternal lift (RV heave=R sided
overload)
Systolic ejection murmur of TR
S3 gallop (advanced RV failure)
Signs of RV failure:
Jugular venous distention
Hepatomegaly
Perepheral edema

CLEAR LUNGS

:INVESTIGATIONS
Right heart catheterization is the gold standard
to confirm the diagnosis and establish the
. severity of PH
Transthoracic echocardiogram (TTE) remains
the method of choice for screening and
.assessing the PH when clinically suspected
Once the diagnosis is confirmed, other
diagnostic tools assist in establishing the
underlying etiology and clinical group to which
.the patient belongs

Diagnosis
condition

Associated

Echocardiography

Left ventricular systolic and

diastolic dysfunction

Left-sided valvular heart disease

CHD with systemic to pulmonary
shunt
X-ray chest, PFT
Interstitial pulmonary fibrosis
VV/QV scan, CTPA
pulmonary
Sleep study
Serological test
Lupus, scleroderma, HIV(
Liver ultrasound
Right heart Catheterisation

Postcapillary PH due to left heart

disease
Cardiac MRI
Over night Oxymetry

COPD, sarcoidosis
Chronic thromboembolic
disease
Obstructive sleep apnoea
ANA, HIV)
Portopulmonary hypertension
CHD with systemic to pulmonary
shunt

CHD, cardiomyopathies

PH with OSAH

ALGORITHM FOR INVESTIGATION OF SUSPECTED PH

TREATMENT OF PH
Goals of Therapy

Alleviate symptoms, improve exercise capacity and

quality of life

Improve cardiopulmonary hemodynamics and

prevent right heart failure

Delay time to clinical worsening

morbidity and mortality

TERAPUTIC TARGETS FOR PH

.ANESTHETIC MANAGEMENT OF PH
PH is a serious condition.
perioperative mortality of 7-24%.
Peri-operative morbidity 1442% includes:
Respiratory failure
Heart failure, dysrhythmias
Sepsis,
Renal insufficiency,
Myocardial infarction.

pre-operative evaluation:
Multidisciplinary team
anesthetists, surgeons,
pulmonologists, and cardiologists.

Patients suspected of having PH and ungraded severity are

at higher risk of peri-operative complications.
Elective surgery must be postponed till a proper pre-op
evaluation & optimization.

pre-operative evaluation:

Patient with established PH should be based on a risk

assessment :

functional state
severity of the disease
type of surgery.

WHO CLASSIFICATION OF FUNCTIONAL

STATUS OF PATIENT WITH PH

SIGNS OF DISEASE SEVERITY

Dyspnea at rest ( WHO- FC class 4)

Low cardiac output with metabolic acidosis

Hypoxemia

Signs of right heart failure

Syncope (poor prognosis)

Chest pain (secondary to RV ischemia)

Rapid progression of symptoms

6 minute walking test <300m.

PREOPERATIVE MANEGMENT

pre-operative evaluation:
A detailed history and physical examination should be
complemented with relevant investigations :
Laboratory tests, electrocardiography, chest
radiography, arterial blood gas analysis,
echocardiography,
recent right heart catheterization which is the gold
standard for diagnosis of PH.

PREOPERATIVE MANEGMENT
before surgery, mean PAP should be reduced to a
normal of 25 mm Hg.
Ideally

If substantial RV dysfunction is present, the advisability of

surgery should be reexamined.
Any chronic pulmonary hypertensive therapies that patients
are currently taking should be continued perioperatively to
avoid rebound PH
Short

acting anticoagulant like heparin should replace indirect

anticoagulant until the surgical procedure.

Avoid

anxiety, pain, and sympathetic stimulation.

Avoid

over sedation and hypoventilation.

Antibiotic

prophylaxis must be given.

INTRAOPERATIVE MANAGEMENT
Anesthetic and Hemodynamic goals for PH :

ANESTHETIC CONSIDERATIONS
Intraoperative basic treatment to avoid an increase of
pulmonary arterial pressure:
Luxury-oxygenation with inspiratory FiO2 0.6 1.0
Moderate hyperventilation (goal: PaCO2 30-35 mmHg)
Avoidance of metabolic acidosis (pH > 7.4)
Recruitment-manoeuver to avoid ventilation/perfusionmismatch.
Low-tidal-volume ventilation to avoid over-inflation of aveoli
(goal: 6 ml/kg ideal body weight)
Temperature management to maintain body temperature of
36-37 C
Goal-directed fluid- and volume-therapy with
hemodynamic monitoring

INTRAOPERATIVE MANAGEMENT
Optimize RV function and CO with adequate preload,
SVR, and avoid contractility, avoid myocardial
depressants
Consider pulmonary vasodilators to decrease RV
afterload
Maintain sinus rhythm.
It is good practice to remove air from intravenous
syringes
and lines

MONITORING
There is no strong evidence to suggest that any specific
type of monitoring has an influence on patient morbidity
and mortality.
The standard monitoring is considered sufficient for
minor & medium procedures in functional state 2.

