Anesthetic Considerations in Pulmonary Hypertension by Stephanie Grant for OPENPediatrics

Aug 24, 2023

Anesthetic Considerations in Pulmonary Hypertension by Stephanie Grant for OPENPediatrics

In this video, Dr. Stephanie Grant discusses the anesthetic management of patients with pulmonary hypertension.
2:58 Chapter 2: Case Example Part 1
3:40 Chapter 3: Pre-Operative Anesthetic Management
6:59 Chapter 4: Intra-Operative Anesthetic Management
11:50 Chapter 5: Post-Operative Anesthetic Management
12:28 Chapter 6: Case Example Part 2
Chapter 7: Pulmonary Hypertensive Crisis

Please visit: www.openpediatrics.org

OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children’s Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open access-and thus at no expense to the user.

For further information on how to enroll, please email: [email protected]

Please note: OPENPediatrics does not support nor control any related videos in the sidebar, these are placed by Youtube. We apologize for any inconvenience this may cause.

Content

10 ->

24.12 -> Anesthetic Considerations in Pulmonary Hypertension,

27.34 -> by Dr. Stephanie Grant.

30.7 -> Hello.

31.28 -> My name is Stephanie Grant and today I'm

32.946 -> going to be talking to you about pulmonary hypertension.

35.39 -> The goals of today's talk are to talk

37.01 -> about perioperative management of pulmonary hypertension,

40.01 -> including during the pre-operative, intra-operative,

42.46 -> and post-operative time.

44.15 -> We will also talk about pulmonary hypertensive crisis.

47.98 -> Background.

48.85 ->

52.35 -> Pulmonary hypertension is a rare disease in neonates, infants,

55.11 -> and children.

56.04 -> Patients with pulmonary hypertension

57.54 -> present for cardiac and non-cardiac surgery,

60.17 -> and for general anesthesia and sedation.

62.67 -> Pulmonary hypertension is associated

64.23 -> with significant morbidity and mortality,

66.51 -> and poses an increased perioperative risk.

69.18 -> Patients with pulmonary hypertension

70.77 -> have increased risk of arrhythmias, cardiac arrest,

73.5 -> and death during the perioperative time.

75.87 -> This graph depicts three different studies.

78.49 -> The small green bar, which is on the left of each grouping,

82.17 -> shows the Pediatric Perioperative Cardiac Arrest

84.57 -> Registry.

85.89 -> This depicted a study which involved all patients

88.77 -> regardless of diagnosis and regardless of surgery

91.26 -> that they were having.

92.88 -> The incidence of cardiac arrest in these patients

95.49 -> was very small at .014%, and of those patients,

99.81 -> the risk of death was .0036%.

104.13 -> The study depicted in the red bar

106.02 -> indicates a study of patients with pulmonary arterial

108.69 -> hypertension who had general anesthesia for procedures

111.9 -> in the cardiac cath lab and also for non-cardiac surgery.

116.13 -> The incidence of cardiac arrest in these patients was 1.17%,

120.42 -> and the incidence of death in these patients was .78%.

124.68 -> These studies indicate that the incidence of cardiac arrest

128.22 -> and death is significantly higher in patients

130.53 -> with pulmonary hypertension.

133.18 -> This study indicates that the perioperative complications

137.11 -> are directly related to the severity

138.759 -> of pulmonary arterial hypertension.

141.49 -> Patients with supra-systemic right ventricular pressures

144.58 -> have greater complications during surgery

147.43 -> than patients with less severe forms

149.38 -> of pulmonary hypertension.

151.33 -> The baseline supra-systemic pulmonary arterial hypertension

154.72 -> is a significant predictor of major complications

157.27 -> during anesthesia.

159.1 -> This table is a nonvalidated tool

161.56 -> that looks at patients who may have low risk or high risk

165.16 -> complications during general anesthesia.

167.75 -> The patients are grouped into low risk or high risk

170.08 -> based on patient factors, surgery factors,

174.19 -> as well as the anesthetic factors involved.

178.33 -> Case Example - Part 1.

179.905 ->

183.05 -> Let's look at a case as an example of a patient

185.3 -> with pulmonary hypertension.

