Acute Recognition and Management of Congestive Heart Failure

Rapidly progressive pulmonary artery hypertension and end-stage liver disease

Pulmonary hypertension is a recognized but unusual complication of liver disease. It can complicate the perioperative course of liver transplantation. Mild to moderate pulmonary hypertension is generally well tolerated during the procedure and does not appear to contribute to mortality. Since the pulmonary vascular disease may progress rapidly, it may have advanced to the point of irreversibility at the time of surgery. So, patients with known moderate pulmonary hypertension should have pulmonary arterial catheterisation immediately prior to transplantation. If pulmonary artery hypertension has become severe, then a preoperative trial of vasodilators is warranted. If this fails, the procedure should be cancelled. We present a patient with alcoholic liver cirrhosis in whom a rapidly progressive pulmonary hypertension made liver transplantation impossible.

Enalaprilat controls postoperative hypertension while maintaining cardiac function and systemic oxygenation after neurosurgery

OBJECTIVE

The efficacy of intravenous enalaprilat in lowering postoperative hypertension.

DESIGN

Prospective, randomized, controlled, single blind trial.

SETTING

Surgical ICT in a university hospital (tertiary care center).

PATIENTS

18 neurosurgical patients subjected to the extirpation of a supratentorial intracerebral tumour were studied after detection of postoperative hypertension. This was defined as a constant elevation of systolic arterial pressure over 160 mmHg or diastolic arterial pressure over 95 mmHg.

INTERVENTIONS

Enalaprilat 0.015 mg kg-1 was injected within 5 min to 9 patients.

MEASUREMENTS AND RESULTS

Central haemodynamics and systemic oxygenation were assessed at baseline before enalaprilat injection, and repeatedly during four hours after the injection. The statistical analysis was performed with analysis of variance for repeated measurements. As compared to control patients, the blood pressure lowering effect of enalaprilat became evident within 15 min and lasted for over four hours (p = 0.008). It was mainly due to the reduced systemic vascular resistance. Enalaprilat also induced a small decline in myocardial perfusion pressure. Cardiac performance, preload, heart rate and systemic oxygenation were not affected by enalaprilat.

CONCLUSIONS

We found intravenous enalaprilat effective and safe in lowering postoperative hypertension following neurosurgery as assessed by it's effects on central haemodynamics and systemic oxygenation.