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Perioperative Management of Patients With Severe Pulmonary Hypertension in Major Orthopedic Surgery: Experience-Based Recommendations

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Perioperative Management of Patients With Severe Pulmonary Hypertension in Major Orthopedic Surgery: Experience-Based Recommendations

Hans-Jürgen Seyfarth et al. GMS Interdiscip Plast Reconstr Surg DGPW.

Abstract

Introduction: It is known that pulmonary hypertension is associated with worse outcome in both cardiac and non-cardiac surgery. The aims of our retrospective analysis were to evaluate the outcomes of our patients with pulmonary hypertension undergoing major orthopedic surgery and to give experience-based recommendations for the perioperative management.

Material and methods: From 92 patients with pulmonary hypertension undergoing different kinds of surgical procedures from 2011-2014 in a tertiary academic hospital we evaluated 16 patients with major orthopedic surgery for perioperative morbidity and mortality.

Results: Regarding the in-hospital morbidity and mortality, one patient died postoperatively due to pulmonary infection and right heart failure (6.25%) and 6 patients suffered significant postoperative complications (37.5%; bleeding = 1, infection = 1, wound healing deficits = 3; dysrhythmia = 1).

Conclusion: Our data show that major orthopedic surgery is feasible with satisfactory outcome even in cases of severe pulmonary hypertension by an individualized, disease-adapted interdisciplinary treatment concept.

Keywords: general anesthesia; intraoperative monitoring; local anesthesia; perioperative management; pulmonary hypertension.

Figures

Table 1
Table 1. Classification of pulmonary hypertension (Nice [8])
Table 2
Table 2. Hemodynamic characteristics in patients with pulmonary hypertension (mod. [9], [10])
Table 3
Table 3. Therapy of pulmonary hypertension: approved drugs (mod. [12], [13], [14])
Table 4
Table 4. Clinical findings in patients with pulmonary hypertension (mod. [17])
Table 5
Table 5. Functional classification of pulmonary hypertension (WHO 1998) [18]
Table 6
Table 6. Intraoperative monitoring: recommendation for patients with PH (mod. [22])
Table 7
Table 7. Authors recommendations: human, structural and technical requirements for the perioperative management of patients with severe pulmonary
Table 8
Table 8. Intraoperative “basic treatment” to avoid an increase of pulmonary arterial pressure (mod. [22], [24], [26])
Table 9
Table 9. Specific interventions for therapy of intra- and/or postoperative
increase of pulmonary arterial pressure (mod. [22], [24], [27])
Table 10
Table 10. Patients characteristics
Table 11
Table 11. Operation characteristics, complications and outcome
Figure 1
Figure 1. Clinical findings in a patient with chronic right heart insufficiency and severe pulmonary hypertension
Figure 2
Figure 2. Intraoperative selective pulmonary vasodilation with inhaled iloprost via ultrasonic nebulizer (m-neb®, nebutec Elsenfeld, Germany) in the ventilatory circuit
Figure 3
Figure 3. Mechanisms of acute right heart failure (adapted from [22])

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