Anesthesia Considerations 

Pulmonary Hypertension 

 

 

Considerations 

 

• Potential for acute perioperative right ventricular (RV) dysfunction & hemodynamic collapse

• Optimize pulmonary pressures & right heart function:

  • Avoid hypoxia, hypercarbia, acidosis, hypothermia, sympathetic stimulation (pain), high PEEP

  • Cautious fluid administration

  • Maintain RV perfusion

• Associated conditions (see table below) 

• Medication management:

  • Anticoagulation

  • Calcium channel blockers 

  • Vasodilators (e.g. sildenafil)

  • Prostacyclin analogs (e.g. epoprostenol/flolan)

  • Endothelin antagonists (e.g. bosantan)

  • Diuretics

• Need for invasive monitoring, optimized analgesia & post-op disposition

• Potential or R → L shunt through PFO: hypoxemia & paradoxical emboli 

 

 

Goals 

 

• Make all attempts to optimize pulmonary vascular resistance (PVR) before surgery

• Avoid ↑ in PVR (minimize pain, sympathetic stimulation, hypoxia, hypercarbia, acidosis, optimize airway pressures)

• RV failure management principles: 

  • Optimize RV rate & rhythm: sinus & normal-high rate 

  • Optimize RV filing 

  • Maintain RV perfusion & inotropy 

  • ↓ PVR 

 

 

Conflicts 

 

• Pulmonary hypertension & laparoscopy:

  • ↑ PaCO2, sympathetic stimulation = bad

  • Case is longer than open

• Ortho cases with cement, joint replacement (embolic risk)

• Hemodynamic stability vs need for RSI 

 

 

Pregnancy Considerations

 

• Hemodynamic goals:

  • Prevent ↑ PVR

  • Maintain intravascular volume & venous return

  • Avoid aortocaval compression

  • Maintain adequate systemic vascular resistance 

  • Avoidance of myocardial depression during general anesthesia 

• Mode of delivery:

  • Controversial

  • Multidisciplinary meeting required

  • Termination of pregnancy definitely an option as maternal mortality is high

  • Scheduled cesarean section in a controlled setting might be the optimal route

• Monitoring:

  • High acuity environment preferably in a center with cardiac surgery expertise

  • Standard CAS monitors + 5 lead ECG

  • Arterial line & central line essential

  • PAC a consideration but must weigh risk vs. benefits

• Anesthetic technique:

  • A carefully titrated epidural likely the best option

  • Avoid ↓ SVR & treat hypotension with fluids/pressors

  • Single shot spinal should be avoided as it can cause severe hemodynamic instability

  • Continuous spinal has been used successfully (slow & careful titration)

  • General anesthesia has been used successfully

  • Potential hazards of GA include ↑ PA pressure during laryngoscopy/intubation, adverse effects of PPV on venous return, & negative inotropic effects of certain anesthetic agents

  • May consider a gentle narcotic-based induction/maintenance, any fetal narcotic effects should be easily reversible 

  • Avoid ergotamine & carboprost; use oxytocin & misoprostol 

 

 

Managing Acute Episodes/Acute RV Failure = 4 Principles 

 

1. RV Rate & Rhythm: keep sinus & high-normal rate 

2. RV perfusion & inotropy: maintain with vasopressor/inotrope combo (e.g. norepinephrine & milrinone or epinephrine alone)

3. RV filling: optimize with CVP, PAC, TEE 

4. ↓ PA pressures: 

   • Avoid hypercarbia, hypoxemia, acidosis, hypothermia, high airway pressures 

   • Use pulmonary vasodilators: 

     • Nitric oxide: 20-40ppm 

     • Inhaled flolan

     • Milrinone: 0.25-0.75 mcg/kg/min; possible loading dose is 50mcg/kg over 10 min 

 

 

WHO Pulmonary Hypertension Classification