May Fy21

[kristenhorsman]

The May journal club is presented by Lisa Lo. She chose an AANA article entitled "Pulmonary hypertension and cardiac anesthesia: Anesthesiologist's perspective."



You can find the article here.



Please respond to the following two questions:



1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?

2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?

[Katya]

1. In preoperative evaluation should be included routine blood tests, CXR, ECG, echo, PFTs, blood gas, and right heart catheterization. Cardiologist recommendations. Assessment of functional capability, severity of the disease, and type of surgery proposed.
2. Avoid elevation of PVR: avoid hypoxia (keep iFiO2 60-100%), hypercarbia (CO2 30-35), pain, acidosis, hypothermia. Low TV ventilation 6-8 ml per kg. Maintain SVR, SR, preload. Avoid cardiac depressants.

[Monica Douglas]

1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?

A preoperative evaluation routine blood tests, EKG, Echo, PFTs and routine blood tests.


2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?

Invasive arterial blood pressure monitoring is required to monitor hemodynamics, secondary to possible unexpected deterioration. Regional anesthesia has the added benefit of maintaining spontaneous breathing and, therefore, avoiding elevation of pulmonary pressures. Also, histamine releasing relaxants should be avoided in these patients to avoid further increases in pulmonary resistance. However, any standard anesthesia technique can be used in these patients. Important to avoid hypoxic pulmonary vasoconstriction, hypercarbia, hypothermia, high airway pressures and acidosis.

[Jennifer Hannon]

1 Routine blood tests, a recent EKG and preferably a comparative one, ECHO and results, and Cardiac Cath report with cardiologist's input should be included in the preoperative evaulation in addition to the regular Anesthesia preop assessment.

2. Anesthesia Considerations: Avoid elevation of PVR (avoid hypoxia, hypercarbia, pain, acidosis, hypothermia). Use Low TVs. Maintain Preload, SVR. Avoid medications resulting in cardiac depression.

[aileenm4]

1. preoperative evaluation needs to involve functional capacity, current PFTs, smoking status, Echo, stress test, current medications and if the patient is optimized or what else can be dome to get patient to best to tolerate the anesthesia and surgery since they are at very high risk for morbidity and mortality, patients need to know that they are extreme high risk
2. the usual avoid hypoxemia, hypercarbia, hypovolemia, hypothermia, pain, acidosis and intraoperative TEE or some method maybe non invasive heart monitoring should be done, and aline

[Kels]

A detailed and complete preop evaluation should be done on any patient with pulmonary hypertension . This evaluation should include blood tests , cardiac studies or images such as EKG and ECHO and pulmonary studies .

The Anesthetic management of a pulmonary hypertensive patient involves avoiding hypovolemia, hypercarbia, hypoxia, hypothermia, pain , acidosis, high tidal volumes and possibly placing an a line

[Ben Waldbaum]

1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?
Cardiologist recommendations, including possible right heart catherization, echo.

2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?
Avoid elevation of PVR, Use Low TVs. Maintain Preload, SVR. Avoid nitrous or medications resulting in cardiac depression

[Christine Velarde]

What should be included in preop evaluation of a patient with pulmonary hypertension? A detailed history of symptoms should be elicited. Routine blood tests, xray EKG. echo PFT's cardiac cath ABG may be needed depending on the type of surgery proposed.
What aae the anesthesia considerations in the perioperative management of pulmonary hypertension?
Prevent PH crisis and subsequent RV failure.
Keep systolic B/p > 90, MAP >65 . Maintain cardiac output, may need to use vasopressors, inotropes. Reduce RV afterload. Avoid hypoxic vasoconstriction, hypercarbia. acidosis. hypothermia and high airway pressures,

[Anne McNulty]

Pre -Op eval should include routine blood tests , Ekg, Echo , Rt Heart Cath results, functional capacity and PFTS. Intra-op should avoid hypoxemia, hypercarbia, hypovolemia, hypervolemia, hypothermia. Intra-op Arterial line for any long cases and TEE may be indicated.

