Management of the crashing RV failure patient with acute PE

Oren Friedman MD

Pulmonary and Critical Care

• Pathophysiology

• Clot Reduction

• Intubation

• Vasopressors

• Ecmo

From 2014 ESC PE Guidelines European Heart Journal (2014)

Wood Chest 2002

Degree of Clot obstruction

Pu

lmo

nar

y V

ascu

lar

Re

sist

ance

Wood Chest 2002

The RV is much more sensitive to Increases In Afterload than the LV

Vascular Pressure in mmHg

Stro

ke V

olu

me

( %

of

con

tro

l)

Right Ventricle Left Ventricle

Wood Chest 2002

Interventricular Dependence

Wood Chest 2002

The RV is normally perfused during systole AND diastole

Ao

PA

DecreasePVR

Increase Systemic

BP

OptimizePreload

Improve Contractility

Game On

Clinical Assessment

and Risk of bleeding

Catheter Directed Lysis

Systemic Lysis

ECMO/Surgical Thrombectomy

Big PE

DecreasePVR

Increase Systemic

BP

OptimizePreload

Improve Contractility

There is rationale for using Nitric Oxide as a pulmonary vasodilator in acute pulmonary embolism

Trummer Annals of Thorac Surg 2002Schenk AnnEmergMed 1999Bottiger Chest 1999

-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

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

When it comes to tidal volume, you have

to aim for the “ sweet spot”

West J, Essential Physiology, 10th edition

-100

0

100

200

300

400

500

600

700

0 20 40 60 80 100 120

% In

cre

ase

PV

R

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

Low TVNormoxia

NormocapneaPEEP limitation

Cardiostable Induction

Pre-induction A line

How do I intubate a patient without killing them?

Pressors/iNOReady to go

DecreasePVR

Increase Systemic

BP

OptimizePreload

Improve Contractility

Volume loading can paradoxically worsen LV filling

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

DecreasePVR

Increase Systemic

BP

OptimizePreload

Improve Contractility

NorepinephrineVasopressinPhenylephrine

Increase Systemic BP to improve coronary perfusion and prevent RV myocardial

ischemia

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

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

Hirsch et al Norepinrpehrine and phenylephrine effects on RV function Chest 1991

Norepi increased myocardial blood flow in acute PE model

DecreasePVR

Increase Systemic

BP

OptimizePreload

Improve Contractility

Enhancing Contractility of RV may improve the hemodynamic profile

Dobutamine

EpinephrineMilrinone

AGENT CO PVR SVR

Norepinephrine + +/- ++

Phenylephrine - + +

Vasopressin - - ++

Dobutamine ++ - -

Epinephrine ++ - +

Milrinone ++ - - -

Adapted and modified from Price et al., Critical Care, 2010

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 lyticsDon’t mess it up

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

Intubation: caution, aim for normoxia, normocapnea, low TV

Recognize: RV death spiral : septal D-ing, RV ischemiaGet early and frequent echo

1.PVR: Rapidly assess for declotting( lysis/thrombectomy) iNO2. For shock: norepi/ dobuta

Ecmo

References

• Bottiger, 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.

RV strain

RV strain “septal D-ing”

Intubation: caution, aim for normoxia, normocapnea, low TV

Recognize: RV death spiral : septal D-ing, RV ischemiaGet early and frequent echo

1.PVR: Rapidly assess for declotting( lysis/thrombectomy) iNO2. For shock: norepi/ dobuta

Ecmo