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Anesthesia for Pulmonary Hypertension: Your Guide

Medically reviewed by Steven C. Pugliese, M.D.
Written by Emily Wagner, M.S.
Posted on January 10, 2022

Before Surgery | During Surgery | After Surgery | Get Support

Anesthesia is medication given during surgery so that you may be unconscious, do not feel pain, do not move, or do not remember the procedure. Pulmonary hypertension (PH) affects the heart, lungs, and surrounding blood vessels. There is no cure, and it can be difficult to manage during surgery, especially when anesthesia is used.

There are five main types of PH:

  • Group 1 — Pulmonary arterial hypertension (PAH) due to no known cause, caused by certain types of infections, genetic causes, or other underlying diseases
  • Group 2 — PH caused by heart disease
  • Group 3 — PH caused by lack of oxygen (hypoxia or hypoxemia) over an extended period of time due to certain lung diseases
  • Group 4 — PH caused by blood clots, known as chronic thromboembolic PH (CTEPH)
  • Group 5 — PH caused by several factors or underlying diseases and conditions that affect the lung’s blood vessels

Each type of PH is treated differently, and certain medications may interfere with surgery and anesthesia. Some cases of PH can even be treated using surgery. However, because PH is a complicated disease, proper presurgical planning with your medical team is essential, and your doctor will speak with you about how to prepare for undergoing anesthesia with PH.

Before Surgery

Before surgery, your doctor will run many tests to see how well your heart and lungs are functioning. These tests may also be helpful to diagnose PH in a person who is suspected of having the condition but has never received an official diagnosis before surgery. They can help the surgeon and anesthesiologist prepare for the procedure. One of the most important factors in preparing for anesthesia is to minimize the risk of causing or worsening right-sided heart failure. The tests include:

  • Electrocardiogram (also called an EKG or ECG)
  • Echocardiography (detailed ultrasound of the heart)
  • Chest X-rays
  • Laboratory tests
  • Lung function tests
  • Right heart catheterization

The results of these tests will help your doctor, surgeon, and anesthesiologist prepare for your procedure. Special modifications may be made to your surgical plan depending on how well your heart and lungs are working. For people with better heart and lung function, surgery is less risky.

Before surgery, your medical team will want to make sure your PH is being treated as well as possible — time permitting. Many people with PH will be taking medications or treatments to manage their disease. These are generally safe to take before undergoing anesthesia, but your doctor will talk to you if there are any concerns.

If medications need to be stopped before surgery, your surgical team will let you know which ones and how many days before surgery you should stop taking them. Below are some of the most common types of treatment people with PH may be taking before surgery.

Blood Thinners

Many people with PH take blood thinners (anticoagulants), and the most common is warfarin (sold as Coumadin). These medications can be continued before surgery for those with CTEPH, a blood clot in the lungs (pulmonary embolism), or a mechanical heart valve. The anesthesiologist will take special care when choosing an anesthetic to prevent complications.

Calcium Channel Blockers

Calcium channel blockers can also be continued before surgery in people with idiopathic (from an unknown cause) PAH. These medications include:

  • Nifedipine (Procardia XL)
  • Diltiazem (Cardizem)
  • Amlodipine (Norvasc)

Vasodilators

Many people with PH are treated with vasodilators to help lower high blood pressure in the lungs, and these medications are known to be generally safe during surgery and under anesthesia.

Vasodilator dosing can be changed before surgery to help reduce the risk of complications during the procedure. Vasodilators may also need to be given as crushed tablets or injected into a vein (intravenously).

Oxygen

Some people with PH will be on supplemental (additional) oxygen to help them breathe. This should be maintained before and during surgery. In addition to oxygen, those with PH and obstructive sleep apnea should be receiving special pressurized oxygen at night.

During Surgery

PH is a disease that affects the heart, lungs, and surrounding blood vessels. It is caused by increased pressure in the arteries of the lungs and can lead to shortness of breath, fatigue, and chest pain. PH can be difficult to treat and manage, and it can become more difficult during surgery. There are several factors during and immediately after surgery that can increase the risk of complications:

  • Pain
  • Stress
  • Inflammation
  • Mechanical ventilation (being on a breathing machine during surgery)
  • Effects of the anesthesia itself

The anesthesiologist will focus specifically on preventing complications that can arise during surgery in people with PH. For example, having PH puts you at a high risk for developing right ventricular failure (right heart failure). This occurs when the right side of the heart is too weak to pump blood to the lungs properly. The blood does not get enough oxygen, and not enough blood is pumped out to the body (low cardiac output).

