Respiratory and Thoracics Flashcards
Anterior Mediastinal Mass (AMM)
Background
Considerations
Goals & Conflicts
Anterior Mediastinal Mass (AMM)
Background
The anterior mediastinal space is bordered by the sternum anteriorly, the middle mediastinum comprising the heart & great vessels posteriorly, the thoracic inlet superiorly, & the diaphragm inferiorly
The most frequent causes of AMMs are:
Lymphoma
Thymoma
Germ cell tumours
Metastatic lesions
Bronchogenic masses
Thyroid mass
Considerations
Risk of cardiopulmonary collapse upon induction of anesthesia:
Tracheobronchial obstruction, dynamic hyperinflation
RVOT obstruction, cardiac chamber compression
Possible SVC syndrome:
Airway edema & potential for difficult intubation
↑ intracranial pressure
Unreliable upper extremity IVs
Underlying etiology & comorbid disease:
Cancer 4 M’s (mass effects, metastases, medications, metabolic abnormalities)
Myasthenia gravis, Eaton-Lambert, thyroid, lymphoma
Pericardial/pleural effusions
Need for preoperative risk stratification based on symptoms & CT findings:
Low risk: asymptomatic or mildly symptomatic, without postural symptoms or radiographic evidence of significant compression of structures
Intermediate risk: mild to moderate postural symptoms, tracheal compression < 50%
High risk: severe postural symptoms, stridor, cyanosis, tracheal compression > 50% or tracheal compression with associated bronchial compression, pericardial effusion or SVC syndrome
Considerations of surgical procedures (e.g., mediastinoscopy) & feasibility of performance under local/sedation
Goals & Conflicts
Multidisciplinary optimization & planning:
Optimize medically prior to procedure (steroids, radiation, chemotherapy)
Perform procedures/biopsies under local if possible
Guide approach by CT findings (> 50% tracheobronchial obstruction) & positional symptoms (supine dyspnea, pre-syncope)
Cautious approach to general anesthesia, if it is necessary:
Maintain spontaneous ventilation & awake during ETT placement distal to obstruction
Avoid positive pressure ventilation & muscle paralysis if possible
Planning for intraoperative crisis:
Preoperative cardiopulmonary bypass
Invasive monitors & lines, lower extremity IVs
Rigid bronchoscopy & thoracic surgeon immediately available during anesthetic induction
Stretcher immediately available for repositioning: prone, decubitus
Complications: complete airway obstruction with dynamic hyperinflation, cardiac arrest from obstructive shock, hemorrhage from SVC syndrome, cardiac tamponade
Asthma
Considerations
Goals & Conflicts
Severe Asthma Exacerbation Treatment Options
Asthma
Considerations
Risk of perioperative respiratory complications:
Bronchospasm, mucous plugging, pneumothorax, atelectasis, pneumonia
Possible pulmonary hypertension & RV failure
Need for preoperative optimization:
Treatment of bronchospasm, infection, atelectasis
Avoidance of triggers & exacerbating factors:
Avoid general anesthesia, endotracheal intubation, histamine releasing medications, light anesthesia
Medication management:
Continue usual inhalers pre-operatively
Stress dose steroids if recent high dose steroid use
Goals & Conflicts
Assess preoperative respiratory function for stability:
Stable symptoms (sputum, bronchospasm), PFTs, imaging, ABG
Assess for pulmonary hypertension, cor pulmonale
Medical optimization: bronchodilators, glucocorticoids, antibiotics, BiPAP
Anesthetic management principles:
Avoid airway instrumentation
Blunt airway reflexes: deep anesthesia, topical local anesthetics, opioids
Bronchodilation: avoid histamine releasing medications (e.g., morphine), use ketamine, volatiles, MgSO4, salbutamol, ipratropium, epinephrine
Permissive hypercapnia: ↓ respiratory rate, ↑ expiratory time, adequate tidal volumes
Monitor intrinsic PEEP, presence of dynamic hyperinflation & pulmonary tamponade
Postoperative monitoring for bronchospasm, respiratory failure
Severe Asthma Exacerbation Treatment Options
Salbutamol 2.5-5mg via nebulizer q20 minutes
Ipratropium 500mcg via nebulizer q20 minutes
Corticosteroids:
Prednisone PO 40-60mg single dose
Methylprednisolone 60-80mg IV q6-12h
Epinephrine if anaphylaxis suspected or severe asthma refractory to standard therapy:
Dose is 0.3-0.5mg IM/SC or 10-50 mcg IV bolus, followed by infusion @ 2-10 mcg/min
