Anesthetic Considerations in Pulmonary Hypertension,
by Dr. Stephanie Grant.
Hello.
My name is Stephanie Grant and today I'm
going to be talking to you about pulmonary hypertension.
The goals of today's talk are to talk
about perioperative management of pulmonary hypertension,
including during the pre-operative, intra-operative,
and post-operative time.
We will also talk about pulmonary hypertensive crisis.
Background.
Pulmonary hypertension is a rare disease in neonates, infants,
and children.
Patients with pulmonary hypertension
present for cardiac and non-cardiac surgery,
and for general anesthesia and sedation.
Pulmonary hypertension is associated
with significant morbidity and mortality,
and poses an increased perioperative risk.
Patients with pulmonary hypertension
have increased risk of arrhythmias, cardiac arrest,
and death during the perioperative time.
This graph depicts three different studies.
The small green bar, which is on the left of each grouping,
shows the Pediatric Perioperative Cardiac Arrest
Registry.
This depicted a study which involved all patients
regardless of diagnosis and regardless of surgery
that they were having.
The incidence of cardiac arrest in these patients
was very small at .014%, and of those patients,
the risk of death was .0036%.
The study depicted in the red bar
indicates a study of patients with pulmonary arterial
hypertension who had general anesthesia for procedures
in the cardiac cath lab and also for non-cardiac surgery.
The incidence of cardiac arrest in these patients was 1.17%,
and the incidence of death in these patients was .78%.
These studies indicate that the incidence of cardiac arrest
and death is significantly higher in patients
with pulmonary hypertension.
This study indicates that the perioperative complications
are directly related to the severity
of pulmonary arterial hypertension.
Patients with supra-systemic right ventricular pressures
have greater complications during surgery
than patients with less severe forms
of pulmonary hypertension.
The baseline supra-systemic pulmonary arterial hypertension
is a significant predictor of major complications
during anesthesia.
This table is a nonvalidated tool
that looks at patients who may have low risk or high risk
complications during general anesthesia.
The patients are grouped into low risk or high risk
based on patient factors, surgery factors,
as well as the anesthetic factors involved.
Case Example - Part 1.
Let's look at a case as an example of a patient
with pulmonary hypertension.
The patient is a 15-year-old male
who is evaluated prior to an open reduction
internal fixation of his tibia.
The patient sustained this fracture
after falling while skateboarding.
The patient was diagnosed with pulmonary hypertension
one year ago after a syncopal event.
He reports occasional dyspnea on exertion,
but is otherwise doing OK.
His past medical history includes
idiopathic pulmonary hypertension.
He has never had surgery, and his medications
include Sildenafil, and he uses nasal cannula oxygen just
at night.
What is your anesthetic plan for this patient?
Pre-operative Anesthetic Management.
The pre-operative management for this patient and any patient
with pulmonary hypertension should include a visit
to the pre-op clinic if possible.
A thorough history and physical should
be performed for the patient, and review of any echo and cath
lab reports that the patient may have.
For a patient with an echo report,
it is important to look at the most recent echo report,
specifically looking at the patient's anatomy,
and if the patient has any pop-off.
A pop-off is a left to right shunt
which may convert to a right to left shunt
if the patient has an acute event,
and the right ventricular pressures
begin to increase in the heart and are greater
than the left pressures.
This is important because it serves
to decompress the right side of the heart
and to increase cardiac output.
On the echo report, it is also important to look
at the patient's function, look at the patient's
pulmonary arterial pressure as well as the right ventricular
pressure.
In our case example, looking at the echo report
we see that this patient has a flattened septal position
in systole, which is consistent with right ventricular
pressures greater than one half systemic levels.
This indicates that the patient does
have an increased risk for complications during surgery
due to the greater than one half systemic levels.
This patient also has qualitatively good
biventricular systolic function, which is a good sign.
On catheterization reports, it is
important to look at the pulmonary arterial pressure,
looking at the systolic, diastolic and mean levels.