All major interventions and those in functional state III

should be carried out under extended monitoring.
. Transesophageal echocardiography (TOE)
. pulmonary artery catheter

MONITORING
Invasive arterial monitoring before anesthetic
induction
Early recognition of hemodynamic instability.
Intermittent arterial blood gas sampling to check
adequacy of ventilation.
Right atrial pressure measurement (central venous
pressure)reflects the relationship of blood volume to
the capacity of the venous system and also reflects
the functional capacity of the right ventricle.

ANESTHETIC TECHNIQUES

All standard anesthetic techniques

can, in principle applied to patients with
PH

ANESTHETIC TECHNIQUES
Regional anesthetic techniques:
Not impairing spontaneous breathing
postoperative analgesic therapy
Nearly all patients with pulmonary hypertension receive
continuous anticoagulant therapy; this fact must be taken
under.
In severe PH or in diseases affecting the lung, patients
cannot be subjected to remaining in a flat position for long
period of time.
Regional anesthesia combined with careful GA to ensure
adequate oxygenation.

GENERAL ANESTHESIA

the main advantages are

Safe oxygenation , uncomplicated airway
management, and intraoperative selective pulmonary
vasodilation can if necessary easily be
administered through the breathing circuit.

GENERAL ANESTHESIA
All standard induction anesthetics can be used in
combination with opioids, as they have no influence on
pulmonary vascular resistance and oxygenation.
Ketamine may PVR due to catecholamine effect. However
patients with RV failure may be catecholamine depeleted.

Histamine-releasing muscle relaxants (atracurium ,

mivacurium) should be avoided for patients with PH, PVR.

GENERAL ANESTHESIA
Volatile anesthetic agents of concentrations up to 1
MAC can be administered without any negative effects
on pulmonary pressure and resistance.
Nitrous oxide better avoided as it may raise PVR.
So use balanced technique, mixing higher doses of
opioids and low-dose volatile anesthetic agents
,careful with stress response during intubation.

:During Extubation
Maintaining haemodynamic stability and adequate
.ventilation can be difficult
Deep extubation
May decrease SVR, contractility
Hypoxia and hypercarbia will increase PVR
Awake extubation
Can cause severe pulmonary vasoconstriction
Need tube tolerance without increased sympathetic
tone
Patient may need post-op ventilation with ICU

POSTOPERATIVE MANEGMENT

postoperative monitoring until pulmonary

pressures and right-sided heart functions have
stabilized at the preoperative level.

sufficient analgesic therapy in the form of continuous

regional anesthesia to avoids higher doses of opioidbased analgesics.

The specific therapy for PH should be resumed at the

preoperative dosage as soon as possible.

In the postoperative course, it is also advisable to

treat pressure elevations.

PERI-OPERATIVE MANAGEMENT OF PH CRISIS

PULMONARY HYPERTENSION WITH LAPAROSCOPY

Pneumoperitoneum with CO2 causes an increase in end tidal
carbon dioxide. Acidosis, arrhythmias ,decrease preload
PH crisis.
post operative benefits of laparoscopic surgery must be balanced
with intraoperative risk involved.
IAP to be maintained at 10-12 mm of Hg.
CO2 insufflation slow rate to attenuate abdominal stretch response
Temporarily deflate the abdomen if necessary.
Combined general with epidural anaesthesia
decreasing intraoperative anaesthetic requirement.
post operative pain relief.

PULMONARY HYPERTENSION WITH PREGNANCY

Mortality rate of 30% in patients with idiopathic PAH and

56% in patients with PH associated with other conditions.
GA associated with a four-fold increase in maternal
mortality
Physiological increase in blood volume causes volume
overload in the right heart may cause:
thromboembolic events.
cerebrovascular accidents.
General principals for high risk parturient.
Left lat. Position .

Fetal monitoring as IUGR due to hypoxemia and increased

Hct level.
Anticoagulation is usually recommended. LMWH.
Warfarin and Endothelin receptor antagonists are avoided
due to potential teratogenicity.
Elective CS before 32 Ws allows for better planning, a
.multidisciplinary team
.Oxytocine use low dose (10 units IV inf) slowly over 4-8 hr
Methergine absolute CI

SUMMARY

SUMMARY