Foresman Ryan N, Connors Christopher W
Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA.
Semin Cardiothorac Vasc Anesth. 2011 Dec;15(4):179-82. doi: 10.1177/1089253211424223. Epub 2011 Oct 24.
The 2007 American College of Cardiology/American Heart Association guidelines report that no significant studies have been conducted assessing the perioperative risk of pulmonary hypertension in noncardiac surgery. However, the presence of right ventricular failure has been well documented to have poor prognostic implications. The presence of pulmonary hypertension and right ventricular failure present unique perioperative challenges. These include maintenance of adequate cardiac function, acid-base management, intraoperative monitoring, and postoperative pain management.
The authors report the case of a patient with severe pulmonary hypertension who underwent an open total abdominal hysterectomy. The case was complicated by known right ventricular failure, severe portal hypertension, obstructive sleep apnea, extensive smoking history, and systemic anticoagulation therapy. The patient was not a candidate for postoperative neuraxial analgesia because of the timing and dose of systemic anticoagulation. Two-dimensional transesophageal echocardiography was used for real-time visualization and intraoperative cardiac monitoring. The patient was transferred to the intensive care unit for careful titration of opioids and slow ventilator wean to extubation. The postoperative course proceeded without significant morbidity or mortality.
(a) Preoperative assessment of pulmonary hypertension, (b) postoperative pain control, (c) cardiovascular stability, and (d) intraoperative monitoring.
This case illustrates the unique challenges associated with pulmonary hypertension and right ventricular failure in the setting of noncardiac surgery. This case also demonstrates that continuous, real-time data provided by transesophageal echocardiography can be used to successfully manage a complicated patient with pulmonary hypertension.
2007年美国心脏病学会/美国心脏协会指南报告称，尚未开展评估非心脏手术中肺动脉高压围手术期风险的重要研究。然而，右心室衰竭的存在已被充分证明具有不良预后意义。肺动脉高压和右心室衰竭的存在带来了独特的围手术期挑战。这些挑战包括维持足够的心脏功能、酸碱管理、术中监测和术后疼痛管理。
作者报告了一例重度肺动脉高压患者接受开放性全腹子宫切除术的病例。该病例合并已知的右心室衰竭、严重门静脉高压、阻塞性睡眠呼吸暂停、广泛吸烟史和全身抗凝治疗。由于全身抗凝的时机和剂量，该患者不适合术后进行椎管内镇痛。二维经食管超声心动图用于实时可视化和术中心脏监测。患者被转至重症监护病房，以便仔细滴定阿片类药物并缓慢撤机至拔管。术后过程顺利，无明显并发症或死亡。
（a）肺动脉高压的术前评估，（b）术后疼痛控制，（c）心血管稳定性，以及（d）术中监测。
本病例说明了非心脏手术中与肺动脉高压和右心室衰竭相关的独特挑战。本病例还表明，经食管超声心动图提供的连续实时数据可用于成功管理一名患有肺动脉高压的复杂患者。