Also, look at the right ventricular
pressure, the pulmonary vascular resistance,
the structure of the heart, the function of the heart,
to look at measured wedge pressures, as well
as the results of vasoactive testing.
For our sample patient, his cardiac catheterization report
indicated that at baseline, his right ventricle systolic
pressure was 72 millimeters mercury,
and systemic pressure was 100 millimeters mercury.
This indicates that his right ventricle pressure
is greater than one half systemic,
meaning that this places him at greater risk for complications
during general anesthesia.
During vasoreactive testing at baseline of 21% oxygen,
the patient had a mean pulmonary arterial pressure of 50,
and a pulmonary vascular resistance of 10.6.
During vasoreactive testing with 100% oxygen and exposure
to inhaled nitric oxide, both his mean pulmonary artery
pressure and pulmonary vascular resistance did decrease.
This was a mild decrease, but does
indicate that he does have vasoreactivity
within his pulmonary vasculature and would respond well
to inhaled nitric oxide or 100% oxygen
if he does have an acute event during surgery.
It is important to discuss the post-op plan
with the patient's cardiologist or an ICU physician.
It is important in these patients to minimize NPO times,
avoiding dehydration and decreased preload
during the pre-op time.
It is also very important to prepare emergency drugs
before the patient even enters the operating room.
These include having things such as inotropes,
including epinephrine, ready.
Inhaled nitric oxide available and in the operating room,
and to also consider ECMO on standby,
depending on the severity of the patient.
Intra-operative Anesthetic Management.
For anesthetic management of this patient,
it is important to give an adequate premedication,
including a benzodiazepine, or even ketamine.
It's important to have a calm patient
because a crying, screaming, and agitated patient
will lead to increased pulmonary vascular resistance,
will lead to changes that will cause
an acute event for pulmonary hypertension.
If the patient is on a pulmonary vasodilator
such as a targeted therapy, it is
important to continue this medication
during the perioperative time.
The main goals of an anesthetic management
for patients with pulmonary hypertension
is to avoid increases in pulmonary vascular resistance
and avoid decreases in systemic vascular resistance.
Decreases in systemic vascular resistance
will lead to changes that cause decreased coronary perfusion
pressure and decreased oxygen delivery to the myocardium,
leading to ischemia, which may precipitate
a pulmonary hypertensive crisis.
For these patients, it is important to place standard ASA
monitors on the patient before induction.
And depending on the case and the patient,
to determine if an arterial line is needed.
Induction of these patients, it's
important to use a balanced anesthetic technique.
It's important to maintain a dedicated
IV if the patient comes to the operating room
already on a pulmonary vasodialator infusion.
Stopping this infusion, even for a brief second for induction,
can lead and precipitate to an acute pulmonary hypertensive
crisis.
An IV induction is preferred for these patients.
However, it is possible to do an inhalational induction
on these patients, if the patient has
adequate ventricular function.
The potential problem with an inhalational induction
is that if you lose the patient's airway,
the patient will begin to hypoventilate,
become hypercarbic.
This will lead to acidosis and eventually hypoxia,
which is going to cause the patient
to have an acute pulmonary hypertensive crisis.
The ideal anesthetic for pulmonary hypertension
includes one in which it causes pulmonary vasodilation,
maintains cardiac contractility, maintains systemic vascular
resistance, and also maintains cardiac output.
However, an ideal anesthetic for pulmonary hypertension
does not exist.
We have our drugs that we are very familiar with,
our volitile anesthetics and our IV anesthetic agents.
However, each is not a perfect anesthetic
for pulmonary hypertension.
Most have good qualities, but also
have an element that causes hemodynamic instability,
potentially for a patient with pulmonary hypertension.
The use of ketamine in patients with pulmonary hypertension
has been controversial in the past.
However a study by Dr. Paul Hickey at Boston Children's
Hospital indicated that ketamine does not
change the pulmonary vascular resistance,
unless the patient also is hypoventilating and becomes
hypercarbic.
