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Mortality Conference– FESS and Pulmonary Hypertension

Mortality Conference– FESS and Pulmonary Hypertension. R1 陳建宇 / VS 李宗勳. Brief History (1). 81/3/6: BOD 81/6(3m/o): s/p Kasai operation 86/6/24 (5y/o): RV: 66/6 mmHg/ MPA: 63/17mmHg 87/4/27 (6y/o): Living related liver transplantation( Prednisolone, FK506). Brief History (2).

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Mortality Conference– FESS and Pulmonary Hypertension

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  1. Mortality Conference– FESS and Pulmonary Hypertension R1 陳建宇 / VS李宗勳

  2. Brief History (1) • 81/3/6: BOD • 81/6(3m/o): s/p Kasai operation • 86/6/24 (5y/o): RV: 66/6 mmHg/ MPA: 63/17mmHg • 87/4/27 (6y/o): Living related liver transplantation( Prednisolone, FK506)

  3. Brief History (2) • 89/5(8y/o): MgSO4, PGE1 for pulmonary HTN • 89/8/24: RV: 123/21 mmHg/ MPA: 120/75 mmHg, start i.v. use of PGI2 7 ng/kg/min • 89/10/13: Timentin and Vancomycin for Pseudomonas and MRSA • 89/10/17: FESS

  4. EKG • 89/8/24

  5. 89/10/7 89/10/17 CXR

  6. Induction drugs: Fentanyl 1ml Pentothal 125mg Atracurium 15mg Droperidol 0.5mg Gas: Isoflurane ETT: 5.5mm with cuff (17cm) A-line: L’t pedal a. I/O: 300/300ml Anesthesia Course(1)

  7. Anesthesia Course(2)

  8. Brief History(3) • 89/10/17 • 3:50pm: Transferred to PICU-- bradycardia, desaturation; CPR; ABG revealed metabolic acidosis. Pupil was dilated. • 7:05pm: Another episode of bradycardia followed by asystole happened • 8:00pm: ECMO • 89/10/19 12:10am: expired

  9. Pulmonary Hypertension • Primary (Idiopathic)Pulmonary Hypertension • Secondary Pulmonary Hypertension • Postoperative Pulmonary Artery Hypertension

  10. Primary Pulmonary Hypertension • A progressive, fatal d’x • PAP↑PVR↑ • Mean pressure>25mmHg • Young population, F>M • Median survival from time of diagnosis is 2-3 years

  11. Secondary Pul. HTN • Causes: L’t heart dysfunction, Hypoxic lung d’x, L’t to R’t shunt, Liver d’x • Same treatment as PPH

  12. Postoperative Pul. Artery HTN • Especially perioperative • Rapidly fatal

  13. Treatment of Pul. HTN • Conventional Mamagement • General support care • Hyperventilation • Pharmacologic vasodilator

  14. General Support Care • CO2: O2 with mechanical positive-pressure ventilation(PPV) • PH • Blood Pressure • Narcotics and muscle relaxants can decrease the morbidity and mortality

  15. Hyperventilation • To produce respiratory alkalosis: • Pulmonary circulation is sensitive to hydrogen ion than CO2 • Respiratory alkalosis promotes PGI2 release • High intrathoracic pressure may compromise CV function and exacerbate the hypoxemia

  16. Vasodilator Therapy • Alpha-adrenergic antagonists • Nitrovasodilators • Beta-adrenergic agonists • Prostaglandins • Calcium channel blockers

  17. Alpha-adrenergic Antagonists • Tolazoline • Neonate • PVR↓ • Systemic hypotension

  18. Nitrovasodilators • Sodium nitroprusside • Direct vascular smooth m. relaxant • Both arterial and venous smooth m. • Nitroglycerin • Venous vasodilator • Reduction in PVR and PAP • Systemic hypotension

