Intensive care management of right ventricular failure and pulmonary hypertension crises

Abstract

Pulmonary hypertension (PH), an often unrelenting disease that carries with it significant morbidity and mortality, affects not only the pulmonary vasculature but, in turn, the right ventricle as well. The survival of patients with PH is closely related to the right ventricular function. Therefore, having an understanding of how to manage right ventricular failure (RVF) and acute pulmonary hypertensive crises is imperative for clinicians who encounter these patients. This review addresses the management of these patients in detail, addressing: (a) the pathophysiology of RVF, (b) intensive care monitoring of these patients in the intensive care unit, (c) imaging of the right ventricle, (d) intubation and mechanical ventilation, (e) inotrope and vasopressor selection, (f) pulmonary vasodilator use, (g) interventional and surgical procedures for the acutely failing right ventricle, and (h) mechanical support for RVF.

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

“…While a few patients in our cohort were treated with phenylephrine, it is important to note that this medication can increase PVR, 27 thus worsening hemodynamic compromise. Interestingly, while PH patients are known to be at risk of cardiac arrest due to hemodynamic collapse, 6,22 these episodes were not seen in our cohort of patients despite higher vasopressor requirements. With our data, we believe future prospective studies on emergent intubation strategies in PH patients with acute right heart failure should focus on fluid and vasopressor management in the early postintubation period.…”

“…10 Though definitive intubation approaches that decrease the risk of hemodynamic collapse have yet to be recognized, there may be a few emerging approaches. 6,22 Our previous study of a small group of patients using awake intubation bridged by noninvasive ventilation demonstrated a promising technique in reducing major complications from intubation such as AKI, despite the need for significant vasopressor support in 5 of 9 patients (55.6%). 10 Other possible solutions include using ketamine or etomidate for induction which may prevent profound hypotension and significantly decrease the rate of hemodynamic collapse.…”

“…4 Brief periods of hypoxemia and hypercapnia may provoke RV failure by increasing pulmonary vascular resistance (PVR), contributing to the pronounced effects of induction medications on hemodynamic instability. 5 – 7 For these reasons, there is an increased risk of mortality in PH patients who undergo ETI and, in particular, emergent intubations. 8 – 10 While alternate approaches such as awake intubation have been suggested, 10 we have yet to study the efficacy of specific interventions in the immediate post-intubation period that could increase survivability.…”

Antibiotics and ECMO in the Adult Population—Persistent Challenges and Practical Guides

“…Liver and kidney failure can influence drug metabolism and excretion, and their function is highly dependent on ECMO performance, especially in VA ECMO [76]. Liver clearance is affected by blood stasis, which is highly dependent on the performance of the right ventricle [77]. Said performance may be affected by the emergence of cor pulmonale due to hypoxia, one of the primary reasons of ECMO implementation [6][7][8].…”

“…Said performance may be affected by the emergence of cor pulmonale due to hypoxia, one of the primary reasons of ECMO implementation [6][7][8]. Fluid resuscitation can further exacerbate venous liver congestion [77,78]. The significant increase in fluid balance results in excessive mortality in ECMO [74].…”