Postoperative pulmonary hypertension

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2. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Increased PVR during postop period:
• SIRS 20
to CPBP (pulmonary vasoconstriction)
• Protamine (pulmonary vasoconstriction)
• Hypoxia (pulmonary vasoconstriction)
• ↑ pCO2, acidemia (pulmonary vasoconstriction)
• PEEP, ventilator dysynchrony (pulmonary vasoconstriction)

3. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Hyperventilation counteracts hypoxic pulmonary vasoconstriction in
man
• PAP increased (p < 0.001) with elevations in PaCO2
• Marked decrease in SVR with increasing PaCO2
• Blood pressure decreased (p < 0.001) with ↑ in PaCO2 up to 50
mmHg

4. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Can precipitate acute right heart failure
• More frequent conditions: MVR, CHD with L → R shunt
• Heart Tx, Lung Tx
• Pneumonectomy
Dr. Armaan Singh

5. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Treatment of the underlying cause:
• Pulmonary vasoconstriction (pre-capillary PH)
Avoidance of hypoxemia, hypercarbia & acidosis
Sedation, analgesia & muscle relaxants
Selective pulmonary vasodilatation
• Passive pulmonary hypertension with ↑ LAP (post-capillary PH)
Improve LV contractility
Decrease degree of MR
Nesiritide
Dr. Armaan Singh

6. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide :
 Perioperative management of patients with severe MR, severe LV
dysfunction and secondary pulmonary hypertension
 Expected mortality by EuroSCORE 26%
 Preoperative treatment with Nesiritide for 13-55 hr (mean=24 hr)
 Postoperative treatment with Nesiritide for 2-80 hr (mean=22 hr)
 Improves postop renal function and survival

7. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide :

8. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide:
Hemodynamic benefits: ↓ PAP, ↓ CVP, ↑ CO
Improves postop renal function
Decreases respiratory failure and AF
Decreases LOS
Decreases mortality

9. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide (Natrecor):
• Standard Dilution:
[1.5 mg] [250 ml D5W, D5½S or NS]
• Loading dose:
2 mcg/kg over 20 min
• Followed by 0.01 mcg/kg/min
• Continuous infusion x 48 hours

10. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Selective pulmonary vasodilatation:
• Right heart failure resistant to therapy
• Pre-existing pulmonary hypertension
* Inhaled Nitric Oxide (iNO)
* Inhaled Prostacyclin (iPGI2)
* Inhaled Iloprost
* Sildenafil
Dr. Armaan Singh

11. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled Nitric Oxide (iNO):
• Usual dose: 5 - 40 ppm
• Selective pulmonary vasodilator
• Does not cause systemic hypotension
• Distributed only to ventilated portions of the lungs
• Requires accurate gas delivery system to monitor NO and NO2
• May cause methemoglobinemia
• May cause rebound pulmonary hypertension
• Expensive
Dr. Armaan Singh

12. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Usual dose: 5 - 50 ng/kg/min
• Short-acting selective pulmonary vasodilator
• Equally effective as iNO
• Does not cause systemic hypotension
• Distributed only to ventilated portions of the lungs
• May cause thrombocytopenia
• Does not cause rebound pulmonary hypertension
• Inexpensive
Dr. Armaan Singh

13. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Usual starting dose: 50 ng/kg/min
• Weaning (3-4 days): 25-10-5-3 ng/kg/min
• Selective pulmonary vasodilator
• Does not cause systemic hypotension
• Equally effective as iNO
• Prolonged use is not associated with systemic effects
• Readily available in most hospitals
• Inexpensive

14. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Selective pulmonary vasodilatation:
n= dobut norepi reop intub mort
IV dilators 18 4.1 0.03 2 31 2
iNO group 21 2.9 0 0 20 1
iPGI2 group 19 3.1 0 1 18 0

15. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Equally effective as iNO
• Neither iPGI2 nor its metabolites have toxic effects
• Possible thrombocytopenia but does not increase risk of bleeding
• Easy administration
• Inexpensive

16. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled iloprost:
• Usual dose: 12 - 20 mcg q 4-6 hr
• Intermittent nebulization
• Longer half-life selective pulmonary vasodilator
• Equally effective as iNO
• Does not cause systemic hypotension
• May cause thrombocytopenia
• Does not cause rebound pulmonary hypertension
• Intermittent nebulization requires periodic interruption of PEEP
Dr. Armaan Singh

17. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled iloprost:

18. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
• Equally effective as iNO
• Increases cardiac output
• Does not increase wedge pressure
• Oral or IV administration
• Inexpensive

19. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:

20. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:

21. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
• Initial dose: 50-75 mg PO 10-30 min before induction of anesthesia
• Maintenance dose: 25 mg BID - 50 mg TID
• Pediatric dose: 0.4 mg/kg before discontinuing iNO