Avneep Aggarwal, MD
Attending Physician
Cleveland Clinic, United States
Disclosure information not submitted.
Title: Major non-cardiac surgery in a patient with severe pulmonary hypertension: Perioperative challenges
Case Report Body:
Introduction:
Patients with pulmonary hypertension have significantly increased perioperative morbidity and mortality. Deaths of these patients often occur during the first several postoperative days and may occur suddenly. We discuss the unique perioperative challenges in management of a patient with severe pulmonary hypertension who underwent radical nephrectomy.
Description:
A 39-year-old female with history of severe pre-capillary pulmonary hypertension presented for laparoscopic left radical nephrectomy for renal cell carcinoma. Initial hemodynamics showed elevated RA pressure, mean PA of 53, TPG of 43 and PVR of 9 with CI of 2.67 by thermodilution. She was started on tadalafil and ambrisentan with improvement in her functional capacity. During the surgery, arterial line, PA catheter and TEE were utilized for monitoring during rapid fluid shifts. Inhaled epoprostenol, infusions of epinephrine and vasopressin were initiated and titrated to maintain stable hemodynamics. She tolerated the procedure and was admitted to ICU postoperatively. Based on the high risk of severe perioperative exacerbation of her pulmonary hypertension, deep sedation and mechanical ventilation were continued. The patient was gradually weaned off of Inhaled epoprostenol after transitioning to enteral pulmonary vasodilators via feeding tube. A transverse abdominis plane block was also performed to optimize analgesia and prevent further worsening of pulmonary hypertension. Subsequently, she was extubated to high-flow nasal cannula successfully on POD1 and had an uneventful recovery.
Discussion:
Patients with severe pulmonary hypertension have a significantly elevated risk of perioperative morbidity and mortality. Stress and pain from surgical trauma, fluid shifts and ventilation can further exacerbate pulmonary hypertension and cause right-sided heart failure. Selective inhaled pulmonary vasodilators and continued controlled mechanical ventilation, early initiation of enteral pulmonary vasodilators, adequate analgesia and invasive hemodynamic monitoring during the postoperative phase in the ICU are all critically important for a successful perioperative outcome.