Links To Right Ventricular failure due to pulmonary hypertension IBCC – Right Ventricular failure due to pulmonary hypertension With Links To Additional Resources

In this post I link to the Internet Book of Critical Care [Link is to the Table Of Contents] chapter, Right Ventricular failure due to pulmonary hypertension. August 20, 2021 by Dr. Josh Farkas.

All that follows is from the above IBCC chapter.

Right Ventricular failure due to pulmonary hypertension



going further

rapid reference

approach to decompensated RV failure ✅

correct any precipitating factors (link)
  • D/C negative inotropes (e.g., beta-blockers).
  • D/C alpha-agonists (e.g., decongestants).
  • D/C systemic vasodilators, if hypotensive.
  • Manage arrhythmia (e.g., cardioversion of new AF).
  • Manage acidosis.
  • Treat other active processes (e.g., infection, pulmonary embolism).
optimize the lungs (link)
  • Aggressive oxygenation (O2 is a pulmonary vasodilator).
  • Consider drainage of any substantial pleural effusions.
  • Treat hypercapnia (but avoid intubation).
  • If intubated:  avoid excess PEEP or airway pressures.
volume management (link)
  • Most patients require diuresis (even if on vasopressors).
  • If CVP >>10, may diurese to a target CVP of ~8-12 mm.
  • Avoid fluid administration unless there is unequivocal, profound hypovolemia.
establish adequate MAP (link)
  • Vasopressin may be preferred if central access is available.
  • In mildly unstable patients, norepinephrine is often effective.
  • Epinephrine may be the most reliable agent for the sickest patients.
  • Target a MAP >65 mm, or perhaps >(60 + CVP).
inhaled pulmonary vasodilators PRN (link)
  • Indications may include:
    • Refractory hypoxemia (especially with R–>L shunt).
    • High risk of death (e.g., peri-intubation stabilization).
    • Failure of above measures to cause improvement.
  • Main contraindication:  Left ventricular failure.
Inotrope PRN (link)
  • Consider if persistent RV systolic failure with poor perfusion, despite all of the above interventions.
  • Options include the addition of dobutamine, or switching from norepinephrine to epinephrine.

lack of evidentiary support

There is nearly no high-quality evidence regarding the management of right ventricular failure in the ICU.

There is nearly no high-quality evidence regarding the management of right ventricular failure in the ICU.

Right ventricular failure in the context of pulmonary hypertension is extremely common, occurring in perhaps about a third of patients with ARDS or septic shock.  Our most important task in the ICU is identifying all patients with RV failure and providing them with RV-friendly resuscitation.  Simple interventions can go a long way in these patients, if we can merely understand their precarious physiology.

relationship between RV failure & pulmonary hypertension

relationship between RV failure & pulmonary hypertension
  • The right ventricle generally fails due to two mechanisms:
    • (1) Primary failure of the RV muscle (e.g., due to MI or myocarditis).
    • (2) Pulmonary hypertension causing excessive afterload on the right ventricle.
  • In practice, nearly all right ventricular failure is due to pulmonary hypertension (#2).  Thus, these phenomena are generally considered together.  However, they are not exactly the same; for example, many patients have chronic, severe pulmonary hypertension with preserved right ventricular function (chronic compensated pulmonary hypertension).
  • From the ICU standpoint, the key issue is whether or not the right ventricle is failing:
    • Right ventricular failure is often an ICU issue.
    • Pulmonary hypertension with preserved right ventricular function is largely an outpatient issue.
  • The remainder of this chapter will discuss right ventricular failure due to pulmonary hypertension.
definition of RV failure in the context of pulmonary hypertension
  • There is no universal definition of RV failure.(29744563)  This is problematic, because lacking a definition hinders the ability to reach a definitive diagnosis and institute therapy.  The concept of RV failure remains a nebulous constellation of ideas that is difficult to grasp onto.
  • Technically, the RV could fail in two ways:
    • “Forwards failure” – RV fails to generate an adequate cardiac output, leading to cardiogenic shock.
    • “Backwards failure” – RV fails to decongest the systemic venous system, leading to an excessively high central venous pressure with systemic congestion.
  • Physiologically, RV failure nearly always involves systemic congestion (more on this below).  Thus, isolated “forwards failure” of the RV is extremely rare (although this might occur in a patient with chronic pulmonary hypertension and marked hypovolemia).
  • Consequently, a clinically useful bedside definition of RV failure due to pulmonary hypertension might simply be anyone with marked elevation of central venous pressure (CVP).  No definition is 100% perfect, but this may serve as a useful clinical stimulus to consider RV failure:

For details on using POCUS to determine CVP, please see Three YouTube Videos On The Use Of POCUS For Determining Jugular Venous Pressure
Posted on October 25, 2021 by Tom Wade MD

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