A balanced anesthetic technique is the best technique
for patients with pulmonary hypertension.
This technique includes sub-anesthetic doses
of multiple anesthetics in order to achieve an anesthetic state.
The anesthetic management for airway of these patients
is selected based on the procedure.
If the patient is to be intubated,
there needs to be an adequate depth of anesthesia
before intubation is achieved.
An LMA can be used, however it is
important to avoid hypoventilation in order
to avoid hypercarbia, which can lead
to increases in pulmonary vascular resistance.
For maintenance of these patients,
it is important to continue the depth of anesthetic that
is adequate for the stimulus.
A volatile inhalational anesthetic
or a total intravenous anesthetic
can be used for maintenance of these patients.
For ventilation of these patients,
it is very important to avoid hypercarbia and respiratory
acidosis, which both can lead to increases
in the pulmonary vascular resistance
as well as avoiding excessively low or high tidal volumes,
which both can increase the pulmonary vascular resistance.
And it is also important to avoid
excessive low or high peak inspiratory pressures, which
will lead to an increased pulmonary vascular resistance.
As well as avoiding increases in PEEP,
which will increase pulmonary vascular resistance.
The emergence of these patients.
It is very important to minimize noxious stimuli.
Suctioning the endotracheal tube or the patient's oropharynx
should be done while the patient is
under a deep plane of anesthesia.
Tracheal suction and oropharyngeal suction
have been known to precipitate an acute pulmonary hypertensive
crisis.
It is very important to have a smooth and calm extubation
of these patients.
Post-operative Anesthetic Management.
It is important to have adequate post-op monitoring for patients
with pulmonary hypertension.
If the patient is to be monitored
in the PACU versus the ICU depends
on patient factors, surgical factors,
and anesthetic factors.
It is very important in the post-operative course
to provide adequate analgesia and antiemesis,
and also to avoid hypoxia, hypotension, and hypovolemia.
It is very important to be prepared
when you have a patient with pulmonary hypertension,
and to always stay two steps ahead of potential changes
that can occur in these patients.
Case Example - Part 2.
Let's go back to our sample case--
a 15-year-old male with past medical history
of pulmonary hypertension for an ORIF of his tibia.
The patient received a pre-med consisting of midazolam,
and on induction a balanced anesthetic technique
was used with fentanyl, ketamine, propofol,
and rocuronium.
The patient remained stable on induction.
He had an easy intubation, and was also hemodynamically
stable on-- during intubation.
However, 30 minutes after incision, the patient suddenly
had a decrease in oxygen saturation, blood pressure
and end-tidal carbon dioxide.
What is your differential diagnosis,
and what are you going to do to treat this patient?
Pulmonary Hypertensive Crisis.
Patients with pulmonary hypertension,
you should always think if the patient decompensates,
the first thing that should be on your differential diagnosis
is a pulmonary hypertensive crisis.
The definition of pulmonary hypertensive crisis
is an acute on chronic increase in pulmonary vascular
resistance, resulting from an acute increase
in vascular tone of the reactive portion
of the pulmonary vasculature.
During these changes, a rapid increase in pulmonary vascular
resistance will lead to an increased right ventricular
afterload, causing right ventricular pressure
to increase, which will in turn lead
to decreases in the left ventricular preload, decreases
in coronary perfusion pressure, and eventually causing
ischemia, which will lead to changes such as hypoxia
and acidosis, which will further increase this cycle.
During an acute event, it is possible to have cardiac arrest
with low cardiac outputs.
If the patient does develop cardiac arrest,
it may be difficult to resuscitate these patients.
CPR may be ineffective due to an enlarged right ventricular
size that compresses the left ventricle, causing
ineffective cardiac output.
Pulmonary hypertensive crisis can happen at any time
during the perioperative period, and this can occur even hours
after the intra-operate time.