Magnesium for life-threatening exacerbation: 2g IV over 20 min
Heliox & humidified O2 (conflicting studies)
Anesthetics:
Ketamine
Propofol
Volatiles all are bronchodilators but sevoflurane is likely best choice
Leukotriene receptor antagonists (only PO available in Canada)
Always consider noninvasive PPV as rescue before intubation
If intubation & ventilation:
Use permissive hypercapnia
Use low respiratory rates: start at 10-12 breaths/minute but may need lower rates
Use prolonged expiratory time (e.g. I:E ratios 1:3, 1:4, or even 1:5)
Tidal volume 6-8cc/kg
FiO2 to achieve PaO2 >60mm Hg
ECMO as last resort
Asthma Severity Based on Airflow Obstruction
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Bronchiectasis
Considerations
Goals & Conflicts
Bronchiectasis
Considerations
Etiology & co-existing disease: cystic fibrosis, COPD, TB, congenital
Risk of postoperative pulmonary complications:
Mixed restrictive & obstructive lung disease
Risk of intraoperative bronchospasm, pneumothorax, pulmonary tamponade
Recurrent pulmonary infections, mucus plugging
Hypoxemia, hypercarbia, V/Q mismatch
Pulmonary hypertension, cor pulmonale
Potential need for lung isolation due to massive hemoptysis & active bronchial infection
Medications including need for steroid replacement
Goals & Conflicts
Maintain integrity of healthy lung in setting of infection & hemorrhage with lung isolation
Preoperative optimization of infection & bronchospasm with antibiotics, steroids, bronchodilators
Optimize intraoperative ventilation to avoid barotrauma, dynamic hyperinflation, pulmonary tamponade
Arrange for possibility of postoperative ventilation, high acuity care
Bronchopleural Fistula (BPF)
Considerations
Goals & Conflicts
Bronchopleural Fistula (BPF)
Considerations
Etiology of BPF & associated urgency:
Trauma, empyema/abscess, bullous disease, post lung resection, carcinoma
Comorbid disease:
Chronic obstructive lung disease, malignancy, coronary artery disease, arrhythmias
Absolute indication for lung separation:
Pathophysiological impact of positive pressure ventilation
Ineffective ventilation (with chest tube in place)
Tension pneumothorax (without chest tube in place)
Systemic air embolus
Protection of healthy lung from soiling
Repeat thoracotomy considerations:
Hemorrhage
Sepsis, septic shock
Postoperative analgesia
Postoperative ICU disposition for PPV
Goals & Conflicts
Need for lung isolation prior to PPV in order to prevent pathophysiological complications as outlined above
Balanced with possible full stomach, difficult airway, hemodynamic instability, limited functional reserve
Rapid sequence lung isolation techniques:
Regional anesthesia
Awake fibreoptic intubation: single lumen ETT +/- bronchial blocker, double lumen ETT prior to GA
Asleep intubation with spontaneous ventilation prior to isolation
Modified RSI with no or limited PPV prior to lung isolation
Double lumen ETT preferred to bronchial blocker to support suctioning, optimal ventilation & isolation
Need for resuscitation & stabilization prior to OR:
Fluids, vasopressors, antibiotics, chest tube placement
If no chest tube in place prior to OR, thoracic surgeon must be immediately available to place a chest tube
Intraoperative goals:
Lung protective ventilation
Restrictive fluid strategy
Maintenance of normothermia & normal metabolics
Optimization to facilitate postoperative extubation:
Resuscitation
Bronchial suctioning
Bronchodilators
Extubation to BiPAP
Bullous Lung Disease
Considerations
Goals & Conflicts
Bullous Lung Disease
Considerations
Etiology with associated considerations:
Chronic obstructive lung disease, congenital, carcinoma, infection/abscess
Absolute indication for lung isolation due to pathophysiological sequelae:
Bronchopleural fistula, infection/sepsis, obstructive lung physiology causing airspace expansion during PPV with risk of pneumothorax, restrictive lung physiology & mass effect
Patient co-morbidities & limited physiological reserve
Need for pre-op assessment as per 3-legged stool approach:
Respiratory mechanics
Gas exchange
Cardio-respiratory interaction
Goals & Conflicts
Patients may present for non-thoracic surgery with lung cysts, blebs, bullae
Use local & regional techniques if feasible
Maintain spontaneous ventilation if feasible with supraglottic device or ETT