186.86 -> The patient is a 15-year-old male

188.72 -> who is evaluated prior to an open reduction

190.97 -> internal fixation of his tibia.

193.34 -> The patient sustained this fracture

194.99 -> after falling while skateboarding.

196.952 -> The patient was diagnosed with pulmonary hypertension

199.16 -> one year ago after a syncopal event.

201.71 -> He reports occasional dyspnea on exertion,

204.02 -> but is otherwise doing OK.

206.06 -> His past medical history includes

207.68 -> idiopathic pulmonary hypertension.

209.75 -> He has never had surgery, and his medications

212 -> include Sildenafil, and he uses nasal cannula oxygen just

215.66 -> at night.

217.4 -> What is your anesthetic plan for this patient?

220.57 -> Pre-operative Anesthetic Management.

225.37 -> The pre-operative management for this patient and any patient

228.7 -> with pulmonary hypertension should include a visit

231.28 -> to the pre-op clinic if possible.

233.72 -> A thorough history and physical should

235.36 -> be performed for the patient, and review of any echo and cath

239.59 -> lab reports that the patient may have.

242.17 -> For a patient with an echo report,

244.45 -> it is important to look at the most recent echo report,

246.88 -> specifically looking at the patient's anatomy,

249.86 -> and if the patient has any pop-off.

252.3 -> A pop-off is a left to right shunt

254.71 -> which may convert to a right to left shunt

257.05 -> if the patient has an acute event,

259.57 -> and the right ventricular pressures

261.4 -> begin to increase in the heart and are greater

264.52 -> than the left pressures.

266.302 -> This is important because it serves

267.76 -> to decompress the right side of the heart

270.25 -> and to increase cardiac output.

273.05 -> On the echo report, it is also important to look

275.78 -> at the patient's function, look at the patient's

278.51 -> pulmonary arterial pressure as well as the right ventricular

281.69 -> pressure.

283.1 -> In our case example, looking at the echo report

285.56 -> we see that this patient has a flattened septal position

288.92 -> in systole, which is consistent with right ventricular

291.8 -> pressures greater than one half systemic levels.

294.71 -> This indicates that the patient does

296.21 -> have an increased risk for complications during surgery

299.51 -> due to the greater than one half systemic levels.

304.19 -> This patient also has qualitatively good

306.38 -> biventricular systolic function, which is a good sign.

309.9 -> On catheterization reports, it is

311.9 -> important to look at the pulmonary arterial pressure,

314.45 -> looking at the systolic, diastolic and mean levels.

317.552 -> Also, look at the right ventricular

319.01 -> pressure, the pulmonary vascular resistance,

322.17 -> the structure of the heart, the function of the heart,

326.03 -> to look at measured wedge pressures, as well

328.1 -> as the results of vasoactive testing.

330.78 -> For our sample patient, his cardiac catheterization report

334.25 -> indicated that at baseline, his right ventricle systolic

337.25 -> pressure was 72 millimeters mercury,

340.04 -> and systemic pressure was 100 millimeters mercury.

342.95 -> This indicates that his right ventricle pressure

345.08 -> is greater than one half systemic,

347.3 -> meaning that this places him at greater risk for complications

350.21 -> during general anesthesia.

352.25 -> During vasoreactive testing at baseline of 21% oxygen,

356.24 -> the patient had a mean pulmonary arterial pressure of 50,

359.21 -> and a pulmonary vascular resistance of 10.6.

362.57 -> During vasoreactive testing with 100% oxygen and exposure

366.17 -> to inhaled nitric oxide, both his mean pulmonary artery

369.35 -> pressure and pulmonary vascular resistance did decrease.

373.04 -> This was a mild decrease, but does

374.69 -> indicate that he does have vasoreactivity

377.63 -> within his pulmonary vasculature and would respond well

380.93 -> to inhaled nitric oxide or 100% oxygen

384.23 -> if he does have an acute event during surgery.

387.61 -> It is important to discuss the post-op plan

390.1 -> with the patient's cardiologist or an ICU physician.

393.41 -> It is important in these patients to minimize NPO times,

396.49 -> avoiding dehydration and decreased preload

399.19 -> during the pre-op time.

