Recently published research reveals that orthopedic (musculoskeletal) surgery in patients with pulmonary hypertension (PH), while challenging, is feasible and offers decent outcomes even in severe stages of the disease, provided proper care is given. The paper entitled “Perioperative management of patients with severe pulmonary hypertension in major orthopedic surgery: experience-based recommendations“ was published in the GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW journal.
PH is a disease characterized by increased blood pressure in the lungs and in the heart’s arteries. Data from published retrospective analyses reported that the mean pulmonary artery pressure (PAPm) in healthy individuals is around 14 mmHg, but in patients with PH can be above 25 mmHg. This makes it difficult for the heart to pump blood through the lungs.
Pulmonary hypertension can be either idiopathic, hereditary, or a result of other diseases. Factors such as stress, pain, intra-/post-operative mechanical ventilation, and trauma-induced inflammation can increase pressure and resistance in the pulmonary arteries, causing right heart failure. Furthermore, published data suggest that PH is associated with poor prognosis in both cardiac and non-cardiac surgeries.
In this study, the researchers examined the outcomes of PH patients subjected to major orthopedic system surgery. A total of 16 patients who underwent such orthopedic surgery were selected from 92 PH patients who received surgical procedures at St. Georg Hospital in Leipzig, Germany, between 2011 and 2014. All patients with precapillary forms of PH were examined for mortality and major complications such as infections, bleeding, cardiac and neurologic aggravations, and a lack of wound healing. A variety of methods were used in patients’ examination, including clinical testing, thoracic X-ray, pulmonary function evaluation, right heart catheterization, and echocardiography.
The results from the clinical data, operation, and anesthesia characteristics and outcomes suggested that all the patients experienced arterial capillary forms of PH that are treated either with single or combination therapy, and the recorded mean PAP-values was around 39.3 mmHg. Other data showed that general anesthesia (GA) was preferred for surgery in 6 patients, GA combined with regional techniques was performed on 6 other patients, and regional anesthesia was used on the remaining 4 patients. With respect to in-hospital morbidity and mortality, the recorded data indicated that 6 patients (37.5%) had important post-operative complications, mainly related to bleeding (1 patient), infection (1 patient), wound healing deficits (3 patients), and dysrhythmia (1 patient). One patient died postoperatively from right heart failure and pulmonary infection.
In summary, these findings suggest that perioperative (preoperative, intraoperative, and postoperative) management of PH patients is challenging and needs to include multi-disciplinary team of pulmonologists, cardiologists, anesthetists, and surgeons. Overall, these data demonstrate that orthopedic surgery in PH patients is achievable with acceptable outcomes even for patients with severe stages of PH, if proper concepts like individualization and disease-adapted interdisciplinary treatment were followed.