What are anesthesia considerations in the perioperative management of pulmonary hypertension (PH)?

Updated: Sep 11, 2019
  • Author: Swapnil Khoche, MBBS, DNB, FCARCSI; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

Regional vs general anesthesia

The literature has not yet clarified whether regional or general anesthesia is preferable in patients with PH. [8]  One small limited study showed a nonsignificant trend toward increased perioperative complications for those undergoing general anesthesia. [4]  In view of the known effects of general anesthesia and PPV, a recommendation can be made to lean toward using regional or neuraxial techniques if possible. The benefit to be gained may be the result of blockade of increases in sympathetic tone, which prevent any resultant increases in PVR.

Neuraxial anesthesia must be used with caution because it has the potential to cause profound systemic hypotension, decreased cardiac perfusion, and subsequent hemodynamic collapse. Accordingly, epidural anesthesia, being readily titratable and having a gradual onset, carries less risk than a single-shot subarachnoid block does. It is also recommended that moderate or deep sedation not be used concurrently with these techniques; hypoxia and hypercarbia from hypoventilation can drastically increase PVR and trigger a pulmonary hypertensive crisis.

Regional or neuraxial catheter-based techniques have the advantage of reducing sympathetic tone through excellent pain control that extends into the postoperative period, without the respiratory depression that can occur with opiates. Anticoagulant therapy, which these patients may be receiving, is sometimes the prohibiting factor and must be considered in making the choice.

General anesthesia has the advantage of allowing control of the patient's airway, oxygenation, and carbon dioxide levels; however, the provider must be prepared and vigilant and must use the appropriate pharmacologic therapy to minimize PVR. 


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