400.84 -> It is also very important to prepare emergency drugs

403.51 -> before the patient even enters the operating room.

406.12 -> These include having things such as inotropes,

408.88 -> including epinephrine, ready.

410.86 -> Inhaled nitric oxide available and in the operating room,

414.37 -> and to also consider ECMO on standby,

416.8 -> depending on the severity of the patient.

419.62 -> Intra-operative Anesthetic Management.

422.2 ->

424.71 -> For anesthetic management of this patient,

426.83 -> it is important to give an adequate premedication,

430.01 -> including a benzodiazepine, or even ketamine.

433.48 -> It's important to have a calm patient

435.14 -> because a crying, screaming, and agitated patient

437.63 -> will lead to increased pulmonary vascular resistance,

440.72 -> will lead to changes that will cause

442.37 -> an acute event for pulmonary hypertension.

445.55 -> If the patient is on a pulmonary vasodilator

447.68 -> such as a targeted therapy, it is

450.11 -> important to continue this medication

452.27 -> during the perioperative time.

454.79 -> The main goals of an anesthetic management

457.97 -> for patients with pulmonary hypertension

459.77 -> is to avoid increases in pulmonary vascular resistance

462.77 -> and avoid decreases in systemic vascular resistance.

466.34 -> Decreases in systemic vascular resistance

468.56 -> will lead to changes that cause decreased coronary perfusion

471.59 -> pressure and decreased oxygen delivery to the myocardium,

475.34 -> leading to ischemia, which may precipitate

477.98 -> a pulmonary hypertensive crisis.

480.35 -> For these patients, it is important to place standard ASA

483.26 -> monitors on the patient before induction.

485.87 -> And depending on the case and the patient,

488.78 -> to determine if an arterial line is needed.

492.83 -> Induction of these patients, it's

494.46 -> important to use a balanced anesthetic technique.

497.7 -> It's important to maintain a dedicated

499.83 -> IV if the patient comes to the operating room

502.86 -> already on a pulmonary vasodialator infusion.

506.87 -> Stopping this infusion, even for a brief second for induction,

511.16 -> can lead and precipitate to an acute pulmonary hypertensive

514.82 -> crisis.

515.71 -> An IV induction is preferred for these patients.

518.51 -> However, it is possible to do an inhalational induction

521 -> on these patients, if the patient has

523.19 -> adequate ventricular function.

525.74 -> The potential problem with an inhalational induction

528.14 -> is that if you lose the patient's airway,

530.59 -> the patient will begin to hypoventilate,

532.909 -> become hypercarbic.

534.5 -> This will lead to acidosis and eventually hypoxia,

538.16 -> which is going to cause the patient

540.17 -> to have an acute pulmonary hypertensive crisis.

544.13 -> The ideal anesthetic for pulmonary hypertension

546.78 -> includes one in which it causes pulmonary vasodilation,

551.07 -> maintains cardiac contractility, maintains systemic vascular

554.52 -> resistance, and also maintains cardiac output.

557.46 -> However, an ideal anesthetic for pulmonary hypertension

560.04 -> does not exist.

562.509 -> We have our drugs that we are very familiar with,

564.55 -> our volitile anesthetics and our IV anesthetic agents.

568.54 -> However, each is not a perfect anesthetic

571.75 -> for pulmonary hypertension.

573.61 -> Most have good qualities, but also

575.8 -> have an element that causes hemodynamic instability,

579.01 -> potentially for a patient with pulmonary hypertension.

581.92 -> The use of ketamine in patients with pulmonary hypertension

584.92 -> has been controversial in the past.

587.36 -> However a study by Dr. Paul Hickey at Boston Children's

590.44 -> Hospital indicated that ketamine does not

592.51 -> change the pulmonary vascular resistance,

594.91 -> unless the patient also is hypoventilating and becomes

599.44 -> hypercarbic.

601.01 -> A balanced anesthetic technique is the best technique

604.03 -> for patients with pulmonary hypertension.

606.25 -> This technique includes sub-anesthetic doses

609.1 -> of multiple anesthetics in order to achieve an anesthetic state.

