POTS&anaesthesia

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DrRogerCorderyConsultantinCardiothoracicAnaesthesiaandCri;calCare

POTS&anaesthesia

» 0.2%popula;on» Rare,under-recognisedbycliniciansandprobablyunder-diagnosed

»  Someimportantassocia;onsforanaesthe;sts»  Chronicfa;gue»  Ehlers-Danlos»  Mitralvalveprolapse»  Inflammatoryboweldisease

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Pathophysiology

» Peripheralautonomicdenerva;on» Hypovolaemia» Decondi;oning(↓SV,↓LVmass)» Anxietyandhyper-vigilance

» HyperadrenergicPOTS

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Anaesthesia

» Autonomicchanges

»  Significantvasodila;on

» Moresowithregionalanaesthesia

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Anaesthesia

» Posi;vepressureven;la;on»  Surgicalissues» Bloodloss» Pneumoperitoneum» Posi;on

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Evidencebase

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Pre-opera;veassessment

»  Iden;fica;onofpa;ents»  Increasedawarenessamongstcliniciansofimplica;ons

»  Triggerfactors» Associatedsyndromes» POTStreatment

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Pharmacology

» Midodrine(pro-drugα1-agonist)

»  Fludrocor;sone» Propranolol» Pyridos;gmine

» Clonidine» Methyldopa

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Intra-opera;vecare

» Caseseries13pa;ents» 3developedprolongedhypotension»  Invasivemonitoring?

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Intra-opera;vecare

» Caseseries13pa;ents» 3developedprolongedhypotension»  Invasivemonitoring?

» HyperadrenergicPOTS»  Exaggeratedhypertensiveresponse»  Avoidketamine

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Obstetriccare

» RegionaltechniquespreferredforLSCS»  Epiduralanalgesiacommon» RegionaltechniquesinPOTSonlydescribedinobstetrics

»  EarlyepiduralinhyperadrenergicPOTS

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Post-opera;vecare

»  IdeallydoneincentrewithPOTSphysician»  Earlymobilisa;onmaybeproblema;c»  Suitabilityfordaycase?»  Poten;alfor↑DVTrisk/respiratorycompromise

»  Importancetomaintainpre-optherapyifpossible

» Avoiddrugswhichcausetachycardia(e.g.cyclizine)

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Painmanagement

» Chronicfa;gue,hyper-vigilance&anxiety»  Issueswithpainmanagement

»  Earlymul;-modalapproach

» Regional/neuraxialtechniques»  Ehlers-Danlosmayberesistanttolocalanaesthesia

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Summary

»  Poten;allydifficultgroup»  Uncommonandcanpresentformul;pleinterven;ons

»  Notonradarofmostsurgeons/anaesthe;sts&needincreasedawareness

»  Shouldhavemul;-disciplinarycare» MaintenanceofpreopRximportant»  Painmanagementmaybeproblema;c

» THANKYOU!

rogercordery@nhs.net