RV Failure Decompensation Pulmonary HTN — FRCA Final MCQ

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HardGeneral AnaesthesiaRV Failure Decompensation Pulmonary HTNFRCA Final

A 72-year-old woman (ASA IV) with known pulmonary hypertension (mean PAP 55 mmHg) and right heart failure undergoes emergency hip fracture repair under spinal anaesthesia. Post-operatively her SpO2 drops to 82% and she becomes hypotensive with a new loud P2 and raised JVP. What has likely occurred?

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Correct answer: D — Tension pneumothorax

In a patient with pre-existing pulmonary hypertension and RV failure, acute decompensation of right ventricular function is the most likely cause. Triggers include: hypoxia, hypercarbia, acidosis, hypothermia, fluid overload, and sympathetic activation (pain) – all of which increase pulmonary vascular resistance. The spinal anaesthetic may have reduced SVR, reducing RV coronary perfusion pressure (RV CPP = systemic MAP – RV end-diastolic pressure). Management: 100% O2, inhaled nitric oxide or prostacyclin (pulmonary vasodilators), vasopressin or noradrenaline (to maintain systemic pressure), and inotropes (milrinone/dobutamine).

Reference: ESC – 2022 – Pulmonary hypertension guidelines; RCOA – 2023 – Cardiac anaesthesia