Pulmonary Hypertension Requiring Procedure, Anesthesia or Sedation Clinical Pathway — ICU and Inpatient

Pulmonary Hypertension Crisis

Triggers can include

  • Hypoxia
  • Hypercarbia
  • Fever
  • Hypovolemia
  • Increase cardiac demand
  • Interruption of medication
  • Agitation
  • Delirium
  • Shivering
  • Hypothermia

Occurs when pulmonary vascular resistance (PVR) increases to the point that:

  • Pulmonary blood flow decreases, pulmonary arterial constriction occurs, pulmonary edema may develop, which leads to hypoxia and respiratory acidosis
  • Right ventricular (RV) pressure and volume increases, interventricular septum bows leftward, thereby reducing Left ventricular (LV) volume, dropping cardiac output, which causes acidosis, decreased coronary artery filling

Presents with

  • Tachycardia (bradycardia ominous sign)
  • Hypotension
  • Poor perfusion (cool extremities)
  • Altered mental status
  • Loud single s2
  • Holosystolic murmur
  • Engorged liver that extends well below costal margin

Managed by

  • Reduce pulmonary vascular resistance
    • Increase oxygen
    • Decrease hypercarbia
    • Avoid acidosis
    • Treat pain
    • Initiate inhaled
    • Nitric oxide
  • Augment RV preload and cardiac output
    • Judicious fluid administration
  • Resolve systemic hypotension (vasopressor support) and maintain coronary artery flow
    • Reduce metabolic demand: treat fever, pain, or whatever the trigger
  • Transition from negative pressure to positive pressure ventilation may precipitate a cardiopulmonary arrest and, therefore should be undertaken by experienced providers with consideration for extracorporeal membrane oxygenation availability
  • Consult pulmonary hypertension team for optimization of pulmonary hypertension drug therapy