WHEN EVERYTHING YOU DO IS WRONG: RESUSCITATION IN RV FAILURE. Jacob A. Miller, NP, CNS, NRP

(1)

WHEN EVERYTHING YOU DO IS WRONG:

RESUSCITATION IN RV FAILURE

(2)

Disclosures and Disclaimers

• No financial or other conflicts of interest

• Views/opinions are entirely my own and may not be

reflective of my employers.

• Any specific brands or products mentioned are

illustrative and/or for clarity and not intended as

product endorsement.

• This presentation is not a substitute for sound

medical judgment or common sense. Know and

follow your local protocols. Consult medical control

as indicated.

(3)

Objectives

• Describe the basic cardiovascular anatomy and

physiology

• Differentiate right-sided cardiac physiology from

left-sided physiology

• Describe the pathophysiology of acute right

ventricular failure

• Identify common interventions or pharmacologic

treatments that could be detrimental in the setting of

acute right ventricular failure.

• Describe an appropriate treatment regimen for the

(4)

(5)

Interfacility transfer

Community ER to Tertiary ICU

Acute pulmonary embolism

(6)

Anxious, dyspneic, distressed

HR 120s RR 30s SBP 100

Unable to obtain reliable SpO

₂

(7)

Initial Management

• IV Fluid bolus

• RSI induction

• Intubation

• Mechanical ventialtion

..

(8)

(9)

Resuscitation

• Additional crystalloid bolus

• Push dose phenylephrine

• Rapid norepi titration

Deteriorated into cardiac arrest

..

(10)

Discussion

(11)

Epidemiology

True prevalence difficult to know

• Acute vs chronic

• Failure vs dysfunction

(12)

Cardiol Clin 2013;31:545

pHTN

LV Fx

Leading cause of RV dysfunction is pulmonary hypertension

Leading cause of pulmonary hypertension is LV dysfunction

(13)

Circulation 2018;137:e578

(14)

(15)

Estimated prevalence of RV dysfunction

• Up to 48% of HFrEF cases (LV dysfunction)

• Approx 16% of ischemic cardiomyopathies

• Approx 60% of nonischemic cardiomyopathies

• Around 25-60% of pulmonary emboli

(16)

(17)

Cardiol Clin 2012;30:167 Cardiol Clin 2013;31:545 Arq Bras Cardiol 2000;75(2):111

2 mm

5 mm

RV Differences

• Thinner wall

• “C” shaped

• Low–pressure system

RV and LV encased within fairly “rigid” pericardium

5

20

5

20

10

120

10

(18)

Cardiol Clin 2012;30:167

(19)

Cardiol Clin 2012;30:167 Cardiol Clin 2013;31:545

20

5

20

10

120

10

120

80 LV Syst: 120 - 120 =

X

LV Dias: 80 - 10 =



RV Syst: 120 - 20 =



RV Dias: 80 - 5 =



(20)

Ciculation 1954;9:706

Preload

Str

oke

V

olume

RV

LV

Normal

Ischemic

(21)

RV

LV

Afterload

Ann Am Thorac Soc 2014;11:811 Circulation 2018;137:e578

Str

oke

V

(22)

J Clin Invest 1966;45:399

PO

₂

Pulm

V

asc

Reistance

pH 7.4

pH 7.3

pH 7.2

pH 7.1

(23)

RV

DEATH

SPIRAL

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

↓ pH (acidosis)

Systemic hypoxia

and/or hypercarbia

↑ PVR

↑ RV afterload

RV DEATH SPIRAL

(24)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

↑ RV pressure

↑ RV volume

(25)



Cardiol Clin 2012;30:167 Cardiol Clin 2013;31:545

20

5

20

10

120

10

120

80 LV Syst: 120 - 120 =

X

LV Dias: 80 - 10 =



RV Syst: 120 - 20 =

RV Dias: 80 - 5 =

(26)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

RV Ischemia

(27)

Ciculation 1954;9:706

Preload

Str

oke

V

olume

_RV

Normal

Ischemic

(28)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

(29)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

RV Dilation

(30)

Cardiol Clin 2012;30:167 Arq Bras Cardiol 2000;75(2):111

(31)

Cardiol Clin 2012;30:167 Arq Bras Cardiol 2000;75(2):111

(32)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

(33)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

↓ pH (acidosis)

Systemic hypoxia

and/or hypercarbia

(34)

J Clin Invest 1966;45:399

PO

₂

Pulm

V

asc

Reistance

pH 7.4

pH 7.3

pH 7.2

pH 7.1

(35)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

↓ pH (acidosis)

Systemic hypoxia

and/or hypercarbia

↑ PVR

↑ RV afterload

(36)

RV

Afterload

Str

oke

V

(37)

Chest 2005;128:1836 Crit Care 2010; 14:R169

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

↓ pH (acidosis)

Systemic hypoxia

and/or hypercarbia

↑ PVR

↑ RV afterload

(38)

(39)

RV Dysfunction

RV Ischemia

↓ LV preload

RV Dilation

↓ Cardiac Output

↑ RV pressure

↑ RV volume

↑ RV wall tension

↓ RCA perfusion

↓ MAP

↓ pH (acidosis)

Systemic hypoxia

and/or hypercarbia

↑ PVR

↑ RV afterload

IV Fluids:

↑ RV preload

Pressors:

↑ SVR

Positive-pressure

ventilation

RSI

Pressors:

↑ SVR and PVR

(40)

Crit Care 2010; 14:R169

Intensive Care Med 2019;45:1503

α

₁

β

₁

β

₂

V

₁

/V

₂

D

₁

/D

₂

SVR/

MAP

HR/

CO

Norepinephrine

+++

++

-





Epinephrine

+++

++

-



Phenylephrine

+++

-





Vasopressin

-

+++

-





Dopamine

+*

++*

+*

-

+++



Dobutamine

-

+++

-





PVR

PVR/

SVR*



/

/







/





(41)

Oxygen

Nitric oxide

Epoprostenol

Nitroglycerin

/



Crit Care 2010; 14:R169 Pharmacotherapy 2010;30:728 Nitric Oxide 2019;84:60

Intensive Care Med 2019;45:1503

Norepinephrine

Epinephrine

Phenylephrine

Vasopressin

Dopamine

Dobutamine

PVR

PVR/

SVR*



/

/







/





Inhale

d

Off label

(42)

The RV is unique

Avoid hypoxia and acidosis

Caution with IV fluids

Low dose epi or NE probably okay

Consider early vasopressin

Avoid intubation if possible

If not – use minimal pressure settings

Inhaled agents as potential rescue

(43)

Jacob A. Miller ACNP FNP CNS NRP