Intra-operative findings of pulmonary hypertensive crisis
include sudden desaturation, systemic hypotension,
decreases in end-tidal CO2, sinus tachycardia,
elevated central venous pressure, and a new onset
EKG change of RV strain or ischemia,
as well as bradycardia, which is an ominous sign
of impending cardiac arrest.
If you have access to a transesophageal
echocardiograph, you will see that the right ventricle is
dilated and poorly contracting, as well as an under filled
left ventricle.
And you will see pulmonary regurgitation
and tricuspid regurgitation, as well as
elevated right ventricular pressures.
For treatment of a pulmonary hypertensive crisis,
it is important to get rid of the stimulating event
and to stabilize the patient.
It is important to administer 100% oxygen to the patient.
Oxygen is a vasodilator and will vasodilate
the pulmonary vasculature.
It is also important to hyperventilate the patient.
Hyperventilation will lead to decreases in carbon dioxide
levels, and therefore vasodialate
the pulmonary vasculature.
It's also important to exclude other causes that
may mimic a pulmonary hypertensive crisis,
such as a pneumothorax.
It's important to decrease mean arterial pressures if possible,
and to correct metabolic acidosis.
Acidosis will lead to increases in pulmonary vascular
resistance and further increase the acute event.
It is also important to support the heart of the patient,
providing an inotrope such as epinepherine.
If the patient is in the middle of surgery,
it's important to administer proper analgesia
to get rid of any noxious stimuli which
may be precipitating an event.
It is also important to initiate ECMO early in these patients
in order to stabilize the patient
and provide adequate cardiac output to the patient.
If the patient does develop cardiac arrest,
it is very important to start PALS algorithm.
However, keep in mind that CPR may
be ineffective due to the enlarged right
ventricle compressing the left ventricle
and leading to decreased cardiac output.
Today's pulmonary hypertension talk,
the teaching points are: pulmonary hypertension
is associated with significant morbidity and mortality
in the perioperative time, careful planning
is very important pre-operatively,
and pulmonary hypertensive crisis
can occur both intra-op and post-op.
Thank you very much.
Please help us improve the content by providing us
with some feedback.
For more infomation >> "Anesthetic Considerations in Pulmonary Hypertension" by Stephanie Grant for OPENPediatrics - Duration: 17:27.-------------------------------------------
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Treatment for Young People with Eye Bags and Deep Creases Under Eyes - Duration: 8:04.
Thank you for your question.
You submitted a question with a single photo and you state that you're 25 and that you've
always had under eye bags and you're looking for a way to address these issues. And you're
asking about creams and other options.
Well, I can certainly give you my perspective as a specialist. A little bit of background,
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And I can tell you that I've dealt with a lot of patients with exactly this type of
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Under eye bags is probably the most common procedure that we perform or helping people
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So to begin with, it is extremely common for a person like yourself to state that they've
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Hey Guys , this is RacingRich
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plz note guys after downloading the software then you need to open the file
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Angela Constance MSP - Keynote, Achieving Inclusive Growth for Scotland - Duration: 13:46.
