What is a case example of a developing acute pulmonary hypertensive crisis during laparoscopy?

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

Answer

This clinical scenario is suggestive of a developing acute pulmonary hypertensive crisis. Laparoscopy can be extremely detrimental to the physiology of patients with PH. Insufflation of CO2 (a commonly used gas in laparoscopy) raises the intra-abdominal pressure, leads to decreased venous return, and pushes the diaphragm into the chest, thereby increasing the intrathoracic pressure. Furthermore, over time, absorption of CO2 leads to hypercarbia and acidosis. [22]  When these changes occur in a state of sympathetic overdrive (such as may occur immediately after incision), mismatch of supply and demand to the RV can develop, resulting in potentially catastrophic RV failure.

The preoperative evaluation included severely elevated right-side pressures with only mildly elevated pulmonary arterial pressures, suggesting near-exhaustion of compensatory mechanisms. The provider in such cases must be vigilant to minimize any further exacerbation (such as may be caused by hypercarbia or pain) that will vasoconstrict the pulmonary circulation. In this case, it was appropriate to place an awake arterial line. In cases of severe disease, the authors recommend having an inotrope (eg, dobutamine, dopamine, or epinephrine) ready and available for immediate use. In some situations, it is appropriate to start inotropic support even before induction and to have iNO readily available.

Removal of acute exacerbating factors (abdominal desufflation, in this case) should be swift in order to restore homeostasis. It is important to maintain adequate perfusion to the RV, and it is equally important to ensure adequate contractility so as to overcome the increased PVR. In this situation, giving small boluses of  phenylephrine and ephedrine in conjunction would improve forward flow and RV perfusion while one is waiting for the vasoactive infusion to kick in. 


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