Figures
- FIGURE 1
Factors worsening pulmonary artery pressure and consequent right ventricular dilatation/ dysfunction in the perioperative period. CO: cardiac output; NTPE: non-thrombotic pulmonary embolism; PAP: pulmonary artery pressure; PE: pulmonary embolism; PPV: positive pressure ventilation; PVR: pulmonary vascular resistance; RV: right ventricle; SBP: systolic blood pressure.
- FIGURE 2
Suggested intraoperative monitoring and interventions in pulmonary hypertension patients [30, 49]. BB: beta blocker; CCB: calcium channel blocker; CI: cardiac index; CTEPH: chronic thromboembolic pulmonary disease; FIO2: fractional inspired oxygen; FRC: functional residual capacity; iNO: inhaled nitric oxide; MAP: mean arterial pressure; mPAP: mean pulmonary artery pressure; PAC: pulmonary artery catheter; PCO2: carbon dioxide tension; PVR: pulmonary vascular resistance; PEEP: positive end expiratory pressure; RAP: right atrial pressure; RV: right ventricle; SpO2: oxygen saturation; TCI: target controlled infusion; TEE: transoesophageal echocardiogram; VT: tidal volume.
Tables
- TABLE 1
Studies showing the prevalence of perioperative complications after non-cardiac surgery in pulmonary hypertension (PH) patients
Authors, year [ref.] Study type N PH diagnosis Aetiology of PH GA Major surgery Mortality Morbidity Ramakrishna et al. 2005 [34] Retrospective no control 145 TTE or RHC Group 1 45%
Group 3 19%
Group 4 8%100% 79% 7% 42% Minai et al. 2006 [36] Retrospective no control 28# RHC Group 1 100% 79% 86% 18% 19% Lai et al. 2007 [37] Retrospective no control 62 TTE Group 1 18%
Group 2 21%
Group 3 21%58% 65% 9.7% 24% Price et al. 2010 [29] Retrospective no control 28 RHC Group 1 72%
Group 4 28%50% 57% 7% 29% Memtsoudis et al. 2010 [38] Retrospective 1:3 matching with no-PH 3543 Not specified NA NA 100% (THR/TKR) 2.4% (versus 0.9% in no-PH) NA Kaw et al. 2010 [33] Retrospective controlled 96 RHC Group 1 12%
Group 2 40%
Group 5 48%100% 48% 1% 28% Meyer et al. 2013 [32] Prospective no control 114 RHC Group 1 100% 82% 69% 3.5% 6.1% Seyfarth et al. 2015 [39] Retrospective no control 31 RHC Group 1 74%
Group 3 10%
Group 4 16%77% 100% 3% 25% Smilowitz et al. 2019 [40] Retrospective controlled 3500 Variable¶ Group 1 100% NA All types 8.3% 12.9% Deljou et al. 2019 [41] Retrospective no control 196 RHC Group 1 74%
Group 3 14%
Group 4 13%100% 45% 3% 27% GA: general anaesthesia; NA: not available; RHC: right heart catheterisation; TTE: transthoracic echocardiography; THR: total hip replacement; TKR: total knee replacement. #: N=21 patients underwent 28 procedures. ¶: 149 (4.3%) patients had RHC, others were reported PAH.
- TABLE 2
Risk factors for perioperative morbidity and mortality in pulmonary hypertension patients
Patient characteristics
PAH >mixed or postcapillary PH [33, 58]
History of PE, coronary artery disease, OSA or chronic renal insufficiency [28, 30, 59]
WHO functional class III and IV [41]
ASA class>II [30]
6MWD <400 m [30]
ECG: right-axis deviation [30]
NT-proBNP≥300 pg·mL−1 [41]
TTE: RV hypertrophy, RV index of myocardial performance ≥0.75, RVSP/SBP ≥0.66 [34, 59, 60]
Pulmonary haemodynamics: mPAP >45 mmHg, elevated RAP [61] or sPAP >70 mmHg,
CI <2 L·min−1·m−2 [30]
Anaesthesia attributes
Duration of anaesthesia >3 h [29, 58]
Perioperative use of vasopressors [34, 60]
Intermediate to high-risk surgery [41]
Emergency procedures [32, 60].6MWD: six-minute walk distance; ASA: American Society of Anesthesiology; CI: cardiac index; ECG: electrocardiogram; mPAP: mean pulmonary artery pressure, NT-proBNP: N-terminal pro-brain natriuretic peptide; OSA: obstructive sleep apnoea; PAH: pulmonary arterial hypertension; PE: pulmonary embolism; PH: pulmonary hypertension; PVR: pulmonary vascular resistance; RAP: right atrial pressure; RV: right ventricle; RVSP: right ventricle systolic pressure; sPAP: systolic pulmonary artery pressure; SBP: systolic blood pressure; TTE: transthoracic echocardiography; WHO: World Health Organization.
- TABLE 3
Effects of anaesthetic agents, vasopressors and inotropes on pulmonary vasculature and right ventricle function [42, 47, 96, 97, 100, 101]
Agents mPAP PVR RV contractility Anaesthetic agents Isoflurane ↓ ↔ ↓↓ Desflurane ↓ ↔ ↓↓ Sevoflurane ↓ ↔ ↓↓ Nitrous oxide ↑↑ ↑↑ ↓ Thiopental sodium ↔ ↔ ↓ Etomidate ↔ ↔ ↔ Ketamine ↑ ↔/↑ ↓ Propofol ↓ ↓ ↓↓ Fentanyl/sufentanil ↔ ↔ ↔ Remifentanil ↔ ↔ ↔ Vasopressors Norepinephrine ↑ ↑ ↑ Epinephrine ↑ ↑ ↑ Phenylephrine ↑ ↑ ↓↓ Vasopressin ↓ ↓ ↔ Inotropes Dobutamine ↔ ↑, ↔, ↓# ↑↑ Milrinone ↔ ↓ ↑↑ Levosimendan ↓ ↓ ↑ ↑ Increase; ↑↑ marked increase; ↓ reduction; ↓↓ marked reduction; ↔ no effect. mPAP: mean pulmonary arterial pressure; PVR: pulmonary vascular resistance; RV: right ventricle. #: Conflicting data about the effect of dobutamine in PVR. Dobutamine decreases PVR at low dose (<5 µg·kg−1·min−1), no effect at median dose of 10 µg·kg−1·min−1 and increases PVR at higher dose, more than 15 µg·kg−1·min−1 [47, 102–104].
Supplementary Material
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Supplementary figures and tables ERR-0166-2021_Supplementary_figure_and_tables
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- Article
- Abstract
- Abstract
- Introduction
- Classification of PH
- PAH medications
- Haemodynamic pathophysiology of PH
- Anaesthesia in patients with PH
- Preoperative evaluation of PH patients
- Intraoperative management of PH
- Special surgical populations
- Postoperative care of patients with PH
- Supplementary material
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