from EMCrit Conference 2015

1. Management of the crashing RV failure patient with acute PE
Oren Friedman MD
Pulmonary and Critical Care

2. • Pathophysiology
• Clot Reduction
• Intubation
• Vasopressors
• Ecmo

3. From 2014 ESC PE Guidelines European Heart Journal (2014)

5. Wood Chest 2002

6. Degree of Clot obstruction
PulmonaryVascularResistance
Wood Chest 2002

7. The RV is much more sensitive to Increases In Afterload than
the LV
Vascular Pressure in mmHg
StrokeVolume
(%ofcontrol)
Right Ventricle Left Ventricle

8. Wood Chest 2002

9. Interventricular Dependence

12. Wood Chest 2002

13. The RV is normally perfused during systole AND diastole
Ao
PA

14. Decrease
PVR
Increase
Systemic
BP
Optimize
Preload
Improve
Contractility

15. Game On

16. Clinical
Assessment
and
Risk of bleeding
Catheter Directed Lysis
Systemic Lysis
ECMO/Surgical Thrombectomy
Big PE

21. Decrease
PVR
Increase
Systemic
BP
Optimize
Preload
Improve
Contractility

22. There is rationale for using Nitric Oxide as a
pulmonary vasodilator in acute pulmonary embolism
Trummer Annals of Thorac Surg 2002
Schenk AnnEmergMed 1999
Bottiger Chest 1999

24. -Induction medications :
vasodilation/hypotension
-Acute preload reduction to the RV
-Positive Pressure has a
complicated influence on PVR
Intubation and positive pressure can have
deleterious and even devastating hemodynamic
effects

25. Ventetuolo Management of Acute RV failure in the ICU Annals ATS June 2014

26. When it comes to tidal volume, you have
to aim for the “ sweet spot”
West J, Essential Physiology, 10th edition

27. -100
0
100
200
300
400
500
600
700
0 20 40 60 80 100 120
%IncreasePVR
PO2
Acidosis and Hypoxia Increase PVR
pH 7.4
pH 7.3
pH 7.2
pH 7.1
Adapted from Ventetuolo and Klinger Ann Am Thorac Soc 2014

28. Low TV
Normoxia
Normocapnea
PEEP limitation
Cardiostable Induction
Pre-induction A line
How do I intubate a patient
without killing them?
Pressors/iNO
Ready to go

29. Decrease
PVR
Increase
Systemic
BP
Optimize
Preload
Improve
Contractility

30. Volume loading can paradoxically worsen LV
filling
Ventetuolo Management of Acute RV failure in the ICU Annals ATS June 2014

31. Decrease
PVR
Increase
Systemic
BP
Optimize
Preload
Improve
Contractility

32. Norepinephrine
Vasopressin
Phenylephrine
Increase Systemic BP to improve coronary
perfusion and prevent RV myocardial
ischemia

33. Hirsch et al Norepinrpehrine and phenylephrine effects on RV function Chest 1991
Both Norepinephrine and Phenylephrine can restore
systemic pressure in acute PE
Control PE Phenylephrine Norepinephrine

34. Norepi has much more robust effect on
cardiac output than Phe in acute PE
Hirsch et al Norepinrpehrine and phenylephrine effects on RV function chest 1991

35. Hirsch et al Norepinrpehrine and phenylephrine effects on RV function Chest 1991
Norepi increased myocardial blood flow in
acute PE model

36. Decrease
PVR
Increase
Systemic
BP
Optimize
Preload
Improve
Contractility

37. Enhancing Contractility of RV may improve the
hemodynamic profile
Dobutamine
Epinephrine
Milrinone

38. AGENT CO PVR SVR
Norepinephrine + +/- ++
Phenylephrine - + +
Vasopressin - - ++
Dobutamine ++ - -
Epinephrine ++ - +
Milrinone ++ - - -
Adapted and modified from Price et al., Critical Care, 2010

39. Central Access is sketchy
Do you really need that central line?
Don’t stop the heparin for a central line
Do try to get line in before lytics
Don’t mess it up

40. Stand alone treatment
for shock from PE or
bridge to catheter
directed lysis or surgical
thrombectomy
VA ECMO
Adapted from Westaby, cardiogenic shock in ACS Nature Reviews Cardiology 2012

41. Intubation: caution, aim for
normoxia, normocapnea, low
TV
Recognize: RV death spiral :
septal D-ing, RV ischemia
Get early and frequent echo
1.PVR: Rapidly assess for
declotting
( lysis/thrombectomy) iNO
2. For shock:
norepi/ dobuta
Ecmo

42. References
• Böttiger, Bernd W., et al. "Inhaled nitric oxide selectively decreases pulmonary artery pressure and
pulmonary vascular resistance following acute massive pulmonary microembolism in piglets." CHEST
Journal 110.4 (1996): 1041-1047.
• Dalen, James E. "Pulmonary embolism: what have we learned since Virchow? Natural history,
pathophysiology, and diagnosis." CHEST Journal 122.4 (2002): 1440-1456.
• Hirsch, L. J., et al. "Norepinephrine and phenylephrine effects on right ventricular function in experimental
canine pulmonary embolism." CHEST Journal 100.3 (1991): 796-801.
• Konstantinides, Stavros V., et al. "2014 ESC Guidelines on the diagnosis and management of acute
pulmonary embolism." European Heart Journal (2014): ehu283.
• McGlothlin, Dana, Natalia Ivascu, and Paul M. Heerdt. "Anesthesia and pulmonary hypertension." Progress
in cardiovascular diseases 55.2 (2012): 199-217.
• Poor, Hooman D., and Corey E. Ventetuolo. "Pulmonary hypertension in the intensive care unit." Progress
in cardiovascular diseases 55.2 (2012): 187-198.
• Price, Laura C., et al. "Pulmonary vascular and right ventricular dysfunction in adult critical care: current
and emerging options for management: a systematic literature review." Crit Care 14.5 (2010): R169.
• Rich, Stuart, S. Gubin, and K. Hart. "The effects of phenylephrine on right ventricular performance in
patients with pulmonary hypertension." CHEST Journal 98.5 (1990): 1102-1106.
• Schenk, Peter, Christoph Mittermayer, and Klaus Ratheiser. "Inhaled nitric oxide in a patient with severe
pulmonary embolism." Annals of emergency medicine 33.6 (1999): 710-714.
• Trummer, Georg, et al. "Successful treatment of pulmonary hypertension with inhaled nitric oxide after
pulmonary embolectomy." The Annals of thoracic surgery 73.4 (2002): 1299-1301.
• Tapson, Victor F. "Acute pulmonary embolism." New England Journal of Medicine 358.10 (2008): 1037-
1052.
• Ventetuolo and Klinger, james ‘ Management of Acute Right Ventricular Failure in the Intensive Care Unit”
Ann Am Thorac Soc Vol 11, No 5 Jun 2014
• Wood, Kenneth E. "Major pulmonary embolismReview of a pathophysiologic approach to the golden hour
of hemodynamically significant pulmonary embolism." CHEST Journal 121.3 (2002): 877-905.

43. RV strain

44. RV strain “septal D-ing”

48. Intubation: caution, aim for
normoxia, normocapnea, low
TV
Recognize: RV death spiral :
septal D-ing, RV ischemia
Get early and frequent echo
1.PVR: Rapidly assess for
declotting
( lysis/thrombectomy) iNO
2. For shock:
norepi/ dobuta
Ecmo