Consideraciones

Anestsicas en Hipertensin Pulmonar en Nios

Dr. Francisco Cordero J. Becado Anestesia USACH 24 de mayo 2013

INTRODUCCION
mortalidad y morbilidad (1) 1-6% RN vivos (2) Tradicionalmente sobrevida de 2,8 aos (1) Nuevas terapias HTP avanzada mortalidad(1)
(1) Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515 (2) Galante D. Intraopera`ve managment of pulmonary arterial hypertension in infants and childres. Current opinion in anaesthesiology. 2009; 22:378-382

DEFINICION
Cateterizacin cardiaca Presin Arteria Pulmonar Media (PAP) > 25 mm Hg (reposo) > 30 mm Hg (ejercicio) En asociacin con grados variables de: - Remodelacin vascular pulmonar - Vasoconstriccin - Trombosis in situ
Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

DEFINICION
Ecocardiograga: PAPS > PAS/2

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

 PAP depende de Flujo arteria pulmonar y RVP Feto: RVP PAP shunt preferencial desde AP hacia circulacin sistmica via ductus arterioso Dentro de los primeros das del nacimiento: RVP PAP
Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

CAUSAS
Idiop`ca 35% RVP Insuciencia VD Secundaria 65 % - Cardiopakas congnitas shunt I-D hiperujo pulmonar con Insuciencia VI
Galante D. Intraopera`ve managment of pulmonary arterial hypertension in infants and childres. Current opinion in anaesthesiology. 2009; 22:378-382

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

PATOGENESIS
Proliferacin de clulas de msculo liso en arterias pequeas Hipertroa media en arterias musculares crecimiento y prdida de arteriolas Necrosis brinoide Obliteracin luminal Estados precoces reversibilidad
Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

CLINICA
Sntomas no especcos Idiop`ca insuciencia VD Secundaria a cardiopakas congnitas insuciencia VI

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Examen cardiaco
Click de eyeccin pulmonar Soplo sistlico (regurgitacin pulmonar) Soplo diastlico (insuciencia pulmonar) Distencin venosa yugular

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

CLASIFICACION FUNCIONAL

Rich S. Clinical insights into the pathogenesis of primary pulmonary hypertension. Chest. 1998;114:237-241

DIAGNOSTICO Y ESTUDIO

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Radiograga de Trax
Prominencia de la arteria pulmonar principal Recorte de las arterias pulmonares distales Cardiomegalia

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Ecocardiograma
Deteccin causas secundarias Velocidad Doppler de regurgitacin pulmonar > 2,5 mt por segundo PAP es`mada > 50% de la PAS

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Cateterismo Corazn Derecho

Conrma diagns`co y severidad de HTP Test vasodilatar con NO o prostaciclina reversibilidad

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Cateterismo Corazn Derecho

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Tratamiento

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Tratamiento

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Hawkins Amy, Tulloh R. Treatment of pediatric pulmonary hypertension. Vascular Health and Risk Managment; 509-515

Riesgo Perioperatorio
Mayor experiencia con adultos Mayor riesgo de desarrollo de complicaciones cardiovascular amenazantes para la vida

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Cohorte retrospec`vo Anestesia general o sedacin 1999 a 2004 156 pacientes 256 procedimientos

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

 HTP basal promedio (en relacion a PA sistmica) Subsistmica (PAP < 70%) Sistmica (PAP 70-100%) Suprasistmica (PAP > 100%)
Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Mecanismos de deterioro HD
Hipoxia alveolar < 60 mmHg Hipoxemia Hipercapnia Acidosis (M y R) Sistema simp`co (dolor)

rpido RVP

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Crisis hipertensiva pulmonar

rpido RVP PAP > PAS fracaso VD ujo pulmonar disminucin eyeccin VI hipoxia + falla biventricular

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Otros mecanismos
Compresin del VI por crecimiento VD perfusin coronaria

Periopera`ve Complica`ons in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheteriza`on

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Monitorizacin

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Manejo anestsico
HTP idiop>ca PAP mejorar funcin VD mejorar funcin VI HTP secundaria a CC shunt I-D mejorar funcin VI

Obje`vos Manejo Anestsico

Proporcionar anestesia y analgesia adecuada

Qp/Qs

-Minimizar RVP -Minimizar funcin miocrdica

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Tratamiento Intraoperatorio

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Tratamiento Intraoperatorio

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Gille J, Seyfarth H, Gerlach S. Periopera`ve Anesthesiological Managment of Pa`ents with Pulmonary Hypertension. Aneasthesiology Research and Prac`ce. 2012

Drogas Anestsicas
Anestsicos Vol`les Atenan la VPH ndice V/Q Vasodilatacin AP componente de anestesia balanceada contrac`lidad miocrdica RVS
Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.

Oxido Nitrico Inhalado

Vasodilatador pulmonar selec`vo Tratamiento de eleccin para controlar la HTP luego de ciruga cardiaca

Fentanyl
Efectos HD sistmicos y pulmonares mnimos Atena la respuesta vascular pulmonar a eskmulos dolorosos Componente importante de la anestesia balanceada Remifentanil bradicardia eyeccin cardiaca

Benzodiacepinas
Efectos HD mnimos Midazolam premedicacin

Etomidato
Escasos efectos HD Efectos vasculares pulmonares no bien estudiado 38 Sarkar M, Laussen PC, Zurakowski D et al. Hemodynamic responses to etomidate on induc`on of anesthesia in pediatric pa`ents. Anesth Analg 2005; 101: 645650.

Propofol
leve de RVS y contrac`lidad miocrdica impacto adverso en perfusin y funcin biventricular en HTP severa y/o falla VD (41 Williams GD, Jones TK, Hanson KA et al. The hemodynamic eects of propofol in children with congenital heart disease. Anesth Analg 1999; 89: 14111416.)

Ketamina
Controversial Asociada con RVP y PAP Si se usa combinada con un vasodilatador pulmonar o FiO2 elevada benecioso (por efectos HD)

 Cohorte retrospec`vo 2002-2008 68 nios, 192 procedimientos

Friesen R, Williams G. Anesthe`c managment of children with pulmonary arterial hypertension. Pediatric Anesthesia 2008; 18:208-216.