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Management von Patienten mit pulmonaler Hypertonie

Management of patients with pulmonary hypertension

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Zusammenfassung

Aufgrund der gesteigerten Lebenserwartung der Patienten mit pulmonaler Hypertonie (PH) werden auch primär nicht in der Kardioanästhesie tätige Anästhesisten häufiger mit diesen Patienten konfrontiert werden. Hämodynamisches Ziel in der perioperativen Phase ist es, einen Anstieg des pulmonalvaskulären Widerstands (PVR) zu vermeiden und ggf. den erhöhten PVR zu senken. Akute Steigerungen eines bereits chronisch erhöhten PVR können durch Hypoxie, Hyperkapnie, Acidose, Hypothermie, erhöhten Sympathikotonus sowie endogene und exogene pulmonale Vasokonstriktoren entstehen. Die frühzeitige Erkennung und Behandlung dieser Veränderungen sind daher lebensrettend bei den betroffenen Patienten. Medikamentöse Maßnahmen zur perioperativen Senkung des PVR umfassen die Gabe pulmonaler Vasodilatatoren wie Sauerstoff, Prostazyklinen (Epoprostenol, Iloprost), Phosphodiesterase-III-Inhibitoren (Milrinon) und Phosphodiesterase-V-Inhibitoren (Sildenafil) sowie Nitraten und Stickstoffmonoxid. Dabei ist im Rahmen einer selektiven pulmonalen Vasodilatation eine inhalative Applikation pulmonaler Vasodilatatoren einer i.v.-Verabreichung vorzuziehen. Neue Applikationsformen wie inhalatives Iloprost, inhalatives Milrinon und i.v.-Sildenafil können auch in kleineren Anästhesieabteilungen mit wenig technischem Aufwand leicht zur Verfügung gestellt werden.

Abstract

Due to the increased survival of patients with pulmonary hypertension, even non-cardiac anesthesiologists will see these patients more frequently for anesthesia. The hemodynamic goal in the perioperative period is to avoid an increase in pulmonary vascular resistance (PVR) and to reduce a possibly pre-existing elevated PVR. Acute increases of chronically elevated PVR may result from hypoxia, hypercapnia, acidosis, hypothermia, elevated sympathetic output and also release of endogenous or application of exogenous pulmonary vasoconstrictors. Early recognition and treatment of these changes might be life saving in these patients. Drug interventions to perioperatively reduce PVR include administration of pulmonary vasodilators, such as oxygen, prostacyclines (epoprostenol, iloprost), phosphodiesterase III (milrinone) and V (sildenafil) inhibitors, as well as nitrates and nitric oxide. Along with the concept of selective pulmonary vasodilation inhalative administration of pulmonary vasodilators has benefits compared to intravenous administration. New therapeutic strategies, such as inhalational iloprost, inhalational milrinone and intravenous sildenafil can be introduced without significant technical support even in smaller departments.

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  1. Department of Anesthesiology, Academic Medical Center AMC, Meibergdreef 9, 1100, Amsterdam, Niederlande

    B. Preckel MA, DEAA, S. Eberl, J. Fräßdorf & M.W. Hollmann

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  1. B. Preckel MA, DEAA
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  2. S. Eberl
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  3. J. Fräßdorf
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  4. M.W. Hollmann
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Correspondence to B. Preckel MA, DEAA.

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Preckel, B., Eberl, S., Fräßdorf, J. et al. Management von Patienten mit pulmonaler Hypertonie. Anaesthesist 61, 574–587 (2012). https://doi.org/10.1007/s00101-012-2040-2

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