  19. Beta-Adrenergic Agonists • Increase intracellular cAMP • Isoproterenol • Dobutamine

  20. Prostaglandins • PGE1 • PGI2

  21. PGI2(Epoprostenol)(1) • Potent vasodilator and inhibitor of platelet aggregation • Adult: 5.5ng/kg/min( 5-20ng/kg/min) • Effects: increase cardiac index, exercise tolerance, subjective improvements • Decrease PVR( 46+/-5%) and SVR( 50+/-4%) • Children greater than adults

  22. PGI2(2) • Unstable at room temporature in solution and must be shielded from light, thus limiting its use to the acute setting • Iloprost is a stable synthetic analogue of PGI2 • Delay the need of transplantation

  23. PGI2(3) • Complications: bradycardia, arrhythmia, hypotension, prolonged bleeding time, severe hypoxemia • Abrupt withdrawal may results in rebound pulmonary hypertension • Expensive: £45,000/yr

  24. Calcium Channel Blockers • Calcium: regulation of smooth muscle contraction • Nifedipine • PAP and PVR↓ • Side effects: sinus arrest, systemic hypotension, decreased myocardial contractility

  25. Nonconventional Management -- Fail to respond to conventional medical t’x -- Only experimental and no routinely practice • Mechanical ventilation • Anticoagulants • Experimental vasodilators • Inhaled nitric oxide • Extracorporeal support • Transplantation

  26. Mechanical Ventilation • Maintain gas exchange while decreasing adverse effort on CV function • High frequency ventilation( HFV) -poor outcome • Airway pressure release ventilation( APRV) -only one case

  27. Anticoagulants • Warfarin • Combined with a vasodilator • Prostacyclin

  28. Experimental Vasodilators • MgSO4: activate adenylate cyclase which suppress the release of catacholamine • Adenosine and ATP: rapid clearance and is relatively selective pulmonary vasodilator

  29. Inhaled Nitric Oxide • Most promise as a routine therapeutic tool • Selective pulmonary vasodilator • Both infants and adults • Unknown potential toxicities

  30. Extracorporeal Support • Extracorporeal membrane oxygenation (ECMO) • Mortality rate: 100% decrease to 40-60% • Complications: bleeding, neurologic injury and multiple organ system failure

  31. Transplantations • Heart/ lung or lung transplantation • Three year survival rate: 50-60% (prognosis similar to the results of i.v. prostacyclin)

  32. I. Ventilatory Strategy 1. Increase Alveolar and Arterial Oxygen a. FiO2 b. Positive pressure ventilation 2. Alkalinization a. Bicarbonate administration 3. Decrease PaCO2 a. Positive pressure ventilation b. High tidal volume( 15-20 ml/kg) c. Low ventilation rate( 15-20bpm) d. Short inspiratory time( ,0.75sec) 4. Decrease Mean Airway Pressure a. Low PEEP<4cmH2O b. Low ventilatory rate ↓ If no improvement ↓ II. High Frequent Jet Ventilation ↓ If no improvement ↓ III.Pharmacologic Manipulation 1. Nitrovasodilators 2. Isoproterenol 3. PGE1, PGI2 4. Nitric oxide ↓ If no improvement ↓ IV. ECMO Decision-making algorithm for postoperative pulmonary HTN

  33. Epinephrine(1) • Powerful alpha- and beta-adrenergic agonist • Alpha-- Pulmonary vasoconstrction • Beta-- Pulmonary vasodilation • Low and medium doses-- PVR↓ • Higher dose-- PVR↑ • Increase of SVR> increase of PVR

  34. Epinephrine(2) • In preinfusion high PVR p’t, high dose epinephrine may predominantly beta-adrenergic stimulation inducing pulmonary vasodilation • Side effects: hypokalemia, hypercapnia( most common metabolic side effects)

  35. Discussing • Pre-evaluation: risk?此刀非開不可嗎? • Monitoring: CVP? Swan-Ganz? • ETCO2為何會上升? • Anesthetic management: 對於麻醉用藥有否其他選擇? • Drug’s effects: Bosmin, PGI2….. • Why pupil dilated and bradycardia?

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