Case Presentation: Anesthetic Management For POEM Procedure
in a Patient with Severe Pulmonary Hypertension
CHUCK STRAUBHAAR BSN, SRNA
OBJECTIVES
Comprehend basic pathophysiology of pulmonary hypertension
Appreciate anesthetic considerations and intraoperative management of pulmonary hypertension
Understand anesthetic management and basic surgical technique for peroral endoscopic myotomy
PULMONARY VASCULATURE PHYSIOLOGY
Low pressure system, less than 10% resistance to
flow compared to systemic vasculature
Normal pulmonary artery pressure at rest at sea
level: 20/10 mm Hg
Resting PA pressure rises with higher altitudes
Systolic PA pressures gradually rise with age
PULMONARY HYPERTENSION
PATHOPHYSIOLOGY
Pulmonary HTN: mean PA pressure greater 25 mm Hg
Pulmonary arterial hypertension: left sided heart filling pressure must be 15
mm Hg or less
5 clinical classifications
PA pressures and PVR increased at rest RV hypertrophy impaired
LV filling impaired CO progressive RV failure and sudden death
PULMONARY ARTERIAL HYPERTENSION PATHOBIOLOGY
Characterized by endothelial dysfunction, ↓ apoptosis:proliferation in pulmonary arterial smooth muscle,
thickened adventitia
Panvasculopathy affecting small pulmonary arterioles
Intimal hyperplasia, medial hypertrophy, adventitial proliferation
Imbalance of vasoactive mediators
Not enough nitric oxide and prostacyclin
Too much thromboxane and endothelin
PULMONARY HYPERTENSION ANESTHETIC CONSIDERATIONS
Preanesthesia evaluation and preoperative testing
Intraoperative goals
Avoid increased pulmonary vascular resistance
Maintain preload but avoid fluid overload
Maximize RV O2 supply, minimize O2 demand
MAC/peripheral nerve block vs Neuraxial vs General
Laparoscopic vs open procedures
Standard monitoring +/- arterial line, CVC, PAC, TEE
PULMONARY HYPERTENSION ANESTHETIC CONSIDERATIONS
Induction – slow and steady
Short acting hypnotic (etomidate 0.15-0.3 mg/kg), moderate dose of opioid (fentanyl 1-2 mcg/kg), lidocaine 50-100 mg, muscle relaxant
Critical to maintain oxygenation and avoid hypercarbia
Maintenance – avoid increased PVR and decreased SVR
Minimal data on inhalational anesthetic effects on PVR
Best to avoid nitrous oxide and ketamine
TIVA?
Ventilation avoid high peak pressures/high PEEP, acidosis, hypoxia, and atelectasis
Fluid avoid abrupt changes
Emergence – smooth
PULMONARY HYPERTENSION ANESTHETIC CONSIDERATIONS
PULMONARY HYPERTENSION TREATMENT
For groups 2-5, management of the underlying disease process
Group 1 Pulmonary Arterial Hypertension
Prostacyclin agonists (epoprostenol, treprostinil)
Endothelin receptor antagonist (bosentan, ambrisentan)
Nitric oxide-cGMP enhancers (sildenafil, tadalafil)
PERORAL ENDOSCOPIC MYOTOMY (POEM)
POEM PROCEDURE AND ANESTHESIA CONSIDERATIONS
Indicated for achalasia esophageal dysmotility
Clear liquids only 1-5 days preop, and NPO at least 6 hours preop
May still retain contents in esophagus
Performed in OR or high-intensity endoscopy suite
Reverse trendelenburg and RSI recommended
Supine throughout procedure, EBL minimal, 1 PIV
Stimulating?
Adverse events: insufflation-related, bleeding, mucosal perforation
CASE PRESENTATION
“No general anesthesia if possible. If no alternative to
GA, she will need anesthesia with knowledge of how to
manage PH and RV failure, as risk of decompensation
following intubation is HIGH”
“Perioperative cardiopulmonary risk is high”
KC is a 29 year old female, 170 cm, 59 kg presenting for a POEM procedure due to gastroparesis, persistent N/V, and early satiety. Other history: severe idiopathic pulmonary arterial HTN, right HF, mild asthma, 2 L O2 at night, and recent URI. KC is also being considered for a lung transplant, but can walk >1000 ft so not yet a candidate. KC has some atelectasis and diminished basilar breath sounds.
Medications
PAH: IV treprostinil via Hickman catheter, ambrisentan, riociguat
Right HF: Lasix
Asthma: Flonase, albuterol
ECG: NSR, RAD, incomplete RBBB, nonspecific ST & T wave changes, QTc 551 ms
CXR: cardiac silhouette enlarged. Main & central PAs dilated with abrupt peripheral tapering
Rt heart cath: RV pressure 116/22, PA 116/60 (79)
Echo: RV & RA severely dilated, RV function severely decreased, 1+ TR, 2+ PR. Main PA dilated at 6.1 cm
SO…. WHAT DID WE DO?
Pre-operative: continued PO PAH meds along with IV treprostinil, thorough interview
Intra-operative: GETA with modified rapid sequence induction
Alfentanil, etomidate, rocuronium
Increasing peak pressures asthma/spasm? Rhonchi?
Postoperative: PONV but prolonged QT
What if things went wrong?
Acute right heart failure inhaled nitric oxide or epoprostenol, IV milrinone
Hypotension norepinephrine
Overall, there are many different ways anesthesia could have been provided to
this patient. This way is not better or worse than other ways, but it did provide
a safe anesthetic.
SOURCES
Hopkins, W., & Rubin, L. J. (2018). Treatment of pulmonary hypertension in adults (J. Mandel & G. Finlay, Eds.).
Retrieved August 4, 2018, from https://www.uptodate.com/contents/treatment-of-pulmonary-hypertension-in-
adults?sectionName=Prostacyclin pathway
agonists&topicRef=94362&anchor=H21&source=see_link#H3257161491
Mclaughlin, V. (2016). Chapter 68 Pulmonary Hypertension. In Goldman Cecil Medicine (25th ed., pp. 397-403).
Philadelphia, PA: Elsevier Saunders.
Pannala, R., Abu Dayyeh, B. K., Aslanian, H. R., Enestvedt, B. K., Komanduri, S., Manfredi, M., . . . Banerjee, S. (2016).
Per-oral endoscopic myotomy. In Gastrointestinal Endoscopy(Vol. 83, pp. 1051-1060). Elsevier.
Sharp, C. D., T. E., & Ginsberg, G. G. (2017). Anesthesia for Routine and Advanced Upper Gastrointestinal
Endoscopic Procedures. In Anesthesiology Clinics (Vol. 35, pp. 669-674).
Zafirova, Z., & Rubin, L. J. (2018). Anesthesia for patients with pulmonary hypertension or right heart failure (B. A.
Borlaug, R. Hines, N. A. Nussmeier, & S. B. Yeon, Eds.). Retrieved August 4, 2018, from
https://www.uptodate.com/contents/anesthesia-for-patients-with-pulmonary-hypertension-or-right-heart-
failure?search=pulmonary%20hypertension%20anesthesia&source=search_result&selectedTitle=1~150&usage_t
ype=default&display_rank=1#H1900480851
QUESTIONS?