ANESTHETIC MANAGEMENT OF SPONTANEOUS

PNEUMOTHORAX PATIENT WITH SEVERE PULMONARY

HYPERTENSION ( Case Report )
Hario Tri Hendroko, Uyun Mufaza, Adhrie Sugiarto SpAn
Departement Of Anesthesiology and Intesive Care
Faculty Of Medicine, University Indonesia

Background
•Pulmonary hypertension increases the risk of morbidity and mortality in perioperative, even in a
noncardiac surgical procedure. In this case, we report a patient with pneumothorax that
can aggravate the pulmonary condition.

Case Presentation
•A 4-year-old boy, 11.4 kg , with diagnosis of spontaneous pneumothorax dextra was planned WSD
insertion procedure under general anesthesia. The patient we assessed with ASA 4E because of
pneumothorax with distress respiration and severe pulmonary hypertension. The hemodynamic stase was
still stable. Blood preasure was 102/54 mmHg, and heart rate 140 x/minute. The patients tended to be
restless, confused and shortness of breath. Respiration rate was 40x/minutes, temperature was 36 C and
with O2 saturation 94% with 6 liters per minute on simple mask. Chest xray showed the right
pneumothorax and echocardiogram results with solitary sinus atrial, AV-VA concordance, RV RA Dilatation,
TR Severe (PG 78 mmHg), moderate PR (PG 42 mmHg), D shaped LV, intact IVS, EF 63 %, TAPSE 17 mm.
Patient was managed with General anesthesia. For premedication, we used Midazolam 1 mg IV In the
reception room and then taken the patien to the operating room with a simple 6 lpm mask. For induction,
we administrated Propofol titration 5 mg IV until the patient asleep and combined with sevoflurane vol 4%
in 100% oxygen. Anesthetic gas was reduced gradually to 2 vol% while maintaining spontaneous breathing.
Then Fentanyl 15 mcg IV was given and LMA 2.5 was inserted to ensure the ventilation. we kept maintains
spontaneous breathing, with the ventilation helped by bagging assisted manually. Before surgery, the
patient was given infiltration lidocaine at the incision site. The pocedure duration was about 45 minutes,
bleeding was minimal, chrystalloid 100 ml. Post procedure, WSD had been attached to the right lung and
there was positive undulation.Patient was stable, oxygen saturation was 99%.heart rate 120x / minutes.
The patient was observed in the ward for couple of days and could be discharge from hospital.

Discussion
• The anesthesia management in pulmonary hypertension is based on the principles of avoiding
factors that increase Pulmonary Vascular Resistance and preservation of right ventricle outflow.
All intravenous anesthesia drug, including propofol, do not inhibit HPV and can be used together
with opioid because it will not influence the PVR and oxygenation. Sevoflurane maintains the
function of the cardiac and lungs during surgery, maintain the pressure and peripheral perfusion
good. During the postoperative, patients have to be monitored and given adequate analgetic in
period time. Perioperative management in patients with pulmonary hypertension involves some
experts such as anesthesia, surgeon, cardiologist, and a pulmonologist for the best outcome

Conclusion
• Management of Pulmonary Vascular Resistance and right ventricle outflow have important role
for patient with pulmonary hypertension under general anesthesia.

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