Acute Pulmonary Hypertensive Crisis in a Patient with Primary Pulmonary Hypertension Treated by Both Epoprostenol (Prostacyclin) and Nitroprusside

Abstract Objectives: To describe the association between successful weaning of inhaled nitric oxide and trends in dead space ratio during such weans in patients empirically initiated on nitric oxide therapy out of concern of pulmonary hypertensive crisis. Patients: Children in a cardiac intensive care unit initiated on inhaled nitric oxide out of clinical concern for pulmonary hypertensive crisis retrospectively over 2 years. Measurements and Main Results: Twenty-seven patients were included, and nitric oxide was successfully discontinued in 23/27. These patients exhibited decreases in dead space ratio (0.18 versus 0.11, p = 0.047) during nitric oxide weaning, and with no changes in dead space ratio between pre- and post-nitric oxide initiation (p = 0.88) and discontinuation (p = 0.63) phases. These successful patients had a median age of 10 months [4.0, 57.0] and had a pre-existent diagnosis of CHD in 6/23 and pulmonary hypertension in 2/23. Those who failed nitric oxide discontinuation trended with a higher dead space ratio at presentation (0.24 versus 0.10), were more likely to carry a prior diagnosis of pulmonary hypertension (50% versus 8.7%), and had longer mechanical ventilation days (5 versus 12). Conclusions: Patients empirically placed on nitric oxide out of concern of pulmonary hypertensive crisis and successfully weaned off showed unchanged or decreased dead space ratio throughout the initiation to discontinuation phases of nitric oxide therapy. Trends in dead space ratio may aid in determining true need for nitric oxide and facilitate effective weaning. Further studies are needed to directly compare trends between success and failure groups.

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Pulmonary Hypertensive Crisis on Induction of Anesthesia

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253216652222 ◽

2016 ◽

Vol 21 (1) ◽

pp. 105-113 ◽

Cited By ~ 7

Author(s):

Travis Schisler ◽

Jose M Marquez ◽

Ibtesam Hilmi ◽

Kathirvel Subramaniam

Keyword(s):

Pulmonary Hypertension ◽

Lung Transplantation ◽

Hypertensive Crisis ◽

Positive Pressure ◽

Metabolic Dysfunction ◽

Anesthetic Induction ◽

Severe Hypotension ◽

Risk Patients ◽

Pulmonary Hypertensive Crisis ◽

End Stage

Anesthesia for lung transplantation remains one of the highest risk surgeries in the domain of the cardiothoracic anesthesiologist. End-stage lung disease, pulmonary hypertension, and right heart dysfunction as well as other comorbid disease factors predispose the patient to cardiovascular, respiratory and metabolic dysfunction during general anesthesia. Perhaps the highest risk phase of surgery in the patient with severe pulmonary hypertension is during the induction of anesthesia when the removal of intrinsic sympathetic tone and onset of positive pressure ventilation can decompensate a severely compromised cardiovascular system. Severe hypotension, cardiac arrest, and death have been reported previously. Here we present 2 high-risk patients for lung transplantation, their anesthetic induction course, and outcomes. We offer suggestions for the safe management of anesthetic induction to mitigate against hemodynamic and respiratory complications.

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