Anesthetic Considerations and Management of Pulmonary Hypertension in Cardiothoracic Surgery

Michael Dieleman^*
*Correspondence: Michael Dieleman, Department of Anesthesiology and Pain Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3, Canada, Email:

Introduction

Pulmonary Hypertension (PH) is a complex and potentially life-threatening condition characterized by elevated pulmonary arterial pressure. It poses significant challenges during cardiothoracic surgery, requiring careful anesthetic management to optimize patient outcomes. This research article provides an overview of the anesthetic considerations and management strategies for patients with PH undergoing cardiothoracic surgery, aiming to enhance perioperative care and improve patient safety. Pulmonary hypertension (PH) is a complex and potentially life-threatening condition characterized by elevated pulmonary arterial pressure. It imposes significant challenges during cardiothoracic surgery, requiring careful anesthetic management to optimize patient outcomes. The presence of pulmonary hypertension adds an additional layer of complexity to the already intricate perioperative care of cardiothoracic surgical patients. Anesthetic considerations and management strategies must be tailored to address the unique pathophysiology and hemodynamic alterations associated with PH [1-3].

Pulmonary hypertension is a hemodynamic disorder that can result from various etiologies, including idiopathic, heritable, associated with other diseases, or due to chronic thromboembolic disease. It is characterized by elevated pulmonary arterial pressure, leading to right ventricular dysfunction and potentially fatal complications. Cardiothoracic surgery in patients with pre-existing or concomitant pulmonary hypertension presents numerous challenges to anesthesiologists due to alterations in hemodynamics, ventilationperfusion matching, and responses to pharmacological agents. Pulmonary hypertension can be classified into different categories based on etiology, including idiopathic, heritable, associated with other diseases, or due to chronic thromboembolic disease. Regardless of the underlying cause, the primary hemodynamic consequence of PH is increased pulmonary vascular resistance (PVR), leading to right ventricular dysfunction and eventual failure. In the context of cardiothoracic surgery, this poses challenges related to maintaining stable hemodynamics, optimizing ventilation-perfusion matching, and choosing appropriate pharmacological agents.

Description

Preoperative evaluation

Thorough preoperative assessment is crucial to identify the severity of pulmonary hypertension and associated comorbidities. It involves evaluating the underlying etiology, assessing right ventricular function, estimating pulmonary artery pressures, and determining the patient's functional capacity. Additional investigations, such as echocardiography, right heart catheterization, and pulmonary function tests, aid in risk stratification and guide anesthetic management decisions.

Hemodynamic optimization

Maintaining stable hemodynamics is paramount in patients with pulmonary hypertension during surgery. Strategies to achieve this goal include avoiding factors that increase pulmonary vascular resistance (PVR), optimizing intravascular volume, maintaining adequate systemic blood pressure, and preventing hypoxemia and hypercapnia. Precise fluid management, titration of vasoactive agents, and judicious use of pulmonary vasodilators are essential components of hemodynamic optimization [4,5].

Ventilation and oxygenation

Ventilation strategies should aim to minimize PVR and right ventricular afterload while ensuring adequate oxygenation and ventilation. Protective lung ventilation techniques, such as low tidal volume and moderate positive endexpiratory pressure, are generally recommended. Maintaining normocapnia and avoiding hypercapnia are important, as excessive CO₂ levels can increase PVR. Careful monitoring of oxygenation and arterial blood gases is crucial to prevent hypoxemia and hypercapnia.

Pharmacological management

Anesthetic agents and medications used perioperatively should be selected with caution in patients with pulmonary hypertension. Careful consideration must be given to avoid drugs that increase PVR, depress myocardial function, or cause systemic vasodilation. The use of inhaled pulmonary vasodilators, such as nitric oxide or prostacyclin analogs, may be beneficial in specific cases to reduce PVR and improve oxygenation.

Postoperative care

Vigilant postoperative monitoring and management are essential in patients with pulmonary hypertension. Close hemodynamic monitoring, including invasive arterial pressure monitoring, central venous pressure monitoring, and pulmonary artery catheterization, may be necessary in certain cases. Early extubation, pain management, prevention of thromboembolic events, and avoidance of factors that worsen pulmonary hypertension, such as hypoxemia and acidosis, are crucial components of postoperative care.

Conclusion

Anesthetic management of patients with pulmonary hypertension undergoing cardiothoracic surgery requires a multidisciplinary approach and meticulous attention to detail. Optimal perioperative care involves preoperative risk stratification, hemodynamic optimization, lung protective ventilation, judicious use of pharmacological agents, and vigilant postoperative monitoring. Collaborative efforts between anesthesiologists, surgeons, cardiologists, and intensive care specialists are vital to ensuring favorable outcomes in this challenging patient population

References

1. Wesselink, Esther M., Sjors H. Wagemakers, Judith AR Van Waes and Jonathan P. Wanderer, et al. "Associations between intraoperative hypotension, duration of surgery and postoperative myocardial injury after noncardiac surgery: A retrospective single-centre cohort study." Br J Anaesth 129 (2022): 487-496.

Google Scholar, Crossref, Indexed at

2. Mort, Thomas C. "Continuous airway access for the difficult extubation: The efficacy of the airway exchange catheter." Anesth Analg 105 (2007): 1357-1362.

Google Scholar, Crossref, Indexed at

3. Sanfilippo, Filippo, Alberto Noto, Grazia Foresta and Cristina Santonocito, et al. "Incidence and factors associated with burnout in anesthesiology: A systematic review." BioMed Res Int 2017.

Google Scholar, Crossref, Indexed at

4. Olsen, Richard W. "GABAA receptor: Positive and negative allosteric modulators." Neuropharmacology 136 (2018): 10-22.

Google Scholar, Crossref, Indexed at

5. Flores, Glenn. "The impact of medical interpreter services on the quality of health care: A systematic review." Med Care Res Rev 62 (2005): 255-299.

Google Scholar, Crossref, Indexed at