614.42 -> The anesthetic management for airway of these patients

617.78 -> is selected based on the procedure.

620.67 -> If the patient is to be intubated,

622.73 -> there needs to be an adequate depth of anesthesia

625.01 -> before intubation is achieved.

627.2 -> An LMA can be used, however it is

629.3 -> important to avoid hypoventilation in order

632.18 -> to avoid hypercarbia, which can lead

634.22 -> to increases in pulmonary vascular resistance.

637.31 -> For maintenance of these patients,

638.84 -> it is important to continue the depth of anesthetic that

642.26 -> is adequate for the stimulus.

644.3 -> A volatile inhalational anesthetic

646.43 -> or a total intravenous anesthetic

648.41 -> can be used for maintenance of these patients.

650.9 -> For ventilation of these patients,

652.82 -> it is very important to avoid hypercarbia and respiratory

655.94 -> acidosis, which both can lead to increases

658.58 -> in the pulmonary vascular resistance

660.92 -> as well as avoiding excessively low or high tidal volumes,

665.03 -> which both can increase the pulmonary vascular resistance.

668.38 -> And it is also important to avoid

670.34 -> excessive low or high peak inspiratory pressures, which

673.55 -> will lead to an increased pulmonary vascular resistance.

676.49 -> As well as avoiding increases in PEEP,

679.67 -> which will increase pulmonary vascular resistance.

682.86 -> The emergence of these patients.

684.3 -> It is very important to minimize noxious stimuli.

687.86 -> Suctioning the endotracheal tube or the patient's oropharynx

690.95 -> should be done while the patient is

692.87 -> under a deep plane of anesthesia.

696.08 -> Tracheal suction and oropharyngeal suction

698.81 -> have been known to precipitate an acute pulmonary hypertensive

702.89 -> crisis.

704.21 -> It is very important to have a smooth and calm extubation

706.595 -> of these patients.

707.345 ->

710.23 -> Post-operative Anesthetic Management.

715.06 -> It is important to have adequate post-op monitoring for patients

718.21 -> with pulmonary hypertension.

720.1 -> If the patient is to be monitored

721.66 -> in the PACU versus the ICU depends

724.48 -> on patient factors, surgical factors,

727 -> and anesthetic factors.

728.84 -> It is very important in the post-operative course

730.9 -> to provide adequate analgesia and antiemesis,

734.26 -> and also to avoid hypoxia, hypotension, and hypovolemia.

738.97 -> It is very important to be prepared

740.74 -> when you have a patient with pulmonary hypertension,

742.96 -> and to always stay two steps ahead of potential changes

745.87 -> that can occur in these patients.

748.91 -> Case Example - Part 2.

750.71 ->

753.99 -> Let's go back to our sample case--

755.66 -> a 15-year-old male with past medical history

757.64 -> of pulmonary hypertension for an ORIF of his tibia.

761.6 -> The patient received a pre-med consisting of midazolam,

764.69 -> and on induction a balanced anesthetic technique

766.91 -> was used with fentanyl, ketamine, propofol,

769.41 -> and rocuronium.

770.87 -> The patient remained stable on induction.

773.36 -> He had an easy intubation, and was also hemodynamically

776.15 -> stable on-- during intubation.

779.5 -> However, 30 minutes after incision, the patient suddenly

782.74 -> had a decrease in oxygen saturation, blood pressure

786.01 -> and end-tidal carbon dioxide.

789.01 -> What is your differential diagnosis,

791.05 -> and what are you going to do to treat this patient?

794.94 -> Pulmonary Hypertensive Crisis.

796.89 ->

799.75 -> Patients with pulmonary hypertension,

801.73 -> you should always think if the patient decompensates,

805.6 -> the first thing that should be on your differential diagnosis

808.24 -> is a pulmonary hypertensive crisis.

810.52 -> The definition of pulmonary hypertensive crisis

812.83 -> is an acute on chronic increase in pulmonary vascular

815.32 -> resistance, resulting from an acute increase

817.9 -> in vascular tone of the reactive portion

820.12 -> of the pulmonary vasculature.

