How are patients monitored 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

Monitoring

One of the central considerations in anesthesia for this patient population is appropriate monitoring. Patients who have severe disease or a decompensated clinical picture cannot be treated effectively if the developing problem is not recognized. To this end, standard ASA-recommended monitors are a prerequisite.

Real-time monitoring of arterial pressure is key to maintaining adequate perfusion pressure to the RV. In any patient with moderate or severe PH, invasive arterial monitoring is generally warranted for all but the shortest procedures. In addition to rapid detection of hemodynamic deterioration, such monitoring enables analysis of arterial blood gas values in order to facilitate normocarbia and adequate oxygenation. Pulse contour analysis can add valuable information regarding volume responsiveness and cardiac output. [19]

A central venous catheter can facilitate measurement of CVP, optimization of fluid status, and administration of vasoactive drugs (if needed). Placement of a pulmonary artery catheter, though invasive and of questionable value, can be useful for titrating therapy to reduce PAP. [8]  The authors advocate placing a central venous catheter in cases where either the severity of PH or the surgical risk is greater than moderate.

Intraoperative TEE can be a useful aid for evaluating RV systolic function in real time and assessing the efficacy of inotropic therapy. At present, however, there are no specific indications for intraoperative echocardiography in this setting, nor are there any clear guidelines as to how it should be conducted. Insertion of a probe must be done carefully and only after the benefit is weighed against the risk.


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