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Pulmonary Hypertension (Anaesthetic Plan (MDT (Monitoring (Arterial line,…
Pulmonary Hypertension
- Pulmonary Arterial Hypertension
- Idiopathic
- Heritable
- Drug-induced/toxins
- Associated with connective tissue, HIV, portal hypertension, CHD, schistosomiasis
- PH due to Left Heart Disease (post-capillary)
- LV systolic dysfunction
- LV diastolic dysfunction
- Valvular disease
- Left heart inflow/outflow obstruction (cong or acqu)
- PH due to lung diseases
- COPD
- Interstitial lung disease
- Sleep disordered breathing
- Alveolar hypoventilation disorders
- Chronic high-altitude exposure
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- Pulmonary Hypertension of unclear multifactorial mechanisms
- Haematological
- Systemic: sarcoidosis, pulmonary histiocytosis
- Metabolic: glycogen storage, gauchers, thyroid
- Others: tumour obstruction, fibrosing mediastinhtis, CRF
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Pathology
PAH
- PGI2 reduced (vasodilator)
- Inc Thromboxane A2 (vasoconstrictor and platelet activator)
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Treatment of PAH only
Endothelial receptor antagonists
- Bosnian
- Ambrisentan
- Macitentan
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Supportive
- Anticoagulation
- Diuretics
- O2
- Infection control
Risk Stratification
Patient factors
NYHA function class >= 2
6MWD <300m
Coronary artery disease
PE
CKD
RVH with severe systolic dysfunction
Higher mean PAP
Echo risk predictors
- RA enlargement
- reduced tricuspid excursion
- pericardial effusion
Surgery factors
Emergency surgery
intermediate - high risk surgery
ASA >2
3hr procedure
Intraoperative vasopressor use
Anaesthetic Plan
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Breathing
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PEEP: good for oxygenation, bad for preload maintenance
Circulation
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Inotropes: Dobutamine, Adrenaline, Milrinone
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Mild mPAP 25-40
Mod 40-55
Severe >55
PASP = RVSP (in the absence of RVOTO or PS)
RVSP = 4v2 + CVP
(4v2 = TV pressure gradient)
Mean PAP = (0.61 x sPAP) + 2
