Safety of regional anesthesia in Eisenmenger's syndrome☆

Martin, John T.; Tautz, Timothy J.; Antognini, Joseph F.

doi:10.1053/rapm.2002.35706

Cited by 62 publications

(66 citation statements)

References 46 publications

(11 reference statements)

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“…We were unable to collect detailed data on the perioperative management of all patients, but it appears that modern anaesthesiology is capable of preventing haemodynamic deterioration in most cases. Although there is consensus amongst anaesthesiologists that regional anaesthesia is preferred over general anaesthesia in patients with PH [18,19], there is no indication from our study that general anaesthesia is associated with more frequent or more serious complications than regional anaesthesia. However, our study was not sufficiently powered to compare the risks and complication of these approaches.…”

Section: Discussioncontrasting

confidence: 59%

Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey

et al. 2012

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We conducted an international, prospective, 3-year questionnaire-based survey among 11 pulmonary hypertension centres to assemble data from patients with pulmonary arterial hypertension (PAH) undergoing noncardiac and nonobstetric surgery.Data were collected between July 2007 and June 2010 from 114 patients with PAH (70% female, mean age 57 years) who underwent major surgery. At the time of surgery, 43% were in functional class III/IV. 82% of the interventions were performed under general anaesthesia and 18% under spinal anaesthesia. Major complications occurred in seven (6.1%) of the patients, of whom four died, resulting in an overall perioperative mortality rate of 3.5%. The mortality rate was 15% (two out of 13) in emergency procedures, compared with 2% (two out of 101) in nonemergency procedures (p50.01). Risk factors for major complications were an elevated right atrial pressure (OR 1.1, 95% CI 1.0-1.3; p50.01), a 6-min walking distance ,399 m at the last preoperative assessment (OR 2.2, 95% CI 1.1-3.7; p50.04), the perioperative use of vasopressors (OR 1.5, 95% CI 1.2-2.7; p50.03) and the need for emergency surgery (OR 2.4, 95% CI 1.4-3.6; p50.01).Major surgery in patients with PAH continues to be a high-risk procedure, particularly when emergency interventions are needed.

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Section: Discussioncontrasting

confidence: 59%

Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey

et al. 2012

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“…This has also been suggested in patients with Eisenmenger's syndrome, where, using 103 noncardiac anaesthetics, the perioperative mortality of those receiving GA was 18% compared to 5% in those undergoing RA, although this may well have been an indirect indicator of the increased mortality seen in major versus minor surgery (24 versus 5%; p,0.01) as more patients undergoing GA also underwent more major surgery [29]. Patients with PAH that tolerate pregnancy have a particularly high perioperative risk, with a historical mortality of 36-50% [21,30], which, even in the modern treatment era, remains as high as 25% [22].…”

Section: Discussionmentioning

confidence: 82%

Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension

Price¹,

Montani²,

Jaïs³

et al. 2009

European Respiratory Journal

118

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The anaesthetic management and follow-up of well-characterised patients with pulmonary arterial hypertension presenting for noncardiothoracic nonobstetric surgery has rarely been described.The details of consecutive patients and perioperative complications during the period January 2000 to December 2007 were reviewed. Repeat procedures in duplicate patients were excluded. Longer term outcomes included New York Heart Association (NYHA) functional class, 6-min walking distance and invasive haemodynamics.A total of 28 patients were identified as having undergone major (57%) or minor surgery under general (50%) and regional anaesthesia. At the time of surgery, 75% of patients were in NYHA functional class I-II. Perioperative deaths occurred in 7%. Perioperative complications, all related to pulmonary hypertension, occurred in 29% of all patients and in 17% of those with no deaths during scheduled procedures. Most (n511, 92%) of the complications occurred in the first 48 h following surgery. In emergencies (n54), perioperative complication and death rates were higher (100 and 50%, respectively; p,0.005). Risk factors for complications were greater for emergency surgery (p,0.001), major surgery (p50.008) and a long operative time (193 versus 112 min; p50.003). No significant clinical or haemodynamic deterioration was seen in survivors at 3-6 or 12 months of post-operative follow-up.Despite optimal management in this mostly nonsevere pulmonary hypertension population, perioperative complications were common, although survivors remained stable. Emergency procedures, major surgery and long operations were associated with increased risk.

