Intraoperative Goal-Directed Anesthetic Management of the Patient with Severe Pulmonary Hypertension

Impact of staged goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing McKeown esophagectomy: a randomized controlled trial

BACKGROUND

Our aim was to evaluate the influence of staged goal directed therapy (GDT) on postoperative pulmonary complications (PPCs), intraoperative hemodynamics and oxygenation in patients undergoing Mckeown esophagectomy.

METHODS

Patients were randomly divided into three groups, staged GDT group (group A, n = 56): stroke volume variation (SVV) was set at 8-10% during the one lung ventilation (OLV) stage and 8-12% during the two lung ventilation (TLV) stage, GDT group (group B, n = 56): received GDT with a target SVV of 8-12% During the entire surgical procedure, and control group (group C, n = 56): conventional fluid therapy was administered by mean arterial pressure (MAP), central venous pressure (CVP), and urine volume. The primary outcome was the incidence of postoperative pulmonary complications within Postoperative days (POD) 7. The secondary outcomes were postoperative lung ultrasound (LUS) B-lines artefacts (BLA) scoring, incidence of other complications, the length of hospital stay, intraoperative hemodynamic and oxygenation indicators included mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), cardiac output (CO), oxygenation index (OI), respiratory indices (RI), alveolar-arterial oxygen difference (Aa-DO2).

RESULTS

Patients in group A and group B had a lower incidence of PPCs (7/56 vs. 17/56 and 9/56 vs. 17/56, p < 0.05), and a fewer B-lines score on postoperative ultrasound (4.61 ± 0.51 vs. 6.15 ± 0.74 and 4.75 ± 0.62 vs. 6.15 ± 0.74, p < 0.05) compared to group C. The CI, CO, MAP, and OI were higher in group A compared to group B and group C in the stage of thoracic operation. During the abdominal operation stage, patients in group A and group B had a better hemodynamic and oxygenation indicators than group C.

CONCLUSIONS

In comparison to conventional fluid therapy, intraoperative staged GDT can significantly reduce the incidence of postoperative pulmonary complications in patients undergoing McKeown esophagectomy, facilitating patient recovery. Compared to GDT, it can improve intraoperative oxygenation and stabilize intraoperative hemodynamics in patients.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry on 24/11/2021 (ChiCTR2100053598).

A Literature Review on the Anesthetic Management of Pulmonary Arterial Hypertension in Non-cardiothoracic Surgery

Pulmonary hypertension (PH) is characterized by narrowing small pulmonary arteries, escalating pulmonary vascular resistance, and affecting the entire cardiovascular system. Pulmonary arterial hypertension (PAH) represents a subgroup of PH and typically affects one in 20,000 individuals. When treating individuals with PAH for non-cardiothoracic surgery, anesthetic management strategies should be tailored to the individual's specific needs. This literature review assessed the anesthetic management of PAH in non-cardiothoracic surgery. Electronic databases such as PubMed, ScienceDirect, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane, and Google Scholar were searched using relevant keywords related to PAH, noncardiac surgery, and anesthesia. Reference lists and author names were also investigated. The articles that met the inclusion criteria provided evidence suggesting that preoperative assessment should be comprehensive, hemodynamic goals should be established, anesthesia providers should be familiar with the underlying pathology, and cross-consultations between surgeons and anesthesia providers are essential for achieving satisfactory outcomes. Furthermore, patient care should extend beyond the surgical procedure into postoperative recovery in the post-anesthesia care unit (PACU) or intensive care unit (ICU) setting. In conclusion, it is vital for anesthetic management strategies to accommodate the unique needs of PAH patients to optimize their safety during perioperative care.

Utility of the FloTrac™ Sensor for Anesthetic Management of Laparoscopic Surgery in a Patient After Pneumonectomy: A Case Report and Literature Review

BACKGROUND Pneumonectomy is associated with various anatomical changes and potential complications involving the respiratory and cardiovascular systems. How laparoscopic surgery affects cardiorespiratory status in postpneumonectomy patients is yet to be ascertained. Here, we describe the use of the FloTrac™ sensor for the anesthetic management of laparoscopic adrenalectomy in a postpneumonectomy patient. CASE REPORT A 35-year-old woman underwent an extended hysterectomy and right pneumonectomy for retroperitoneal angiosarcoma and lung metastases, respectively. The metastasis was found in her left adrenal gland; therefore, laparoscopic adrenalectomy was scheduled. Spirometry demonstrated the following: forced vital capacity (FVC), 1.90 L (55.6% of predicted value); vital capacity, 53.6%; forced expiratory volume (FEV₁), 1.38 L (47.3% of predicted value); and FEV₁/FVC, 72.4%. The heart and mediastinal structures had shifted into the right hemithorax. Hugh-Jones classification was grade 2. The induction of general anesthesia was planned. The patient was orotracheally intubated and managed with the pressure control ventilation-volume guaranteed mode of ventilation, targeting an expired tidal volume of 6-7 ml/kg, without using PEEP. We evaluated cardiac output (CO), cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV) using a FloTrac™ sensor. After the establishment of pneumoperitoneum, SVV increased. CO and SV decreased slightly; however, the patient's hemodynamic status was stable. After surgery, we extubated the patient in the operating room; she demonstrated good progress and was discharged home on postoperative day 5. CONCLUSIONS We found changes in the values of SVV after pneumoperitoneum in a postpneumonectomy patient. The FloTrac™ sensor may be a minimally invasive and promising monitor for detecting hemodynamic changes associated with laparoscopic surgery in postpneumonectomy patients.