If PPV required then employ lung isolation
Lung isolation techniques:
Options: double lumen ETT, bronchial blocker, endobronchial tube
In a patient with marginal lung function, consider lobar/segmental isolation with a bronchial blocker
Avoid PPV prior to lung isolation:
RSI
Awake fiberoptic intubation
Inhalational induction
Have a surgeon skilled in chest tube placement immediately available if the need arises, but do not place prophylactic chest tube
Chronic Obstructive Lung Disease (COPD)
Considerations
Goals & Conflicts
Chronic Obstructive Lung Disease (COPD)
Considerations
High risk of perioperative pulmonary complications including respiratory failure
Physiological changes:
Mechanical: bronchospasm, mucous plugging, obstructive physiology, bullous disease, pneumothorax, pulmonary tamponade, chronic hypoxemia/hypercarbia
Cardiovascular: pulmonary hypertension, cor pulmonale
Etiology & associated co-morbid disease:
Smoking, coronary artery disease, hypertension, cystic fibrosis, bronchiectasis
↑ sensitivity to respiratory depressant effects of anesthetic agents
Medications including recent steroid use
Goals & Conflicts
Optimization prior to elective procedures:
Treat bronchospasm, atelectasis, infection, pulmonary edema
Risk stratify, assess for cor pulmonale
Intraoperative goals of care:
Regional/neuraxial anesthesia preferred to GA
Multimodal analgesia, limit sedative analgesics
Lung protective ventilation balanced with obstructive lung ventilation strategies:
Prevent dynamic hyperinflation & barotrauma:
Long I:E, low peak pressure, low tidal volume, slow rate, permissive hypercapnea
Maintain normothermia, normal metabolics
Postoperative disposition including need for PPV & ICU
Stress dose steroids if indicated
COPD Severity Based on Airflow Obstruction
Cystic Fibrosis
Considerations
Goals & Conflicts
Pregnancy
Cystic Fibrosis
Considerations
High risk for perioperative pulmonary complications
Pathophysiologic sequelae:
Pulmonary: mucous plugging, chronic pneumonia, bronchiectasis & hemoptysis, bronchospasm, pneumothorax, mixed restrictive & obstructive lung physiology, bullous disease, hypoxemia/hypercarbia
Cardiovascular: pulmonary hypertension, cor pulmonale
Extra-pulmonary disease:
Anemia of chronic disease
GERD, sinusitis
Hepatic: abnormal transaminases, cirrhosis, portal hypertension, coagulopathy
Pancreatic insufficiency & diabetes
Chronic malnutrition, cachexia, deconditioning
CF-related medications: oxygen, bronchodilators, mucolytics, antibiotics, steroids, insulin, pancreatic enzymes
Goals & Conflicts
Preoperative optimization in collaboration with respiratory medicine
Avoidance of GA if feasible
Intraoperative management principles:
Lung protective ventilation
Aggressive pulmonary toilet, bronchodilation, hydration
Avoid prolonged ventilation
Multimodal analgesia with limited sedating analgesics
Avoid exacerbation of pulmonary hypertension
Postoperative high acuity setting with aggressive respiratory therapy
Verify normal coagulation parameters prior to neuraxial/regional
Pregnancy
Very high risk patient & ↑ risk of low birth weight babies & pre-term delivery:
Vaginal delivery:
Ensure monitored setting, consider invasive monitoring if significant cardiorespiratory dysfunction
Epidural is an excellent choice to reduce hyperventilation & stress, but titrate carefully to T10 to prevent respiratory muscle weakness
Cesarean delivery:
Epidural preferred:
Careful titration of epidural to avoid high block
GA is acceptable but remember goals:
Prevent perioperative bronchospasm
Frequent suctioning for pulmonary toilet
Appropriate ventilatory settings, especially to avoid air trapping/pneumothorax
Post-op monitoring in HAU/ICU, chest physiotherapy, pulmonary optimization
NIPPV to treat respiratory failure
Esophagectomy
Considerations
Goals & Conflicts
Esophagectomy
Considerations
High risk for postoperative morbidity & mortality
Identify surgical approach & associated considerations
Possible need for lung isolation
Comorbid disease processes:
Full stomach & high risk for aspiration
Malnourishment, deconditioning, anemia, coagulopathy
Smoker, chronic obstructive lung disease, coronary artery disease, hypertension, diabetes mellitus
Cancer 4M’s:
Mass effects, medications, metastases, metabolic abnormalities