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“…This was sited after induction of anaesthesia at the patient's request and also to prevent the potential rise in pulmonary artery pressures associated with pain and anxiety. Peri-operative epidural analgesia has the potential to decrease both afterload and preload, and has been used successfully [6]. The administration of norepinephrine to offset any reduction of sympathetic tone and weak local anaesthetic solution allowed the use of this beneficial technique both intra-and postoperatively.…”

Section: Discussionmentioning

confidence: 99%

Peri‐operative trans‐oesophageal echocardiography and nitric oxide during general anaesthesia in a patient with Eisenmenger's syndrome

Bouch¹,

Allsager

Moore

2006

Anaesthesia

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SummaryWe describe the peri-operative care of a patient with Eisenmenger's syndrome presenting for laparotomy. These patients require techniques to prevent the potential increase in intracardiac shunt caused by anaesthesia, by minimising increases in pulmonary artery pressure and reductions in systemic vascular resistance. The successful use of combined epidural and general anaesthesia with elective use of inhaled nitric oxide as a pulmonary vasodilator, and intra-operative trans-oesophageal echocardiography is described. In 1897, Eisenmenger described pulmonary vascular pathology related to a ventricular septal defect with right ventricular hypertrophy [1]. In 1958, the term Eisenmenger complex was used to describe pulmonary hypertension as a consequence of raised pulmonary vascular resistance (over 800 dyne.s )1 .cm) with reversed or bidirectional shunting through a large ventricular septal defect [2]. The term Eisenmenger's syndrome is applied where communication exists between the pulmonary and systemic circulations, with resultant pulmonary vascular pathology and cyanosis as a consequence of a reversed or bidirectional shunt [2,3], the shunt position being immaterial [2].With advances in medical care, patients with Eisenmenger's syndrome are surviving well into adulthood and are more likely to require non-cardiac surgery [4]. In this group of patients, the leading cause of peri-operative death relates to cardiac morbidity associated with alteration of the ratio of pulmonary to systemic pressures secondary to surgery and anaesthesia. Mortality rates of up to 30% are frequently quoted for this group of patients undergoing non-cardiac surgery [4]. Case reportA 43-year-old woman with Crohn's disease presented with repeated progressive episodes of bowel obstruction, secondary to a terminal ileal stricture. At 27 years of age, following the birth of her fourth child, a diagnosis of pulmonary hypertension secondary to an atrial septal defect was made, which progressed to Eisenmenger's syndrome over the next 5 years.History revealed a patient with only mild symptoms of dyspnoea on reaching the top of a flight of stairs, but who continued to smoke cigarettes, with a 20 pack year history. Daily medications were warfarin, inhaled steroid and b 2 agonist, with nicardipine for treatment of pulmonary hypertension. She was taking no medications for Crohn's disease.On examination, she weighed 45 kg, had finger clubbing, a loud second heart sound and raised jugular venous pulse but no peripheral oedema or hepatomegaly. Arterial pressure measured non-invasively was 85 ⁄ 40 mmHg, and heart rate was 90 beats.min )1 . Electrocardiogram showed sinus rhythm with right axis deviation and right ventricular hypertrophy. Results of a recent cardiac catheterisation (performed for pulmonary assessment) revealed pulmonary artery pressures of 98 ⁄ 27 mmHg (mean 53 mmHg), mean right atrial pressure of 4 mmHg, mean pulmonary capillary wedge pressure 6 mmHg, with systemic arterial pressures of 95 ⁄ 42 mmHg and pulmonary-systemic flow ratio ...

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Safety of regional anesthesia in Eisenmenger's syndrome☆

Cited by 62 publications

References 46 publications

Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey

Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey

Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension

Peri‐operative trans‐oesophageal echocardiography and nitric oxide during general anaesthesia in a patient with Eisenmenger's syndrome

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