Anesthesia and Altitude

Physics and Physiology of Altitude

Definitions
High Altitude=1500 to 3500m
Onset of physiologic effects of diminished Fio2. minor impairment of Sao2 (typically 90-
95%). Increased minute ventilation and decreased PaCo2 at rest
Very High Altitude= 3500 to 5500m
SaO2 falls below 90% and PaO2 falls below 60mm Hg
Extreme hypoxia may occur during sleep exercise or high altitude illness
Extreme Altitude= over 5500em
Significant hypoxia and hypocapnia exist. Deterioration of physiologic function will occur.
Permanent habitation can not exist
Anesthesia and Altitude
Physics and Physiology of Altitude
Previous Medical Research
Serious research started in the late 1940s and early 1950s as Mount Everest
became the worlds foremost goal in Mountaineering. The English and other
Europeans pioneered the research in a quest to summit Mount Everest.
Initiated studies of Oxygen flow requirements for >8000m
Mt Logan 1967-1969 Charles Houston MD AMS and HAPE
Work of Carlos Monge ( South America) was pivotal in the field of chronic
altitude physiology.
Silver Hut research Sir Edmund Hilliary James West MD and Griffith Pugh
7440m Makalu
1982 AMREE Frank Sarnquist MD et al. First to measure alveolar gases and
barometric pressure on Mt. Everest Summit
1982-1990 Denali Medical research project Peter Hacket MD
Operation Everests I and II 1985
Himalayan Rescue Association Pheriche Khumbu Nepal
Anesthesia and Altitude
Environment at High Altitude
Barometric Pressure falls with increasing altitude in logarithmic
fashion.
Therefore partial pressure of oxygen also falls (21% of
Barometric pressure (BP).
Causes Hypoxia. The primary problem. Example: Barometric
Pressure is 50% at 5500m
Related to position relative to equator
Extreme cold fronts also cause a drop in BP.
Anesthesia and Altitude
Physics and Physiology
Ventilation changes
Hypoxic Ventilatory response (HVR) is key
Hypoxia is profound enough to trigger ventilation not hypercarbia!!
Therefore, hyperventilation (relative to normal Carbon Dioxide levels)
occurs. This drops the CO2 levels profoundly. Carotid body senses
the decrease PaO2, triggers respiratory center in Medulla to increase
ventilation.
HVR is genetically determined. Not significantly improved by
exercise.
HVR decreased by ethanol, benzodiazepines, narcotics.
HVR improved by Acetazolamide (Diamox) caffeine and cocaine
Causes a primary respiratory alkalosis reachs maximal effect at 7
days. Plasma HCO3- drops!!
Anesthesia and Altitude
Physics and Physiology
Chronic Altitude Polycythemia
Rise in Hemoglobin levels in response to
chronic hypoxia
First described by Carlos Monge
Leads to a higher viscosity of blood
Higher level of DVTs??
Anesthesia and Altitude
Physics and Physiology
Circulation Changes
Systemic Circulation:
mild increase in Blood Pressure.
Moderate increase in heart rate
Moderate increase in cardiac output
Heart rate returns to normal with acclimatization
Pulmonary Circulation
Hypoxic pulmonary vasoconstriction causes increase PA pressures
Not a complete return to normal with supplemental O2.
Cerebral circulation
Balance of Hypoxic vasodilation and hypocapnic vasoconstriction
Anesthesia and Altitude
Physics and Physiology
Hemopoietic changes
Research first done in 1890 in the Andes showed a increase level of
hemoglobin.
Hypoxia causes erythropoietin secretiion. This causes bone marrow
production of red blood cells.
RBC released as early as 5 days and occurs for several weeks.
Early rise in HgB level is due to decreased plasma levels
 The practice of Medicine at High and
Extremely high Altitude
Illnesses Aggravated by High Altitude
Chronic Lung Disease
Arteriosclerotic Heart Disease
Hypertension
Sickle Cell Disease
Pregnancy
The practice of Medicine and Anesthesia at High and
Extremely high Altitude