Types of Anesthesia

It is generally safe for people with PH to receive anesthesia during surgery, but the anesthesiologist will take special consideration when choosing which drugs to use. The anesthesiologist should be knowledgeable and experienced with cases of PH. Broadly speaking, there are two types of anesthetics, regional and general.

Local and Regional Anesthetics

Local and regional anesthetics affect a specific area of the body during surgery while leaving the rest of the body unaffected. These drugs are preferred because they have less effect on hemodynamics (breathing, oxygenation, and blood pressure) within the lungs. Regional anesthetics can be given using local injections or long, thin tubes (catheters) that are inserted into the surgical area or spine.

General Anesthetics

General anesthetics are used when a person must be asleep during surgery. These drugs are either inhaled into the lungs or injected into a vein to travel through the bloodstream and around the body. General anesthetics act on the entire body and can affect breathing, heart rate, lung blood pressure, and more.

In addition, some anesthesia drugs are not recommended for use in people with PH, such as ketamine and nitric oxide. Instead, the anesthesiologist may use one of these anesthetics:

  • Propofol
  • Etomidate
  • Thiopental

During surgery with general anesthesia, the person is unable to move and will therefore need assistance to breathe. To accomplish this, they are intubated (a tube is inserted down the throat and into the airway). Intubation allows the anesthesiologist to control oxygen levels, keep airways open, and even deliver medications to the lungs to help keep PH stable. They monitor for low blood pressure (hypotension), lack of oxygen (hypoxia), and arterial pressure (how well blood is getting to the organs) in the body.

Medications During Surgery

In addition to anesthetics, medications called vasodilators may also be given during surgery to help open up blood vessels and decrease blood pressure. Some of these include inhaled medications that are given before or during anesthesia:

  • Iloprost (Ventavis)
  • Prostacyclin, epoprostenol (Flolan)
  • Nitric oxide

Other vasodilator medications that are given as intravenous injections include:

  • Dobutamine
  • Sodium nitroprusside
  • Nitroglycerin
  • Milrinone

These medications ensure that blood can pump oxygen around the lungs without excess resistance, thus putting less stress and strain on the heart and lowering the risk of right-heart failure.

Vasoconstrictors serve the opposite function of vasodilators. These medications (and related drugs like inotropes) help improve how well the heart can pump blood into the blood vessels around the heart and lungs and stop blood pressure from getting too low.

After Surgery

People with PH should be closely monitored in the intensive care unit after surgery. Their care team can consist of the surgeon, anesthesiologist, intensive care specialist, pulmonologist (lung doctor), cardiologist (heart doctor), and pain control team. Recovery may take days to weeks, depending on the surgery. Special considerations are ease of breathing, abnormal heartbeats, adequate blood pressure, and blood clots.

Of utmost importance is good pain control, as inadequate pain control can raise blood pressure in the lungs. Additionally, people must be carefully monitored for any signs of infection or excess bleeding. Inhaled pulmonary vasodilators — such as inhaled Flolan or nitric oxide — may be used after surgery when lung blood pressure is too high. A person’s normal medications for PH should be restarted as soon as possible after surgery. Unfortunately, not a lot is known about the best practices for monitoring people with PH during and after surgery, and more research in this area is needed.

Talk With Others Who Understand

On myPHteam, the social network for people with pulmonary hypertension, more than 46,000 members come together to ask questions, give advice, and share their stories with others who understand life with PH.

Are you or a loved one living with pulmonary hypertension? Share your experience in the comments below, or start a conversation by posting on your Activities page.

Posted on January 10, 2022
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Steven C. Pugliese, M.D. is affiliated with the Hospital of the University of Pennsylvania in Philadelphia, serving as the director of the pulmonary embolism response team, co-director of the comprehensive pulmonary embolism program, and an assistant professor of clinical medicine. Review provided by VeriMed Healthcare Network. Learn more about him here.
Emily Wagner, M.S. holds a Master of Science in biomedical sciences with a focus in pharmacology. She is passionate about immunology, cancer biology, and molecular biology. Learn more about her here.

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