Berapa Nilai Parameter Hemodinamik Utk. Diagnosis PH?

Berapa nilai parameter hemodinamik
utk. diagnosis PH?
a. MAP >100 mmHg saat aktivitas

b. MPAP >30 mmHg saat istirahat
c. MPAP >30 mmHg saat aktivitas
d. Systolic PAP >25 mmHg saat aktivitas
e. Semua salah
Patofisiologi umum PH :
a. Peningkatan tekanan hidrostatik di arteri paru

b. Peningkatan tekanan hidrostatik di vena paru
c. Peningkatan tekanan hidrostatik kapiler paru
d. Semua benar
e. Semua salah
Faktor-faktor pendukung
kemungkinan PH pada pasien :
(boleh >1 jawaban)
a. Kelainan katup mitral

b. Intracardiac septal defect
c. SpO2 <92 (room air)
d. Peningkatan corak bronkovaskular pd CXR
e. Penyakit paru menahun
Penyebab peningkatan PVR intra-
anestesia:
(boleh >1 jawaban)
a. Nyeri
b. Hipoventilasi
c. TV > 10 mL/kg
d. Asidosis
e. Dehidrasi
Terapi PH intra-anestesia :
(boleh >1 jawaban)
a. N2O
b. O2
c. Volatile anesthetic
d. Opioid
e. NTG
PULMONARY HYPERTENSION
a big enemy which is rarely seen
Ratna F. Soenarto
Dept. of Anesthesiology & Intensive Care
Medical Faculty, University of Indonesia / Cipto Mangunkusumo Hospital
Jakarta
Definition of PH
• “ a group of disease characterized by

virtualy identical obstructive pathological
changes of the pulmonary microcirculation
and by a favourable response to the long-
term administration of prostacyclin” (WHO,
2004)
Diagnosed as PH, if:
• PA Pressure > 25 mmHg at rest

• PA Pressure > 30 mmHg on excercise
Golden standard : cardiac (pulmonary
artery) catheterization
Echocardiography : indirect detection

through TR
The WHO classification
• Group I: Pulmonary Arterial Hypertension (PAH):

idiopathic, familial, associated with collagen vasc diseases, HIV,
portal hypertension, “Left to Right” shunt, assoc. with venous /
capillary disease.
• Goup II: PH assoc. with left heart disease

• Group III: PH assoc. with lung disease &/ hypoxaemia
• Class IV: Thromboembolic disease
• Class V: Miscellaneous
Secondary PH
Ppa = (Q x PVR) + Ppv
Ppa = Pulm Art Pressure

Ppv = Pulm Vein Pressure
Q = Blood flow to the lungs
PVR = Pulm Vasc Resistance
Ppa↑
PVR ↑
↑↑
Ppv ↑
Q↑ 1
Progressiveness of PH
Clinical change in PH. Kaddoum RN, Mubarak K, Chidiac JE.M.E.J. Anesth18

(6), 2006
RV Failure
• RV failure e.c. pulmonary venous

hypertension is common
• Assoc w/ left heart valve diseases
Right heart Left heart
Systemic
Venous return blood supply
Congestion of
blood flow
Increased right heart Increased pulmonary

pressure vascular pressure
Right Heart
Failure
•Hepatomegaly
•Ascites
•Leg edema
Normal Pulm Vasc
• Tend to vasodilate
• Vasodilator mediators (prostacyclin, NO, β2
agonis, etc)
• Vasoconstrictor mediators (tromboxane A2,
endothelin)
Pressure/ volume overload
Shear force
Endothelium disruption
Dauerman HL, Morgan JP. Pathophysiology of
secondary pulmonary hypertension
Gr I: muscularization of arterioles
II: medial hypertrophy & intimal hyperplasia
III: intimal cells replaced by collagenous tissue
IV:
V:
VI: loss of arterioles
Treatment
• Pulm venous hypertension : increase LV

function → valve surgery
• Multidrugs & O2 therapy
• None is proven beneficial
Treatment
• Endothelin receptor
antagonists (bosentan,
sitaxentan)
• Inhibitors of phosphodiesterase
(3 & 5)
• Prostacyclin (prostaglandin I2)

considered (the most) effective
drug → iloprost & treprotinil
(inhaled), beraprost (oral),
alprostadil (IV)
Prognosis
• Primary PH usually die at the 2nd-3rd decade

• Female > male (3:1)
• Most of PH are secondary
• Median age of survival : 2.8 yr (after
diagnosed)
(NIH 1981-1987)
Pre-anesthesia period
Modified NYHA for PH
• I : no physical limitation
• II: mild physical limitation. Normal activities
lead to symptoms. Relief w/ rest
• III: significant limitation. Mild activities lead to
symptoms. Relief w/ rest
• IV: severe limitation. Symptoms while resting.
Bed side detection of PH
• Dyspnea. Semi-sitting position is common

• Probable cyanosis
• Low SpO2 w/ room air
• Evidence of L to R shunt / mitral or aortic
abnormality / COPD
Anesthesia for PH patients
• High risk.
• Major complication (PH crisis/ arrest): 4.5%
• Minor complication 5.1%
• Significant predictor : suprasystemic PAP
Carmosino MJ, Friesen RH, Doran A, Ivy

