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Rescuing the right ventricle | Sara Crager at TBS23

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Rescuing the right ventricle A talk by Sara Crager at TBS23

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RESCUING THE RIGHT VENTRICLE Sara Crager, MD Assistant Professor, Division of Critical Care Departments of Anesthesia & Department of Emergency Medicine University of California Los Angeles
WHY YOU CARE ABOUT RIGHT VENTRICULAR PHYSIOLOGY
REGULARLY-SCHEDULED ICU ADMISSION
103/77 143 31 94% 7.20 / 44 / 61 / 16
103/77 143 31 94% 7.20 / 44 / 61 / 16
BP drops to 76/40
2L IV FLUID BOLUS
D+
D+
REGULARLY-SCHEDULED ICU ADMISSION
PHYSIOLOGY EPIC FAIL
Not actually that rare
Vallabhajosyula et al. Chest 2021;159(6):2254-2263 Impact of Right Ventricular Dysfunction on Short-term and Long-term Mortality in Sepsis DO you see the occasional Sepsis patient?
Vallabhajosyula et al. Chest 2021;159(6):2254-2263 Impact of Right Ventricular Dysfunction on Short-term and Long-term Mortality in Sepsis
Sato et al. Critical Care 2021;152(1):181-193 The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis You sometimes see ARDS patients too?
Sato et al. Critical Care 2021;152(1):181-193 The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis
Iglesias-Garriz et al. Reviews Cardiovascular Medicine 2012;13:e62-69 Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis heart failure patients every now and then?
Iglesias-Garriz et al. Reviews Cardiovascular Medicine 2012;13:e62-69 Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis
Corica et al. Nature Scientific Reports 2021;11(17774) Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis COVID Anyone?
Corica et al. Nature Scientific Reports 2021;11(17774) Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis
WHY YOU CARE ABOUT RIGHT VENTRICULAR PHYSIOLOGY
HIGH RISK… BUT RESCUABLE
The Princess Ventricle
Crumbles at the first sign of resistance
Afterload Stroke Volume
Afterload A Stroke Volume
Afterload A B Stroke Volume
Afterload A B Stroke Volume
Afterload Stroke Volume
Afterload Stroke Volume A
Afterload Stroke Volume A B
Afterload Stroke Volume A B
Feels entitled to perfusion during the entire cardiac cycle
Right coronary arteries Left coronary arteries
120 80 120 80 Right coronary arteries Left coronary arteries
20 5 120 10 120 80 120 80 Right coronary arteries Left coronary arteries
20 5 120 10 120 80 120 80 CPP 70 Right coronary arteries Left coronary arteries
20 5 CPP 0 120 10 120 80 120 80 CPP 70 Right coronary arteries Left coronary arteries
20 5 CPP 75 CPP 0 120 10 120 80 120 80 CPP 70 Right coronary arteries Left coronary arteries
20 5 CPP 75 CPP 0 120 10 120 80 120 80 CPP 100 CPP 70 Right coronary arteries Left coronary arteries
Pressure Overload
Volume OVERLOAD Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Afterload Stroke Volume A B
20 5 CPP 75 CPP 0 120 10 120 80 120 80 CPP 100 CPP 70 Right coronary arteries Left coronary arteries
20 5 120 80 Right coronary arteries Left coronary arteries
5 120 80 60 Right coronary arteries Left coronary arteries
5 120 80 60 CPP 75 Right coronary arteries Left coronary arteries
5 120 80 60 CPP 75 CPP 60 Right coronary arteries Left coronary arteries
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
“THE RIGHT VENTRICLE IS PRELOAD DEPENDENT”
PHYSIOLOGY EPIC FAIL
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
WHY IS AN RV INFARCT DIFFERENT THAN A MASSIVE PE?
PRIMARY PROBLEM: PIPE IS BLOCKED
What is the next best step in management?
What is the next best step in management? A) Steak dinner
What is the next best step in management? A) Steak dinner B) Large milkshake
What is the next best step in management? A) Steak dinner B) Large milkshake C) One dozen hot dogs
What is the next best step in management? A) Steak dinner B) Large milkshake C) One dozen hot dogs D) Nasogastric tube
Ventricular Interdependence
FLUID ++ Ventricular Interdependence
FLUID ++ Ventricular Interdependence
FLUID ++ Ventricular Interdependence
