Management von Patienten mit pulmonaler Hypertonie

Abstract

Due to the increased survival of patients with pulmonary hypertension, even non-cardiac anesthesiologists will see these patients more frequently for anesthesia. The hemodynamic goal in the perioperative period is to avoid an increase in pulmonary vascular resistance (PVR) and to reduce a possibly pre-existing elevated PVR. Acute increases of chronically elevated PVR may result from hypoxia, hypercapnia, acidosis, hypothermia, elevated sympathetic output and also release of endogenous or application of exogenous pulmonary vasoconstrictors. Early recognition and treatment of these changes might be life saving in these patients. Drug interventions to perioperatively reduce PVR include administration of pulmonary vasodilators, such as oxygen, prostacyclines (epoprostenol, iloprost), phosphodiesterase III (milrinone) and V (sildenafil) inhibitors, as well as nitrates and nitric oxide. Along with the concept of selective pulmonary vasodilation inhalative administration of pulmonary vasodilators has benefits compared to intravenous administration. New therapeutic strategies, such as inhalational iloprost, inhalational milrinone and intravenous sildenafil can be introduced without significant technical support even in smaller departments.

Perioperative Anesthesiological Management of Patients with Pulmonary Hypertension

“…The purpose of these preparations should be, on one hand, to evaluate the functional state of the heart and lung organ systems as good as possible so that the probability of complications, including right-sided heart failure, can be properly estimated. On the other hand, experts should strive to optimize the patient's initial condition as far as possible by adjusting the current specific medication and treatment of comorbidities, which minimizes the individual risk of complications [27]. In many cases, patients with pulmonary hypertension receive ongoing anticoagulant therapy, which necessitates the adaptation and preparation of anticoagulant medication prior to inpatient hospitalization.…”

“…In many cases, patients with pulmonary hypertension receive ongoing anticoagulant therapy, which necessitates the adaptation and preparation of anticoagulant medication prior to inpatient hospitalization. This includes establishing, prior to the surgical procedure, if postoperative recovery at home is an option and if the prerequisites for this option can be fulfilled (family environment, primary care physician, social services, outpatient services, and insurance providers) [27]. …”

“…It is recommended, in particular for patients with chronic lung disease as a cause of pulmonary hypertension, that an examination of pulmonary function and an arterial blood gas analysis be conducted prior to the surgical intervention [27]. …”

“…This applies, in particular, to the specific therapy of pulmonary hypertension. At the time of surgery, the patient should ideally have been in a stable condition for an extended period of time [27, 30]. …”

Allgemeine Therapie der pulmonal arteriellen Hypertonie

“…Unter diesen Bedingungen liegt die perioperative Letalität für elektive Eingriffe bei Patienten mit PAH bei ca. 2 %; bei Notfalleingriffen steigt sie allerdings bis auf 15 % an[21].Ziele des perioperativen Managements bei PH sind die Verbesserung der Oxygenierung, Vermeidung einer Hyperventilation, Atelektasenbildung oder Lungenüberblähung, Katecholaminfreisetzung durch Stress, die Korrektur einer metabolischen Azidose sowie die Behandlung einer systemischen Hypotension[22]. Bei den meisten PH-Patienten ist eine invasive Überwa-chung der pulmonalen Hämodynamik sinnvoll.…”