822.59 -> During these changes, a rapid increase in pulmonary vascular

825.59 -> resistance will lead to an increased right ventricular

828.5 -> afterload, causing right ventricular pressure

831.62 -> to increase, which will in turn lead

834.2 -> to decreases in the left ventricular preload, decreases

838.01 -> in coronary perfusion pressure, and eventually causing

841.4 -> ischemia, which will lead to changes such as hypoxia

844.82 -> and acidosis, which will further increase this cycle.

848.63 -> During an acute event, it is possible to have cardiac arrest

853.49 -> with low cardiac outputs.

855.65 -> If the patient does develop cardiac arrest,

857.93 -> it may be difficult to resuscitate these patients.

860.78 -> CPR may be ineffective due to an enlarged right ventricular

864.48 -> size that compresses the left ventricle, causing

867.56 -> ineffective cardiac output.

870.11 -> Pulmonary hypertensive crisis can happen at any time

872.69 -> during the perioperative period, and this can occur even hours

875.99 -> after the intra-operate time.

878.03 -> Intra-operative findings of pulmonary hypertensive crisis

880.97 -> include sudden desaturation, systemic hypotension,

884.69 -> decreases in end-tidal CO2, sinus tachycardia,

888.71 -> elevated central venous pressure, and a new onset

891.74 -> EKG change of RV strain or ischemia,

895.01 -> as well as bradycardia, which is an ominous sign

897.74 -> of impending cardiac arrest.

899.87 -> If you have access to a transesophageal

902.09 -> echocardiograph, you will see that the right ventricle is

905.09 -> dilated and poorly contracting, as well as an under filled

908.6 -> left ventricle.

909.84 -> And you will see pulmonary regurgitation

911.69 -> and tricuspid regurgitation, as well as

914.3 -> elevated right ventricular pressures.

916.66 -> For treatment of a pulmonary hypertensive crisis,

919.28 -> it is important to get rid of the stimulating event

922.13 -> and to stabilize the patient.

924.02 -> It is important to administer 100% oxygen to the patient.

927.86 -> Oxygen is a vasodilator and will vasodilate

930.83 -> the pulmonary vasculature.

932.72 -> It is also important to hyperventilate the patient.

935.42 -> Hyperventilation will lead to decreases in carbon dioxide

938.39 -> levels, and therefore vasodialate

940.85 -> the pulmonary vasculature.

942.98 -> It's also important to exclude other causes that

946.67 -> may mimic a pulmonary hypertensive crisis,

949.07 -> such as a pneumothorax.

951.08 -> It's important to decrease mean arterial pressures if possible,

954.55 -> and to correct metabolic acidosis.

957.54 -> Acidosis will lead to increases in pulmonary vascular

960.21 -> resistance and further increase the acute event.

963.71 -> It is also important to support the heart of the patient,

966.51 -> providing an inotrope such as epinepherine.

969.42 -> If the patient is in the middle of surgery,

971.67 -> it's important to administer proper analgesia

975.96 -> to get rid of any noxious stimuli which

977.94 -> may be precipitating an event.

980.16 -> It is also important to initiate ECMO early in these patients

984.06 -> in order to stabilize the patient

985.77 -> and provide adequate cardiac output to the patient.

989.16 -> If the patient does develop cardiac arrest,

991.32 -> it is very important to start PALS algorithm.

994.77 -> However, keep in mind that CPR may

996.87 -> be ineffective due to the enlarged right

998.91 -> ventricle compressing the left ventricle

1001.39 -> and leading to decreased cardiac output.

1004.26 -> Today's pulmonary hypertension talk,

1006.06 -> the teaching points are: pulmonary hypertension

1008.43 -> is associated with significant morbidity and mortality

1011.01 -> in the perioperative time, careful planning

1013.35 -> is very important pre-operatively,

1015.51 -> and pulmonary hypertensive crisis

1017.01 -> can occur both intra-op and post-op.

1019.68 -> Thank you very much.

1021.37 -> Please help us improve the content by providing us

1023.85 -> with some feedback.

1025.7 ->

Source: https://www.youtube.com/watch?v=XHUKyqdXHZg