Perioperative management techniques and goals | ||||
---|---|---|---|---|
Medication | Pulmonary vasodilator agents | Continue | ||
Anticoagulation | Switch long term anticoagulation to IV heparin | |||
GA | Opioids | Widely used | ||
Propofol/thiopentone | Widely used | |||
LA | Regional | Widely used | ||
Neuro-axial | Widely used | |||
Agents | Volatile anaesthetics | Widely used | ||
N20 | Avoid | ↑PVR | ||
NMBD | Safe | |||
Monitoring | BP/ECG/HR/SaO2/ETCO2 | Essential | ||
CVP/TTE/PCA | Additional | |||
Arterial line (+ABG) | ||||
Physiology | Respiratory | FIO2 > 0.6 Hyperventilation Recruitment manoeuvres Lung protective ventilation (Tv 6-8ml/kg) | O2 = Pulmonary VD / weak systemic VC Avoid V/Q mismatch and over-inflation | |
Cardiovascular | Preload - normovolemia | |||
Heart | ||||
Rate – Low normal | ||||
Rhythm - SR | ||||
Contractility -preserve | ||||
Afterload – Avoid ↑PVR | ||||
Haematological | pH >7.35 | |||
Others | Normothermia | |||
Location | Level 2/3 care |
Severity | Mean MAP (mmHg) | Units |
---|---|---|
SBP (or Above sPAP) | ≥90 (40) | mmHg |
MAP (or Above mPAP) | ≥65 (20) | |
mPAP (or lower than MAP) | <35 (25) | mmHg |
PVR/SVR | <0.5 | |
Cardiac Index | >2.2 | l/min/m2 |
Severity | Mean mPAP (mmHg) |
---|---|
Mild | 20-40 |
Moderate | 41-55 |
Severe | >55 |
Investigation | Comments | |
---|---|---|
ECG | RVH -RBBB, RAD, rSR’ complex in V1 | |
RV enlargement -P pulmonale | ||
ABG | Type one respiratory failure | |
Blood test do not aid diagnosis but identify aetiology of PH and degree of end-organ damage |
BNP | RV failure |
CXR | Dilated pulmonary arteries | |
Right ventricular enlargement | ||
Echocardiography | PA diameter, >25mm | |
Right ventricle outflow doppler acceleration time, <105ms | ||
Early diastolic pulmonary regurgitation (PR) velocity. >2.2 m/s | ||
Peak TR velocity, >2.8 m/s | ||
Cardiac MRI imaging | ||
Lung function test | Obstructive or restrictive defect | |
Low TLCO a marker of disease severity | ||
CPET | ||
Pulmonary artery catheter |
Agent | Physiological response | |
---|---|---|
Prostanoids | ||
Nitric oxide | ↓PVR/ SVR | |
Prostanoids (epoprostenol, treprostini) | ||
Milrinone / levosimendan | Positive inotropic (<-> HR) | |
Dobutamine / epinephrine | Positive inotropic (↑HR) | |
Norepinephrine / vasopressin / terlipressin | ↑SVR/PVR/RV load |
Classification | Parameter | Value |
---|---|---|
mPAP | > 20mmHg | |
PAWP | ≤ 15mmHg | |
PVR | ≥3 WU | |
mPAP | >20mmHg | |
PAWP | >15mmHg | |
PVR | <3 WU | |
mPAP | >20mmHg | |
PAWP | >15mmHg | |
PVR | ≥3 WU |