DD.Anesth Analg. 2007 Mar;104(3):521-7.
Pre-anesthesia
• Control any infection

• O2 supplement
• Inhalation (β2, anti-inflammation)
• Physiotherapy
• NO donor
• Inhibitor of PDE3 / PDE5
Intra-anesthesia
• Anesthesia can’t change

the histology
• Can change physiology
• PVR usually decreases
• PVR can increase & lead

to PH crisis
Intra-anesthesia
• Anesthesia can’t change - sympathetic

the histology overtone
pain, acidosis, hypercarbia,
• Can change physiology hypothermia
- high
• PVR usually decreases intrathoracic
pressure
• PVR can increase & lead - high blood
to PH crisis
viscosity
Acute Intraop. PH
Thromboemboli Deep vein thrombectomy, pregnancy, partus
CO2 embolism Laparoscopy
Air embolism Surgery in sitting position
Bone cement Orthopaedic procedure
Protamine Cardiac surgery
Extracorporeal circulation Cardiac surgery
Ischaemia-reperfusion synd Clamping-unclamping
Loss of pulmonary vasculature Pneumonectomy

Anesthesia
Positive pressure ventilation is not

contraindicated in PH patients
!!!
Anesthesia
• High FiO2
• IPPV advantages : controlled oxygenation &
ventilation, work of breathing (-)
• IPPV disadvantages : hyperinflation can
increase PVR, difficult to wean
• PEEP : can increase oxygenation
• PEEP can cause high intrathoracic pressure
Anesthetic Drugs
Most of anesthetics are vasodilator → PVR↓

Ketamine : SVR & PVR↑→ PVR/SVR ratio unchanges
Propofol : SVR↓, PVR↓ → PVR/SVR ratio ↑
Thiopental : SVR↓, PVR↓ → PVR/SVR ratio less↑
Opioid : strong analgetic. Morphin : PVR↓
Volatile : SVR↓, PVR↓ → N2O increases PVR
Milrinone: PDE 3 inhib, inodilator, ↑heart contractility, pulmonary
vasodilator
Vasodilator drugs : NO donors, PG
Be careful w/ anti PG drugs
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Anesthetic Drugs

vasodilator
Perioperative Prognosis
• Depends on severity of the disease

• Influenced by surgical event, chemical/
drug used, anesthetic drugs &
techniques
Low Risk Dermatology, endoscopy, cataract, breast
Carotid endarterectomy, head & neck, gynaecology,

gastrointestinal/ intraabdominal, orthopaedy,
Medium Risk prostate,
thorax
Emergent major surgery, aortic / major vascular,

High Risk liver
transplant, surgery w/ large fluid shift/ blood loss
What anesthesia can do
• Pain
• Lung hyperinflation
• Hypercarbia
• Vasoconstrictor
• Drugs acting as anti-PG
Relationship between lung volume & PVR.
Fischer LG, Van Aken H, Bürkle H. Anesth Analg
2003;96:1603–16
Signs of Acute Intraop. PH
• SpO decreases fast & progressively

2
• CVP increases
• BP decreases fast & progressively
• HR increases, then decreases as BP
drops
What anesthesiologists could do
• Hyperventilate w/ high O2
• Stop manipulation
• Deepen anesthesia if possible
• Pulmonary vasodilators
• Positive inotropes if BP drops
SUMMARY
• Proper monitoring
• Prevent vasoconstriction
• Avoid hypoventilation
• Good analgesia
• Avoid high blood viscosity
• Avoid atelectasis
• Avoid lung hyperinflation
INFORMED CONSENT
!!!

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Berapa nilai parameter hemodinamik

utk. diagnosis PH?

a. MAP >100 mmHg saat aktivitas

a. Peningkatan tekanan hidrostatik di arteri paru

a. Kelainan katup mitral

• “ a group of disease characterized by

• PA Pressure > 25 mmHg at rest

Echocardiography : indirect detection

• Group I: Pulmonary Arterial Hypertension (PAH):

• Goup II: PH assoc. with left heart disease

Ppa = Pulm Art Pressure

Clinical change in PH. Kaddoum RN, Mubarak K, Chidiac JE.M.E.J. Anesth18

• RV failure e.c. pulmonary venous

Increased right heart Increased pulmonary

• Pulm venous hypertension : increase LV

• Prostacyclin (prostaglandin I2)

• Primary PH usually die at the 2nd-3rd decade

• Dyspnea. Semi-sitting position is common

Carmosino MJ, Friesen RH, Doran A, Ivy

• Control any infection

• Anesthesia can’t change

• Can change physiology

• PVR usually decreases

• PVR can increase & lead

• Anesthesia can’t change - sympathetic

Thromboemboli Deep vein thrombectomy, pregnancy, partus

CO2 embolism Laparoscopy

Air embolism Surgery in sitting position

Bone cement Orthopaedic procedure

Protamine Cardiac surgery

Extracorporeal circulation Cardiac surgery

Ischaemia-reperfusion synd Clamping-unclamping

Loss of pulmonary vasculature Pneumonectomy

Positive pressure ventilation is not

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

Most of anesthetics are vasodilator → PVR↓

• Depends on severity of the disease

Carotid endarterectomy, head & neck, gynaecology,

Emergent major surgery, aortic / major vascular,

• SpO decreases fast & progressively

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