Prolonged surgery with severe hemodynamic insults:
Need for invasive monitors & access
Lung protective ventilation
Maintenance of anastamotic integrity:
Thoracic epidural anesthesia
Judicious fluid administration & vasopressor usage
Optimize oxygen delivery
Goals & Conflicts
Preoperative:
Assessment of 4M’s
Optimization of comorbidities
Planning for postoperative care
Intraoperative:
Aspiration prophylaxis
RSI due to high risk of aspiration
Thoracic epidural
Arterial & central venous access, large bore IV access
Lung isolation & lung protective ventilation
Planning for repositioning
Preparations for severe hemodynamic instability especially during blunt mediastinal dissection
Restrictive fluid strategy with vasopressors PRN to treat epidural-related vasoplegia
Surgical approach:
Ivor Lewis: laparotomy, right thoracotomy
Transhiatal: laparotomy, left neck
Three hole
Left thoracoabdominal
Laparoscopic/thoracoscopic
Surgical considerations:
Prolonged surgery
Need for one lung ventilation
Intraoperative repositioning
Hemodynamic instability: intrathoracic dissection, supraventricular arrhythmias
No vascular access left neck
Postoperative:
Greatest mortality risk of all thoracic surgery
Attempt postoperative extubation & plan for high acuity stay
Monitor for: aspiration pneumonia, respiratory failure, anastamotic dehiscence with empyema, mediastinitis, septic shock, arrhythmias, CHF
Lung Cancer
Considerations (4Ms)
Lung Cancer
Considerations
Potentially compromised respiratory function with risk of perioperative respiratory complications
4M’s:
M ass effects: obstructive pneumonia, lung abscess, SVC syndrome, tracheobronchial distortion, Pancoast’s syndrome, recurrent laryngeal nerve or phrenic nerve paresis, chest wall or mediastinal extension
M etabolic effects: Lambert–Eaton syndrome, hypercalcemia, hyponatremia, Cushing’s syndrome
M etastases: particularly to brain, bone, liver, & adrenal
M edications: chemotherapy agents, pulmonary toxicity (bleomycin, mitomycin), cardiac toxicity (doxorubicin), renal toxicity (cisplatin)
Need for lung resection, mediastinoscopy/bronchoscopy, non-thoracic surgery
Comorbidities including smoking, chronic obstructive lung disease, coronary artery disease, hypertension
Management of cancer pain with multimodal approach
Goals of care & DNR status
Massive Hemoptysis
Considerations
Goals
Management
Massive Hemoptysis
Considerations
Emergency, full stomach, limited time to optimize
Etiology of hemorrhage & patient comorbidities:
Infection (tuberculosis), bronchiectasis, malignancy, arteriovenous malformation, pulmonary artery catheter, trauma
Difficult airway & requirement for rapid lung isolation to prevent contralateral contamination & asphyxia
Facilitation of subsequent definitive treatment: bronchial artery embolization, lung resection
Resuscitation of hemorrhagic shock
Goals
Prompt mobilization of resources (OR, surgeon, interventional radiology) & effective communication between various parties
Rapid management: airway protection, resuscitation & stabilization, localization of bleeding site, & administration of specific therapy
Rapid isolation of non-bleeding lung (double lumen tube vs bronchial blocker vs endobronchial intubation; bleeding lung down)
↓ bleeding: bleeding lung up after selective bronchial intubation (↓ effective pulmonary artery pressure on that side), CPAP to bleeding lung (for tamponade effect), reversal of anticoagulation
Optimization of oxygenation & ventilation to both lungs (good lung down, CPAP to bleeding lung)
Management
Mobilize resources, call thoracic surgery
Monitors, large IVs x2, 100% O2
Lateral position with bleeding side down
Call for blood, resuscitate if hemodynamically unstable, correct coagulopathy
Secure airway if problems with gas exchange:
Best done in the OR with thoracic surgeon/rigid bronchoscope available
Awake intubation vs RSI
Double lumen tube vs single lumen tube endobronchially or with bronchial blocker
High frequency jet ventilation may be life saving
Suction, suction, suction
Once isolated, CPAP to bleeding side may help tamponade the bleeding site
May need to urgently go to OR for rigid bronchoscopy or thoracotomy
Mediastinoscopy
Considerations
Goals
Conflicts
Complications
Mediastinoscopy
Considerations
Limited access to airway
