What is included in the postoperative 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

Postoperative management

Although acute changes in hemodynamics are less likely during the postoperative period, unpredictable volume shifts and many commonly used medications can still worsen a patient's PH and precipitate RV failure. As always, it is important to avoid hypoxia, hypercarbia, acidosis, and pain, all of which can lead to clamping down of the pulmonary vasculature and increase pulmonary artery pressures.

Accordingly, it is essential that extubated patients be able to spontaneously ventilate in an effective manner without obstruction or concern for respiratory compromise. Particularly with a long case (>12 hours) or in a patient with obstructive sleep apnea, there is a risk of oversedation, and continued intubation should be carefully considered until the patient is fully alert and capable of adequate ventilation.

Treatment of pain in the postanesthesia care unit (PACU) typically involves opioids. In a patient with PH, the concern is decreased respiratory drive in response to hypercarbia and minor episodes of hypoxia from hypoventilation. To avoid exacerbating PH, nonopioid pain control (eg, acetaminophen, ketorolac, injection of local anesthetic, regional blocks, or epidural anesthesia) may be used. If opioid use is unavoidable and respiratory compromise is likely, continued endotracheal intubation and mechanical ventilation in the intensive care unit (ICU) may be considered until alleviation of acute surgical pain allows administration of reduced doses of narcotics.

On one hand, fluid shifts can lead to decreases in preload and impaired flow through the pulmonary circulation; on the other hand, they can also lead to significant increases in intravascular volume. Patients with a positive fluid balance must be monitored closely, and if there is concern that increased intravascular volume may lead to acute exacerbation of right-heart dysfunction, they should remain intubated and undergo appropriate diuresis. Furthermore, any inotrope or vasodilator being given intraoperatively should be either continued into the postoperative setting if needed or carefully tapered. [8]


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