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Abstract Pulmonary hypertension is a major reason Management decision making for nurses 124 case studies elevated perioperative morbidity and mortality, even in noncardiac surgical procedures.
Patients should be thoroughly prepared for the intervention and allowed plenty of time for consideration.
All specialty units involved in treatment should play a role in these preparations. After selecting each of the suitable individual anesthetic and surgical procedures, intraoperative management should focus on avoiding all circumstances that could contribute to exacerbating pulmonary hypertension hypoxemia, hypercapnia, acidosis, hypothermia, hypervolemia, and insufficient anesthesia and analgesia.
Due to possible induction of hypotonic blood circulation, intravenous vasodilators milrinone, dobutamine, prostacyclin, Na-nitroprusside, and nitroglycerine should be administered with the greatest care.
A method of treating elevations in pulmonary pressure with selective pulmonary vasodilation by inhalation should be available intraoperatively iloprost, nitrogen monoxide, prostacyclin, and milrinone in addition to invasive hemodynamic monitoring.
During the postoperative phase, patients must be monitored continuously and receive sufficient analgesic therapy over an adequate period of time. All in all, perioperative management of patients with pulmonary hypertension presents an interdisciplinary challenge that requires the adequate involvement of anesthetists, surgeons, pulmonologists, and cardiologists alike.
Background Pulmonary hypertension represents an important risk factor for increased perioperative morbidity and mortality. Stress, pain, ventilation, and surgery-related inflammation can further increase pressure and resistance within the pulmonary arteries and cause right-sided heart failure.
In a recently published study, Kaw et al. The PH patients had a significantly increased risk for hemodynamic instability, heart failure, postoperative sepsis, and respiratory failure.
In addition, they required significantly prolonged postoperative ventilation and a longer intensive care stay and had to be readmitted for inpatient treatment much more frequently within the first 30 days following surgery [ 6 ]. Perioperative management of patients with major pulmonary hypertension also presents a great challenge to physicians.
In the opinion of the authors, it is crucial to understand the pathophysiological mechanisms underlying this disease, not only for the long-term treatment of patients with pulmonary hypertension, but also for the development of treatment concepts in the perioperative environment.
The anesthetist will have a central role to play in achieving this objective. Consequently, this paper will begin by what is currently known about the pathophysiology of pulmonary hypertension and right-sided heart failure, before outlining concepts for perioperative anesthesiological management focusing on noncardiac surgery.
Definition and Pathophysiology of Pulmonary Hypertension Pulmonary hypertension comprises a number of diseases, all of which have the common symptom of increased pressure in the pulmonary arteries. These diseases are characterized by a progressive course and a poor prognosis for the patient Dana Point Classification; see Table 1 [ 7 ].
In order to diagnose pulmonary hypertension PHit is necessary to measure the mean pulmonary artery pressure PAPm during right-heart catheterization. Classification of pulmonary hypertension Dana-point [ 7 ]. There are multiple reasons for elevated pressure in the pulmonary circulation.
A basic distinction is made between precapillary and postcapillary PH. Postcapillary PH is caused by left-heart disease, whereas the various forms of precapillary pulmonary hypertension are differentiated on the basis of their origin Tables 1 and 2.
Hemodynamic characteristics in patients with pulmonary hypertension mod. The main inducers are hypoxic vasoconstriction and a disequilibrium between vasodilating NO, prostaglandins and vasoconstricting thromboxane, endothelin mediators. In the event of pulmonary fibrosis and emphysema, there is an additional loss of the capillary bed.
It is interesting to note that, in the case of CTEPH, the remodeling processes described previously also occur in vessel regions not affected by thrombi.
The reasons for this disease are multifactorial and include genetic, endothelial, inflammatory, immunological, and coagulatory factors [ 8 ].
In idiopathic pulmonary arterial hypertension IPAHthe modifications to the pulmonary arteries described previously occur even in the absence of the usual trigger mechanisms. The increased pulmonary pressure and resistance, in combination with the chronically elevated afterload, result in hypertrophy and dilation of the right ventricle.
A phase of stable physiological adaptation remodeling of the right ventricle is followed by maladaptive hypertrophy and progressive right-sided heart failure with decreased cardiac output, even at rest, and the typical clinical symptoms Figure 1Table 3.
In this case, the degree of right-ventricular dysfunction is critical in determining the prognosis of the disease. Clinical findings in patients with pulmonary hypertension mod. Development of right-ventricular failure in patients with pulmonary hypertension.
Prevalence of Pulmonary Hypertension There is no reliable data on the prevalence of patients with PH, for example, in an average anesthesiological patient population.
An impression can be gained by considering the prevalence of individual entities of PH. The occurrence of PH in restrictive and obstructive lung diseases varies, depending on the severity of these diseases. In a collective of patients with severe chronic obstructive pulmonary disease or pulmonary emphysema who underwent right-heart catheterization before a planned lung transplantation or lung volume reduction, Type or paste a DOI name into the text box.
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