The Princess Ventricle
THE RIGHT VENTRICLE IS VERY UNFORGIVING
Vicious Cycle
Vicious Cycle
RV Afterload
RV Afterload RV Contractility
RV Afterload RV Contractility RV Volume
RV Afterload RV Contractility RV CO RV Volume
RV Afterload RV Contractility RV CO RV Volume
RV Afterload RV Contractility LV Preload RV CO RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LV Preload RV CO RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV Volume
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP RV Volume
Interventricular Septal Shift RV Ischemia RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP RV Volume
Interventricular Septal Shift RV Ischemia RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP RV Volume
Interventricular Septal Shift RV Ischemia RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP RV Volume
Interventricular Septal Shift RV Ischemia RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP O2 Demand RV Volume
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Interventricular Septal Shift RV Ischemia LVEDP LV Preload RV CO LV CO MAP RV CPP O2 Demand RV Afterload RV Contractility RV Volume
Interventricular Septal Shift RV Ischemia LVEDP LV Preload RV CO LV CO MAP RV CPP O2 Demand PRESSURE OVERLOAD DECREASED CONTRACTILITY VOLUME OVERLOAD RV Afterload RV Contractility RV Volume
! ! 5-STEPS TO RV RESCUE
! ! 5-STEPS TO RV RESCUE
! ! 5-STEPS TO RV RESCUE
! ! 5-STEPS TO RV RESCUE
! ! 5-STEPS TO RV RESCUE
! ! 5-STEPS TO RV RESCUE
RV Afterload RV Contractility LV CO RV CO MAP RV CPP RV Ischemia O2 Demand LV Preload Interventricular Septal Shift RV Volume LVEDP
RV Afterload RV Contractility LV CO RV CO MAP RV CPP RV Ischemia O2 Demand LV Preload Interventricular Septal Shift RV Volume LVEDP Fluids
PRIMARY PROBLEM: PIPE IS BLOCKED
FLUID ++ Ventricular Interdependence
Interventricular Septal Shift LVEDP LV Preload LV CO MAP O2 Demand RV Volume RV CO RV CPP RV Ischemia RV Afterload RV Contractility
HYPOXEMIA HYPERCARBIA ACIDEMIA
INHALED PULMONARY VASODILATORS TO THE RESCUE!
Don’t have access to these?
Don’t have access to these?
Interventricular Septal Shift RV Afterload RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia RV CPP MAP
Perfusion Princess
5 CPP 75 120 80 60 CPP 60
120 80 60 5 CPP 75 CPP 60
60 5 80 40
60 5 CPP 35 CPP 20 80 40
SOOOO I’M SUPPOSED TO PREVENT HYPOTENSION, BUT I’M NOT SUPPOSED TO GIVE A BUNCH OF FLUID?
Pressors for the Win! (…but which one?)
PRESSOR CHOICE IN RV FAILURE?
Interventricular Septal Shift RV Ischemia RV Afterload LVEDP LV Preload LV CO MAP RV CPP O2 Demand RV Volume RV CO RV Contractility
Interventricular Septal Shift RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia MAP RV CPP RV Afterload OPTIMIZE RV AFTERLOAD AND PERFUSION BEFORE ADDRESSING CONTRACTILITY
STEP#1 DO YOU REALLY NEED TO INTUBATE THE PATIENT?
RESPIRATORY FAILURE MASQUERADE
INTUBATION IS A GREAT WAY TO UPSET THE RIGHT VENTRICLE…
Interventricular Septal Shift RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia MAP RV CPP RV Afterload
Interventricular Septal Shift RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia MAP RV CPP RV Afterload Hypotension
Interventricular Septal Shift RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia MAP RV CPP RV Afterload Hypoxemia Hypercarbia Hypotension
Interventricular Septal Shift RV Contractility LVEDP LV Preload RV CO O2 Demand LV CO RV Volume RV Ischemia MAP RV CPP RV Afterload Hypoxemia Hypercarbia Positive Pressure Ventilation Hypotension
Acute Hemodynamic Collapse After Induction of General Anesthesia for Emergent Pulmonary Embolectomy Rosenberger et al. Anes Analg 2006;102(5):1311-5 19% of patients coded on induction
103/77 143 31 94% 7.20 / 44 / 61 / 16
2L IV FLUID BOLUS
D+
The Princess Ventricle
Volume OVERLOAD DECREASED CONTRACTILITY Pressure Overload
Interventricular Septal Shift RV Ischemia RV Afterload RV Contractility LVEDP LV Preload RV CO LV CO MAP RV CPP O2 Demand RV Volume
! ! 5-STEPS TO RV RESCUE
The End

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