Review Highlights Importance of Anesthetic Management in PAH

It is important to construct anesthetic management strategies to accommodate the unique needs of patients with pulmonary arterial hypertension (PAH) and to optimize their safety during perioperative care, according to a new review published in Cureus.

PAH has an incidence of 15 to 50 cases per 1 million adults, and it is more common among those with scleroderma or systemic sclerosis, HIV, or end-stage liver disease. Around 10% of patients with congenital heart disease also have pulmonary hypertension.

“Research has investigated the associations between general anesthesia (GA) and regional anesthesia (RA) in PAH patients. It has been concluded that GA and RA can be safely applied to PAH patients, ensuring vigilant monitoring and managing of hemodynamic parameters,” the study authors wrote.

To better understand the anesthetic management of PAH in noncardiothoracic surgery, the investigators searched PubMed, ScienceDirect, Ovid Medical, and other online databases for relevant studies.

The articles included in the final analysis offered evidence suggesting “preoperative assessment should be comprehensive, hemodynamic goals should be established, anesthesia providers should be familiar with the underlying pathology, and cross-consultations between surgeons and anesthesia providers are essential for achieving satisfactory outcomes,” the researchers explained.

In the preoperative setting, assessments should also evaluate brain natriuretic peptide (BNP) levels, electrocardiogram findings, and imaging studies. Providers should weigh patients’ risk factors, like a history of coronary artery disease and chronic kidney disease, to understand the risks and benefits of surgery.

Additional comorbid conditions like electrolyte imbalance and anemia should also be considered during the intraoperative period.

“Meticulous airway management is necessary during anesthesia induction in PAH patients to avoid increasing pulmonary pressure,” the authors said.

Different anesthetic agents have different effects on pulmonary vasculature. “Therefore, agents that minimize the effect on [pulmonary vascular resistance] and [right ventricular] functions should be utilized,” they said.

Inhalational agents like sevoflurane and isoflurane are particularly beneficial when used in patients with PAH because of their vasodilatory effects on the pulmonary vasculature.

The authors note RA should be considered on an individual basis, because although it can reduce the need for opioids, RA may also cause significant hemodynamic changes and impair compensatory mechanisms in patients. Some experts also caution GA may increase the risk of postoperative complications, like respiratory depression.

Patient care ought to extend to postoperative recovery in the post–anesthesia care unit or intensive care unit, the researchers added. Monitoring postoperative patients can aid in early detection of PAH crisis, right ventricular failure, and arrhythmias.

Additional postoperative considerations include:

• Avoiding the exacerbation of pulmonary vascular resistance and right ventricular failure
• Monitoring hemodynamic parameters
• Assessing for complications such as bleeding or infection

Further postoperative care should take respiratory support, fluid balance optimization, and pain and anxiety management into account.

“Preoperative evaluation, intraoperative monitoring, and postoperative care should be tailored to the unique needs of PAH patients, emphasizing hemodynamic stability maintenance and complication prevention,” the researchers wrote.

For high-risk patients, a multidisciplinary approach involving a pulmonologist, cardiologist, and anesthesiologist is crucial. To ensure the best outcomes for patients undergoing operations, providers should have a deep understanding of the pathophysiology of PAH and expertise in the patient's hemodynamic and mechanical aspects.

Overall, “anesthesia professionals must be proficient in preoperative evaluation, intraoperative monitoring, and postoperative care for these patients, with an emphasis on maintaining hemodynamic stability and preventing complications,” the authors concluded. “By staying informed and adaptable, anesthesia professionals can significantly impact the care and outcomes of patients with PAH.”

Reference

Hendrix JM. A literature review on the anesthetic management of pulmonary arterial hypertension in non-cardiothoracic surgery. Cureus. Published online May 22, 2023. doi:10.7759/cureus.39356