Pro: General Anesthesia Is Superior to Regional Anesthesia for Patients with Pulmonary Hypertension Undergoing Noncardiac Surgery

Abstract

An increasing prevalence of pulmonary hypertension (PH) and a recent change in the definition of PH contribute to a growing population of patients receiving this diagnosis. 1 Condon DF Nickel NP Anderson R et al. The 6th World Symposium on Pulmonary Hypertension: What's old is new. F1000Res. 2019; 8 Crossref PubMed Scopus (62) Google Scholar The modification of the definition of PH in 2019 involved lowering the classification threshold of mean pulmonary artery pressure from 25 mmHg to 20 mmHg, the inflection point for poorer patient outcomes. 2 Wijeratne DT Lajkosz K Brogly SB et al. Increasing incidence and prevalence of World Health Organization groups 1 to 4 pulmonary hypertension: A population-based cohort study in Ontario, Canada. Circ Cardiovasc Qual Outcomes. 2018; 11e003973 Crossref PubMed Scopus (110) Google Scholar PH is a risk factor for patients undergoing noncardiac surgery. Underlying PH has been independently associated with increased rates of postoperative heart failure, hemodynamic instability, respiratory failure, delayed extubation, prolonged intensive care stay, in-hospital death, and 30-day hospital readmission. 3 Kaw R Pasupuleti V Deshpande A et al. Pulmonary hypertension: An important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med. 2011; 105: 619-624 Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar ,4 Lai HC Wang KY Lee WL et al. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth. 2007; 99: 184-190 Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar The perioperative setting can be especially challenging in controlling the increase in pulmonary vascular resistance and the consequential afterload burden that can precipitate right ventricular failure. Surprisingly, despite the association of PH with significant morbidity and mortality, there are no practice guidelines advising the optimal anesthetic approach for patients with this condition. Therefore, it is worth discussing the commonly used but different and polarizing anesthetic techniques for this patient population—regional anesthesia (RA) versus general anesthesia (GA). This side of the discussion will focus on the merits of GA.