Would you please welcome Angela Constance MSP
Morning. I'm absolutely thrilled to be able to join
you all here today and I want to start off with a quote from the political
philosopher John Rawls who said "a just society is one where if you knew
anything about it you'd be willing to enter it at a random place" in other words
you'd choose to join the society no matter where you are born,
and this is a
tough challenge to us all and certainly isn't true for us in Scotland just
yet, and we know that here in Glasgow two children born only a few streets apart
can have very different outcomes throughout their life, and that is why the
Scottish Government is focused on delivering economic growth in a way that
is more inclusive and by that I mean inclusive of people and inclusive of
places. What we all want is a country where people can flourish no matter
where they are born and no matter who they are and those of us here today who
can call Scotland home, we're lucky and we're lucky because we live in
a wealthy country and even without oil GDP per head in Scotland is higher than
the UK average excluding London. Scotland's unemployment rate is lower than that of
the UK. And we're also living longer and healthier lives, a child born today has a
life expectancy higher than ever before and public attitudes towards the quality
and diversity are improving and we are becoming a more equal country in many
respects. Having said that some of us in Scotland today are less, far less fortunate
than others in 2015-16 seven out of ten children in poverty in Scotland were
living in households where someone was actually in work, in other words work
is no longer a guarantee against poverty. Women still get paid less than men are
less likely to be in full-time employment and more likely
to stay at home due to caring commitments. More people are in work in Scotland than
pre-recession high but job opportunities vary considerably across regions, and
crucially as I mentioned to start with some people and some places have over
recent decades benefited much less from economic growth than others. The
challenges I raise are not only seen in Scotland but right across the UK and other
advanced economies and equality has remained stubbornly persistent with the
wealthiest benefiting more from growth than the rest and Barack Obama has
called inequality 'the defining challenge of our time.' The International evidence
is very clear, inequality hardens lives, it leads to poorer educational
prospects well-being and health. It limits social mobility right across
generations meaning that if you are born poor you are more likely to grow up poor.
And what is becoming more apparent too is that inequality damages economic
growth. Analysis by researchers at the OECD in 2014 estimated that rise in income
inequality in the UK between 1990 and 2010 had reduced GDP per capita growth
by 9 percentage points and that's approximately 1600 pounds for every man
woman and child in the UK. So it is in our interest as a government and as a
country to grow the economy in a fairer and more inclusive way and this
means putting people at the heart of how we understand, at the heart of how we
nurture and at the heart of how we share our economy. And our economic strategy
published two years ago recognised this need for a more inclusive approach to
economic growth underpinned by the twin pillars of boosting competitiveness and
tackling inequalities. We made it clear that in Scotland we will put a different
emphasis on growth that we won't pursue growth at any cost or limit it's benefits
to just a few. But that we will ensure growth means
prosperity and opportunity for all regardless of who you are
or what part of Scotland you live in. We put emphasis on understanding what we need
to do to tackle the uncomfortable truths behind some of the positive headline
performance such as tackling the regional variation in economic
performance and opportunity, addressing the gender pay gap, tackling in-work poverty
and issues around pay and progression. Of course these words need
to be backed up by action. So we are investing in a number of areas to promote
inclusive growth for example, from improving wages and working conditions
through a fair work Convention and the business pledge, to helping more parents
back to work by increasing free high-quality early learning and
childcare for all three and four-year-olds to over 1100 hours by the end of this
Parliament. Also by equipping our young people for the future by increasing the
Scottish attainment challenge funding to 750 million pounds and increasing the
number of modern apprenticeship opportunities. And we're also delivering
significant investment in inclusive economic growth across Scotland
through the city region deals and these investments will create thousands of
jobs, raise skills in local labour markets and support inclusive economic
growth. Our approach has been getting international recognition too, the OECD
have called Scotland a real inclusive growth incubator and Professor Joseph
Stiglitz has said that our economic strategy I quote "leads the way in
identifying the challenges around inequality and provides a strong vision
for change and if we succeed we will all benefit because a more inclusive economy
is good for everyone, and an inclusive economy where income and wealth are shared
more widely delivers higher long-term growth and reduces inequality. Sure
it's not just the right thing to do but it's a smart thing to do. Our focus in
government is on making real improvements to the lives of people,
communities and their families. And this means people from
across all parts of Scotland and from all our communities which brings me to
the centrality of place to inclusive growth. So what does inclusive growth
mean for communities the length and breadth of Scotland? It means we are living
in successful communities which are economically physically and socially
strong, to achieve those communities themselves need to be actively involved
in and leading decision-making. Inclusive growth can only be truly long-lasting
and effective if it is done by people and not done to them.
