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Review
. 2021 Dec 22;30(162):210166.
doi: 10.1183/16000617.0166-2021. Print 2021 Dec 31.

Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery

Debabrata Bandyopadhyay  1 , Christopher Lai  2   3   4 , Juan N Pulido  5 , Ricardo Restrepo-Jaramillo  1 , Adriano R Tonelli  6   7 , Marc Humbert  8   4   9
Affiliations
Review

Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery

Debabrata Bandyopadhyay et al. Eur Respir Rev. .

Abstract

Pulmonary hypertension (PH) confers a significant challenge in perioperative care. It is associated with substantial morbidity and mortality. A considerable amount of information about management of patients with PH has emerged over the past decade. However, there is still a paucity of information to guide perioperative evaluation and management of these patients. Yet, a satisfactory outcome is feasible by focusing on elaborate disease-adapted anaesthetic management of this complex disease with a multidisciplinary approach. The cornerstone of the peri-anaesthetic management of patients with PH is preservation of right ventricular (RV) function with attention on maintaining RV preload, contractility and limiting increase in RV afterload at each stage of the patient's perioperative care. Pre-anaesthetic evaluation, choice of anaesthetic agents, proper fluid management, appropriate ventilation, correction of hypoxia, hypercarbia, acid-base balance and pain control are paramount in this regard. Essentially, the perioperative management of PH patients is intricate and multifaceted. Unfortunately, a comprehensive evidence-based guideline is lacking to navigate us through this complex process. We conducted a literature review on patients with PH with a focus on the perioperative evaluation and suggest management algorithms for these patients during non-cardiac, non-obstetric surgery.

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Conflict of interest statement

Conflict of interest: D. Bandyopadhyay received fees for a speaker bureau, advisory committee and research grants from Boehringer Ingelheim; and fees for a speaker bureau, advisory committee and research grants from United Therapeutics corporation. Conflict of interest: C. Lai has nothing to disclose. Conflict of interest: J.N. Pulido has nothing to disclose. Conflict of interest: R. Restrepo-Jaramillo received fees for a speaker bureau, advisory committee and research grants from Bayer; fees for a speaker bureau, advisory committee and research grants from Janssen Actelion; and fees for a speaker bureau, advisory committee and research grants from United Therapeutics corporation. Conflict of interest: A.R. Tonelli has nothing to disclose. Conflict of interest: M. Humbert reports grants, personal fees and non-financial support from GlaxoSmithKline; personal fees from AstraZeneca, Novartis, Roche, Sanofi, Merck and Teva; and grants and personal fees from Acceleron, Actelion and Bayer, outside the submitted work.

Figures

FIGURE 1
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
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.
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Comment in

References

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