Indication for procedure: lung cancer staging, biopsy of anterior mediastinal mass & associated patient comorbidities
Surgical approach: cervical vs anterior (Chamberlain)
Potentially life threatening complications: hemorrhage, pneumothorax, airway disruption, stroke
Monitoring: perfusion monitoring of right arm, consider lower extremity IV, BP monitoring left arm (avoid fictitious BP)
Need for quiet surgical field & airway control
Goals
Optimize surgical conditions: deep anesthesia, paralysis
Safe care of anterior mediastinal mass
Preparation for transfusion: large bore IV, cross match, consider lower extremity IV
Conflicts
Deep anesthesia +/- paralysis vs anterior mediastinal mass
Cerebrovascular disease & innominate compression
Contraindications:
Previous mediastinoscopy or surgery in anterior mediastinum
Relative: SVC syndrome, tracheal deviation, thoracic aortic aneurysm, radiation
Complications
Hemorrhage (aorta, superior vena cava, pulmonary artery ) → may need urgent/emergent thoracotomy
Innominate artery compression → stroke
Recurrent laryngeal nerve injury
Phrenic nerve injury
Tracheal injury
Pneumothorax, pneumomediastinum
Chylothorax
Esophageal injury
Venous air embolism
Bradycardia, arrhythmias
Obstructive Sleep Apnea (OSA)
Considerations
Goals
Conflicts
Risk score
Severity Score
Obstructive Sleep Apnea (OSA)
Considerations
Potentially difficult BMV & intubation
↑ sensitivity to sedatives/hypnotics
Potential for cardiorespiratory changes:
Hypoxia, hypercarbia (chronic)
Obesity hypoventilation syndrome
Polycythemia
Pulmonary hypertension, RV hypertrophy, RV dysfunction
Comorbid disease:
Obesity, diabetes, coronary artery disease, congenital syndromes affecting the airway
↑ risk of perioperative complications → require intensified monitoring:
Obstruction with induction
Apnea & desaturation in PACU
Goals
Safe establishment of airway
Minimize risk of postoperative respiratory depression:
Minimize long acting narcotics (systemic & neuraxial) due to patient sensitivity & risk of opioid-induced upper airway obstruction
Provide monitoring adequate to decrease morbidity from postoperative apnea
Conflicts
Aspiration risk (RSI) vs. OSA (difficult airway)
Desire to minimize narcotic use vs. contraindication/inability for regional
STOP-BANG Questionnaire: ≥3 features indicates high risk of OSA
S noring
T ired excessively
O bserved apneas
P ressure (hypertension)
B MI > 35
A ge > 50
N eck circumference > 40 cm
G ender = male
Apnea Hypopnea Index & Severity of OSA
Mild = 5-15
Moderate = 15-30
Severe = >30
Pneumonectomy
Considerations
Goals
Conflicts
Cardiac Herniation
Pneumonectomy
Considerations
Determine physiological suitability for procedure by assessing predicted postpneumonectomy pulmonary function:
ppoFEV1 > 40%
ppoDLCO > 40%
VO2 max > 15 mL/kg/min (> 4 METS)
Consider V/Q scanning for all pneumonectomies &/or if ppoFEV1 < 40%
Assess & optimize cardiorespiratory comorbidities:
Coronary artery disease & arrhythmias (atrial fibrillation)
Smoking, chronic obstructive lung disease
Pulmonary hypertension
4M’s of lung malignancies (mass effects, metastases, medications, metabolic abnormalities)
Method of lung isolation as determined by:
Type of resection: right vs left, sleeve
Patient factors: difficult airway, anatomical distortion
Management of hypoxemia during one lung ventilation
Perioperative management to avoid acute lung injury:
Fluid restriction (< 20cc/kg first 24 hours)
Lung protective ventilation with open lung techniques (tidal volume 4-6cc/kg, peak pressure < 40 cmH2O, plateau pressure < 30 cmH2O, PEEP/FiO2 for oxygen saturation > 90%)
Postoperative pain management strategies: thoracic epidural, paravertebral block
Postoperative complications:
Acute lung injury/respiratory failure (aka post-pneumonectomy pulmonary edema)
Cardiac herniation (see below)
Arrhythmias, especially atrial fibrillation
Myocardial ischemia
Bronchopleural fistula
Signs & symptoms: fever, productive cough, hemoptysis, subcutaneous emphysema, & persistent air leak from a chest tube
Hemorrhage
Pulmonary embolism
Myocardial infarction
Goals
Determine suitability for resection with “3-legged stool” approach:
Respiratory mechanics, gas exchange, cardio-respiratory interaction
Preoperative optimization: smoking cessation, pulmonary rehabilitation, treatment of lung infections & bronchospasm