[Soo-Ok Kim]

1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?
Pt's functional status including NYHS functional class in addition to routine lab work, proBNP (independent predictor of mortality for cardiac pt with noncardiac surgery), Echo (poor predictor)/(+/-) cardiac cath

2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?
keep PHTN meds until the day of surgery, GA preferred,(some prefer regional anesthesia to minimize PPV,PVR, but caution with anticoagulation)
Keep ventilation, oxygenation, MAP, avoid increasing PVR technique with induction and maintenance of anesthesia is desirable.

[clawry]

1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?

6 minute walk test, Echo, PFTs, assess severity of disease and type of surgery proposed, detailed history of symptoms, CXR, EKG, Right heart cath, proBNP level, ABG, NYHA functional class

2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?

Avoid hypoxic pulmonary vasoconstriction, avoid hypercarbia, avoid acidosis, avoid hypothermia, avoid high airway pressures, avoid increased PVR, keep higher FiO2 .6-1.0, low VT to avoid overinflation of alveoli, maintain coronary blood flow and sinus rhythm, maintain SVR, maintain preload, maintain CO, paCO2 30-35

Great article Lisa!

[Amy Swank]

1. What should be included in pre-op eval of patient with pulmonary HTN?
routine bloodwork, comprehensive clearance by cardiologist with note addressing that (EKG, Echo, Cath results), pulmonary workup that includes severity of pulmonary HTN with regards to type of surgery and anesthetic - including PFTs.

2. What are the anesthesia considerations in the peri-operative management of pulmonary HTN?
With this complex patient, it is critical to avoid: increased PVR, hypoxia, hypercarbia, acidosis, hypothermia, increased airway pressures (regional? if possible), cardiac depression.
This patient would require invasive continuous monitoring of BP and ability to draw ABGs.

[nanci]

1. What should be included in the preoperative evaluation of a patient with pulmonary hypertension?
An echocardiography (TEE or TTE) and right heart catheterization to assess disease severity along with a thorough prep evaluation (functional status, comorbid conditions. EKG, chest X-ray, PFTs, BNP or other heart failure marker)

2. What are the anesthesia considerations in the perioperative management of pulmonary hypertension?
To avoid hypoxic pulmonary vasoconstriction, hypercarbia, acidosis, hypothermia, and high airway pressures. To reduce RV after load and maintain coronary blood flow and sinus rhythm. Maintain cardiac output and preload. Keep PaCO2 between 30-35 mmHg, use low tidal-volume ventilation to avoid overinflation of alveoli. Pain control and avoid histamine-releasing relaxants that may increase pulmonary resistance..

[mary clothier]

1) What should be included in the pre-op eval of patient with polmonary HTN?
CBC, Lytes, EKG, Echo, TEE, Right heart Cath, to assess disease severity.

2) What are the anesthetic considerations in the perioperative management of pulmonary HTN?
Avoid increased PVR, and Hypoxia, Hypercarbia, Acidosis, and Pain. Avoid N2O, to avoid potential cardiac depression.
Hemodynamic stability, and Low tidal volumes.

[Wai-Ling Lo]

1. Preop eval should include complete disease phenotyping by PH specialist; medication review and optimization 2 weeks prior to surgery; clinical exam, 6 mins walk test and right heart cath within 2 weeks of surgery; surgical planning to discussion to minimize operative time.


2. Avoid perioperative changes that increase pulmonary vascular resistance, e.g. Hypoxia & hypercarbia due to sedation, analgesia, poor mask, delayed intubation; acidosis secondary to hypovolemia, infection, decreased cardiac output; hypothermia caused by cold IV fluids or ambient temp; atelectasis and hyperinflation; catecholamine release from pain, inadequate anesthesia, anxiety; or medications that increase PVR such as pure alpha agonists.
Implementation of a collaborative perioperative management program may be beneficial to standardize the perioperative management of PH pts.