What is a clinical scenario for a male patient with pulmonary hypertension (PH) undergoing arthroplasty?

Updated: Sep 11, 2019
  • Author: Swapnil Khoche, MBBS, DNB, FCARCSI; Chief Editor: Sheela Pai Cole, MD  more...
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A 62-year-old male patient with known PAH is scheduled to undergo a revision right total knee arthroplasty (TKA). He has a history of tobacco use, hypertension, and CAD, which was treated with a stent placed 6 years ago. He does not know the severity of his PH, and there are no other records in the chart. He reports that he often feels short of breath, including while walking in the morning from the parking lot; however, he attributes this to his knee and states that he has not felt chest pain since receiving his stent. He has stopped taking his aspirin but did take his metoprolol this morning. His medical history is otherwise insignificant.

The anesthesia team acknowledges the shortness of breath but attributes it to deconditioning. The decision is made to proceed with surgery. Induction and intubation are uneventful; the lower-extremity tourniquet is inflated, and surgery proceeds as normal. The procedure is lengthy, with a 1 L blood loss necessitating transfusion, and the tourniquet remains in place for slightly more than 2 hours. When the procedure is finished, the tourniquet is finally deflated.

The patient becomes tachycardic (to 108 beats/min), and end-tidal CO2 (EtCO2) increases from 38 to 48 mm Hg. The anesthesia provider starts 50% nitrous oxide to prepare for emergence and cycles the blood pressure cuff. Blood pressure is found to have declined from 118/72 mm Hg to 78/48 mm Hg. The provider gives a small bolus of phenylephrine and restarts the blood pressure cuff. Tachycardia persists, and the patient remains hypotensive (82/50 mm Hg). Noting a mild ST depression in lead II, the provider then administers 1 unit of vasopressin IV, puts the patient on 100% fraction of inspired oxygen (FiO2), and begins drawing up dilute epinephrine.

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