Anaesthetic management of a patient with severe pulmonary arterial hypertension for renal transplantation

Abstract

We describe a patient with severe pulmonary arterial hypertension scheduled to undergo live-related renal transplantation. We emphasise on meticulous anaesthetic management and early renal transplantation to prevent the progression of disease which would become refractory to treatment, leading to right ventricular failure. Regional (continuous epidural) anaesthesia has been used as technique of choice, where the selective advantages of this technique have been put to good use.

Urologic Surgery with Multisystem Comorbidities: A Case Report

“…Standard pre-operative screening includes assessment of functional class, cause, exercise tolerance, pulmonary vascular hemodynamics, and overall risks, benefits, and timing of the proposed intervention or surgery in an optimized patient [ 11 , 14 ]. Resting mean pulmonary artery pressures greater than 25 mmHG in the setting of pulmonary vascular resistance greater than 240 dyn s/cm 5 and pulmonary arterial occlusion pressure less than or equal to 15 mmHG support the diagnosis of pulmonary artery hypertension [ 2 , 8 – 10 , 12 , 14 , 16 , 19 ].…”

“…Emphasis is also placed on maintaining systemic vascular resistance and judicious management of hemodynamics during induction of general anesthesia, such as the sympathetic response to intubation, incision, and the decrease in preload from positive-pressure ventilation [ 13 ]. Regional anesthesia with peripheral nerve blocks under ultrasound guidance is beneficial, with improved numerical pain scores and minimizing the pulmonary and cardiac perturbations to which patients with moderate-to-severe pulmonary arterial hypertension are prone [ 11 , 13 , 19 ]. Neuraxial anesthesia is associated with decreased SVR, among other detrimental changes, and is generally contraindicated with the exception of parturients receiving a low dose or slowly titrated epidural, in which general endotracheal anesthesia poses a greater risk due to the presence of pulmonary hypertension [ 9 , 11 , 13 , 17 , 20 ].…”