It also means partners work in a joined up way with communities particularly in
areas like economic development, planing, housing, education and skills. And it
means delivering growth in a way that helps build community cohesion we know
that inclusive and cohesive communities that embrace diversity provide a better
quality of life for everyone. Communities thrive when the feel a
shared sense of belonging, when they learn and grow together, and when they feel
able to live their lives in peace. And finally it means that the benefits of
our economy are spread across different communities, and we want to ensure that
all parts of Scotland have the potential to thrive equally in a truly balanced
economy. We know that the geographic concentration and the segregation of
industries, jobs, poverty and wealth, means that different parts of Scotland face
specific challenges that require tailored responses, and we must ensure social and
economic progress is felt throughout the country from Selkirk to Stornoway
Aberdeen to Arron all parts of Scotland must be able to keep building
sustainable communities and to prosper. So how will we achieve this? The
Community Empowerment Act passed in 2015 sets out in legislation how we
will help to empower community bodies through the ownership of land and
buildings and by strengthening their voices in the decisions that matters
to them. This is backed up by significant funding
that supports communities to take decisions about funding priorities and
priorities to tackle poverty and inequality but in their own terms, and
this includes the aspiring communities fund and the empowering communities fund
also. Because by giving communities the power and confidence to shape their own
futures we can tackle poverty and address
inequalities far more effectively. Stronger community empowerment is also a
key part of our planning work. It is a cornerstone of the forthcoming
planning bill, our work with the place standard and the community involvement
in planning. It will continue to ensure the communities are empowered to
play an active role in designing how their places will work and how they will
grow in the future. We're also taking action to drive a more inclusive and
balanced economy across all parts of Scotland
so our approach to regeneration, working in partnership with local
government and communities makes a big contribution to to delivering this. And one
example that I would like to highlight is our ongoing support for Clyde Gateway
which has transforming one of the most deprived areas in Scotland. The
work of Clyde Gateway is tackling inequalities, creating jobs and opportunities
and most importantly is improving outcomes and chances for local people
and communities. And this work was I am pleased to say was recognised by the Royal
Institution of Chartered Surveyors and awarded the top regeneration project in
the UK in 2013. We will work with our agencies and partners to ensure that our
enterprise and skill support works in a way that helps deliver the skills that
Scotland's people and economy need to progress our inclusive growth ambitions.
Our recommendations published last Thursday have highlighted a particular focus on
regional partnership approaches bringing the agenda firmly back to the importance
of place. Increasingly we are seeing local authorities across Scotland coming
together and working collaboratively with our national agencies the private
sector and other partners these partnerships have evolved for
different reasons, but all are focused on strengthening
regional economies across Scotland and delivering better outcomes for
individuals communities and businesses within the area. For example in order to
tackle the unique challenges faced in the South of Scotland we are going to
create a new enterprise agency in the heart of the region and this will aim to
support inclusive growth and increase productivity, helping the area to thrive
the decentralisation of economic decision-making extends across the
country the Scottish Government is a full partner in all three of the city region
deals agreed in Scotland thus far and has committed to investing 760 million
pounds over the next 10 to 20 years for city region deals in Glasgow, Aberdeen
and Inverness and we are also fully committed to delivering City Region
deals for Edinburgh and Southeast Scotland, Stirling and Clackmannanshire
and the Tay cities. And these investments will create thousands of jobs, raise
skills in local labour markets and support inclusive economic growth. If we
are going to meet the challenge that John Rawls has set us for a just
society we know we've got a long way to go. I hope that the actions I have outlined
are just the foundations for building a more inclusive economy the
length and breadth of Scotland, where everyone
has the opportunity to flourish no matter who they are or where they're
born. And I know you'll have many challenges for myself and other Scottish
Government ministers. I suppose my last remark would be a wee challenge to you
as you move into the second half of the conference and that's to think about
what you can do with others to help deliver inclusive growth in Scotland.
We've already got international recognition on our approach. We now have
to find the ways to translate all of this into practice and on the ground that
will be truly transformational and eradicate poverty and inequality in this
country while achieving sustainable economic growth. So thank you
very much and I look forward to your questions.
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