Illnesses aggravated by high altitude

Chronic Lung Disease:
COPD: Reduced exercise capability. Hypoxemia, pulmonary
hypertension can be expected to worsen. If SaO2 is <85% at sea
level, reccommend supplemental oxygen. 1920m shown to be well
tolerated.
Pulmonary Hypertension: Increased incidence of HAPE. Travel to
high altitude is contraindicated.
Obstructive sleep apnea: May become severely hypoxic at altitude.
Periodic breathing cheyenne stokes respiration is worsened.
Asthma: Can be aggravated by airway heat loss of altitude, however,
problems are quite unusual. Not a contraindication to travel to
altitude but recommend bringing all medications
The practice of Medicine at High and
Extremely high Altitude

Arteriosclerotic Heart Disease

Healthy heart has been shown to tolerate extremely high altitude without
problems. Shown by electrocardiogram, echocardiograms, heart
catheterizations and exercise stress tests.
Little clear evidence as yet for increased cardiac ischemic events in
patients with history of ischemic cardiovascular disease.
Moderate altitude is tolerated, with reduced levels of exercise.
High and very high altitude is not reccomended.
Patients with CABG who are asymptomatic and have normal stress tests
have successfully completed climbs over 5200m
The practice of Medicine at High and Extremely high
Altitude

Hypertension
A small and transient rise in blood pressure
is seen on travel to high altitude.
A similar rise occurs in patients with pre-
existing hypertension
Reccomendations to continue with current
medications make sense. What about
diuretics??
The practice of Medicine at High and
Extremely high Altitude

Sickle cell anemia

Sickle cell crisis is well known complication of exposure to
high altitude
20% incidence of crisis in patients with hemoglobin SC
with travel to 1500-2000m
Splenic infarction syndrome more common,
The practice of Medicine at
High and Extremely high
Altitude
Pregnancy
Limited data exist
Higher incidence of pregnancy induced hypertension and pre-
eclampsia
No documented increase in spontaneous abortion, placenta
abruption, placenta previa,
No fetal heart rate changes appear evident at moderate altitude.
Airplane travel is okay but >4000m is not reccomeded
The practice of Medicine at
High and Extremely high
Altitude
The practice of Medicine at High and Extremely high Altitude
Advisability of Exposure to High and Very High Altitude for
common conditions
Anesthesia and Altitude
The practice of Anesthesia at Altitude
Pre-existing medical conditions and
anesthesia
Reduced Partial pressure of Oxygen at
altitude and hypoxia with anesthesia
N2O at Altitude
The practice of Anesthesia at Altitude
Pre-existing medical conditions and anesthesia

CAD
Congestive Heart Failure
HTN
Serious Arrhythmias
Cerebro-Vascular disease
Sickle Cell Anemia
Pulmonary Conditions
Pulmonary Hypertension
OSA
Pregnancy
The practice of Anesthesia at Altitude

Reduced Barometric pressure causes a reduced partial pressure of

oxygen. Causes an underlying hypoxic precursor. Once patient is
intubated and ventilated in a semi-closed circuit the percentages of
inhaled gases can be tightly controlled but the reduced barometric
pressure remains the same. If patient is undergoing Intravenous
sedation or regional anesthetic, then they are subjected to lower
partial oxygen tension.
Typically this does not cause a significant problem in healthy
individuals. Can lead to issues in patients with underlying diseases
as previously discussed.
Inspired oxygen content is titrated to effect
The practice of Anesthesia at
Altitude
Using Nitrous Oxide at altitude. Remember that the relative
ratios of all gases remain the same. The total number of
molecules in a given space is diminshed with reduced
pressure. Typically our concern is simply with reduced
barometric pressure causing an insuffcient oxygen delivery
to meet the metabolic needs of the tissue.
We recommend not delivering more than 50% Nitrous oxide
over 2500m
Anesthesia and Altitude
Case Report #1
43 year old male for urgent laparoscopic cholecystectomy
Obstructive sleep apnea
Morbid obesity
Lives at sea level
Smokes pack per day
Has a room air SpO2 = 83%, RR=26
He complains of pain despite being apparently over
sedated by emergency room
Anesthesia and Altitude
Case Report #2
75 year old female
smoker,
COPD,
Known coronary artery disease.
History of Congestive heart failure in past
Lives at sea level.
Has fallen, fractured her hip and now needs
open reduction internal fixation of fracture