학술논문
Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement.
Document Type
Academic Journal
Author
Price LC; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK. Electronic address: laura.price@rbht.nhs.uk.; Martinez G; Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK.; Brame A; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK.; Pickworth T; Department of Anaesthesia, Royal Brompton Hospital, London, UK.; Samaranayake C; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK.; Alexander D; Department of Anaesthesia, Royal Brompton Hospital, London, UK.; Garfield B; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.; Aw TC; Department of Anaesthesia, Royal Brompton Hospital, London, UK.; McCabe C; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.; Mukherjee B; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK.; Harries C; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK.; Kempny A; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.; Gatzoulis M; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.; Marino P; Intensive Care unit and Pulmonary Hypertension Service, London, UK.; Kiely DG; Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.; Condliffe R; Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.; Howard L; National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK.; Davies R; National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK.; Coghlan G; National Pulmonary Hypertension Service, Royal Free Hospital, London, UK.; Schreiber BE; National Pulmonary Hypertension Service, Royal Free Hospital, London, UK.; Lordan J; National Pulmonary Hypertension Service, Freeman Hospital, Newcastle upon Tyne, UK.; Taboada D; Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK.; Gaine S; National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland.; Johnson M; Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK.; Church C; Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK.; Kemp SV; Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.; Wong D; Intensive Care unit and Pulmonary Hypertension Service, London, UK.; Curry A; Cardiothoracic Anaesthesia, University Hospital Southampton, Southampton, Hampshire, UK.; Levett D; Anaesthesia and Critical Care Research Area, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.; Price S; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.; Ledot S; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.; Reed A; National Heart and Lung Institute, Imperial College London, London, UK; Respiratory and Lung Transplantation, Harefield Hospital, Uxbridge, UK.; Dimopoulos K; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.; Wort SJ; National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
Source
Publisher: Elsevier Country of Publication: England NLM ID: 0372541 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1471-6771 (Electronic) Linking ISSN: 00070912 NLM ISO Abbreviation: Br J Anaesth Subsets: MEDLINE
Subject
Language
English
Abstract
Background: The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death.
Methods: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research.
Results: Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning.
Conclusions: With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.
(Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)
Methods: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research.
Results: Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning.
Conclusions: With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.
(Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)