Ilustrasi Kasus 5
A 44-year-old woman is scheduled for a vaginal hysterectomy for dysmenorrhea that has failed medical therapy. Although she had been otherwise healthy, over the past year, she has increasingly noticed exertional dyspnea, particularly when shopping in large stores. These symptoms have worsened, to the point that she sometimes felt as though she was about to “pass out.” She consulted her primary physician several months ago. After an extensive workup, she was diagnosed with idiopathic pulmonary hypertension, and treated with amlodipine, a calcium channel blocker, and furosemide. The administration of another medication by permanent central indwelling catheter has been discussed, but is not warranted at this time.
The patient’s vital signs on presentation include a blood pressure 102/56 mm Hg, heart rate 90 bpm, 94% O2 saturation. On physical examination, she has clear lungs to auscultation, mild ankle edema, a 2/6 systolic murmur, and an S4 gallop. The ECG shows right axis deviation and right ventricular hypertrophy. An echocardiogram demonstrates mild right ventricular (RV) enlargement, and a right ventricular systolic pressure (RVSP) of 35 mm Hg. Following the induction of anesthesia, her oxygen saturation decreases to 90%, blood pressure falls to 80/43 mm Hg, and her heart rate increases to 110 bpm.
➤ What should the preoperative evaluation include?
➤ What is the impact of the anesthesia and surgical procedure on pulmonary
hypertension?
➤ What are the goals of anesthetic management?
Comprehension Questions
1. A 45-year-old man with pulmonary hypertension presents to the emergency room with shortness of breath, jugular venous distension, peripheral edema, BP 87/46 mm Hg, HR 122 bpm, pulse oximeter oxygen saturation (SpO2) 91%, and hemoglobin 8.5 g/dL. Match the treatment (left column) with the order in which it would be administered.
A. Transfusion of red blood cells 1. First
B. Fluid bolus of 1 L normal saline 2. Second
C. Oxygen via face mask 3. Third
D. Furosemide dieresis 4. Fourth
E. Norephrine vasopressor infusion 5. Not at all
2. A 37-year-old woman with primary pulmonary hypertension, treated with intravenous epoprostenol infusion, is scheduled for emergency appendectomy. Which of the following statements regarding her anesthetic
plan is correct?
A. Aggressive premedication with opiates is recommended.
B. Induction with standard dose of propofol will help in the control
of hemodynamics.
C. Vasopressor use to treat hypotension is indicated.
D. The epoprostenol infusion should be discontinued to avoid
hypotension.
E. Large fluid bolus before induction is indicated to avoid hypotension.
3. A 32-year-old woman with pulmonary hypertension secondary to mitral stenosis is undergoing laparoscopic nephrectomy for a renal mass. Half an hour after the start of the surgery, her SpO2 is 89%, her
end-tidal CO2 is 55, BP 89/47, and HR 120. She has received 1 L of i.v. fluids. Which of the following is the most likely diagnosis for her hemodynamic compromise?
A. Left ventricular myocardial infarction (MI)
B. Ventilatory failure
C. Excessive IV fluid administration
D. Hypovolemia due to blood loss
E. Pulmonary embolism
F. A CO2 embolus from insufflation
The patient’s vital signs on presentation include a blood pressure 102/56 mm Hg, heart rate 90 bpm, 94% O2 saturation. On physical examination, she has clear lungs to auscultation, mild ankle edema, a 2/6 systolic murmur, and an S4 gallop. The ECG shows right axis deviation and right ventricular hypertrophy. An echocardiogram demonstrates mild right ventricular (RV) enlargement, and a right ventricular systolic pressure (RVSP) of 35 mm Hg. Following the induction of anesthesia, her oxygen saturation decreases to 90%, blood pressure falls to 80/43 mm Hg, and her heart rate increases to 110 bpm.
➤ What should the preoperative evaluation include?
➤ What is the impact of the anesthesia and surgical procedure on pulmonary
hypertension?
➤ What are the goals of anesthetic management?
Comprehension Questions
1. A 45-year-old man with pulmonary hypertension presents to the emergency room with shortness of breath, jugular venous distension, peripheral edema, BP 87/46 mm Hg, HR 122 bpm, pulse oximeter oxygen saturation (SpO2) 91%, and hemoglobin 8.5 g/dL. Match the treatment (left column) with the order in which it would be administered.
A. Transfusion of red blood cells 1. First
B. Fluid bolus of 1 L normal saline 2. Second
C. Oxygen via face mask 3. Third
D. Furosemide dieresis 4. Fourth
E. Norephrine vasopressor infusion 5. Not at all
2. A 37-year-old woman with primary pulmonary hypertension, treated with intravenous epoprostenol infusion, is scheduled for emergency appendectomy. Which of the following statements regarding her anesthetic
plan is correct?
A. Aggressive premedication with opiates is recommended.
B. Induction with standard dose of propofol will help in the control
of hemodynamics.
C. Vasopressor use to treat hypotension is indicated.
D. The epoprostenol infusion should be discontinued to avoid
hypotension.
E. Large fluid bolus before induction is indicated to avoid hypotension.
3. A 32-year-old woman with pulmonary hypertension secondary to mitral stenosis is undergoing laparoscopic nephrectomy for a renal mass. Half an hour after the start of the surgery, her SpO2 is 89%, her
end-tidal CO2 is 55, BP 89/47, and HR 120. She has received 1 L of i.v. fluids. Which of the following is the most likely diagnosis for her hemodynamic compromise?
A. Left ventricular myocardial infarction (MI)
B. Ventilatory failure
C. Excessive IV fluid administration
D. Hypovolemia due to blood loss
E. Pulmonary embolism
F. A CO2 embolus from insufflation