Pristine intraoperative management: thoracic epidural, fluid restriction, lung protective ventilation, avoidance of hypothermia
Conflicts
Requirement for curative treatment vs predicted inability to tolerate lung resection
Lung protective ventilation vs contraindication to hypercarbia (pulmonary hypertension, intracranial hypertension, cardiac ischemia)
Fluid restriction vs chronic kidney disease
Need for thoracic epidural but requirement for full anticoagulation (mechanical heart valve, severe CHADS2, DVT/PE)
Cardiac Herniation
Emergent OR required
Occurs after chest closure due to pressure difference between the two hemithoraces; if a pericardial defect is present, this pressure difference may result in the heart being extruded through the defect
The patient should NOT be placed on the operative side in the dependent position after a pneumonectomy because of the risk of cardiac herniation
Mortality > 50%
Pathophysiology:
Right pneumonectomy: impaired venous return (obstructive shock) → tachycardia, ↑ CVP, hypotension, shock, acute SVC syndrome
Left pneumonectomy: myocardial compression → MI, arrhythmias, LVOT obstruction
Differential diagnosis:
Massive intrathoracic hemorrhage, pulmonary embolism, mediastinal shift
Management principles:
Definitive management is operative repair → notify surgeon immediately & prepare OR
100% O2
Support with vasopressors & inotropes
Check chest tube & ensure not on suction (as this would suck the heart further into the empty hemithorax)
Inject air into chest tube to reduce herniation
Position with the operative side up to minimize cardiac compression
Post Lung Transplant Patient
Considerations
Goals/Conflicts
Post Lung Transplant Patient
Considerations
Allograft physiology:
Heterogeneous compliance, impaired cough, disrupted lymphatics
Need for differential lung ventilation if single lung transplant
Extrapulmonary features of underlying disease requiring transplant (e.g., sarcoidosis, cystic fibrosis):
Pulmonary hypertension, RV failure
Complications:
Allograft rejection
Vascular & bronchial anastamotic complications
Immunosuppression:
Strict aseptic techniques, watch for infection
Side effects: hematologic, renal, hepatic
Goals/Conflicts
Assess allograft function, anastamotic integrity, end-organ function
Employ regional/neuraxial anesthesia if feasible
If endotracheal intubation & PPV are required:
Consider differential lung ventilation
Lung protective ventilation to allograft & CPAP with 100% oxygen to native lung
Restrictive fluid strategy
Strict aseptic technique, avoidance of manipulation of airways, prophylactic antibiotics
Pulmonary Embolism
Considerations
Management
Pulmonary Embolism
Considerations
Acute life threatening hypoxemia, RV failure, cardiogenic shock, PEA arrest
Hemodynamic goals:
Support RV filling/contractility, minimize pulmonary vascular resistance, maintain preload
High risk of cardiac collapse upon initiation of PPV
Life saving maneuvers: thrombolysis, thrombectomy, inotropes, pulmonary vasodilators
Perioperative bridging of anticoagulation, always consider IVC filter
Management
Admission to monitored setting
O2 supplementation as required
Consultation with ICU/respirology
Start anticoagulation immediately (IV heparin, low molecular weight heparin)
If anticoagulation contraindicated → consider IVC filter (controversial)
Hemodynamic instability: similar to treatments of pulmonary hypertension:
Vasopressors to maintain RV perfusion
Intravascular fluid therapy as per CVP, PAC, TEE
Cautious especially with RV dysfunction: only 500-1000 cc at a time
Inotropes if RV dysfunction: dobutamine, epinephrine
Inodilators: milrinone
Pulmonary artery dilators: nitric oxide, epoprostenol (flolan)
Intubation & ventilation:
Avoid if possible
If necessary:
Very high risk for cardiac collapse
Ensure pre-induction arterial line/central line if possible
Have vasopressors in-line
Titrated induction with avoidance of hypoxemia/hypercarbia (bag mask once not breathing)
Avoid high intrathoracic pressures, hypercarbia & hypoxemia
Thrombolytic therapy:
Indications:
Shock: sBP <90 or ↓ sBP of 40 from baseline
Cardiac arrest
Severe hypoxemia
RV dysfunction
Patent foramen ovale
Dose: tPA 100mg IV over 2 hours
Embolectomy:
Catheter embolectomy
Surgical embolectomy
ECMO if all else fails
