Pulmonary Hypertension (Rothen)
Pulmonary circulation
- High flow, low pressure, low vascular resistance
- Determinant of vascular resistance
- intra or extraluminal obstructions
- autonomic tone
- hypoxia, hypercapnia (acidosis)
- circulating vasoactive substances
- blood viscosity
- Interdependence between RV and LV
- RV dilatation causes septal shift
- RV adaptation to large increases in pressure is limited
Management of pulmonary hypertension in the ICU
- Avoid/treat exacerbating factors
- hypoxaemia/hypercania
- acidosis, hypothermia, hypotonia, hypervolaemia
- Consider vasodilators
- inhaled prostacyclin, nitric oxide
- PDEi
- Dobutamine, milrinone, levosimendan
- BE SUSPICIOUS AND ACT EARLY
ESC/ERS Guidelines – http://eurheartj.oxfordjournals.org/content/early/2015/08/28/eurheartj.ehv317
Clinical management of pulmonary hypertension – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452016/
Doppler-defined pulmonary HTN in medical ICU patients: Retrospective investigation of risk factors & mortality https://www.ncbi.nlm.nih.gov/pubmed/22034595
Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology – https://www.ncbi.nlm.nih.gov/pubmed/24355638
Right heart failure (Vieillard-Baron)
Summary
Formal diagnosis of RV failure is difficult
- Clinical signs – significant congestion, shock
- Monitoring – Severe RV dilatation, Decreased CO, CVP>PAOP, pulse pressure variation
- Biological markers – decreased S(c)VO2, Increased lactate, Increased AP
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. – https://www.ncbi.nlm.nih.gov/pubmed/26650055
ACUTE AND CHRONIC HEART FAILURE ESC Clinical Practice Guidelines – http://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure
Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239778/
Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. – https://www.ncbi.nlm.nih.gov/pubmed/22511135
Echo–Doppler Demonstration of Acute Cor Pulmonale at the Bedside in the Medical Intensive Care Unit – http://www.atsjournals.org/doi/full/10.1164/rccm.200202-146CC#.V-9iYZN9634
Is ARDS usually associated with RV dysfunction or failure – https://www.ncbi.nlm.nih.gov/pubmed/7790603
Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation – http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=4326_10.1007_s00134-016-4326-3&doi=
Outcome prediction in sepsis: Speckle tracking echo based assessment of myocardial function – https://ccforum.biomedcentral.com/articles/10.1186/cc13987
Valvular heart disease (Maggiorini)
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease – http://content.onlinejacc.org/article.aspx?articleid=1838843
Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement – www.nejm.org/doi/full/10.1056/nejmoa1200384#t=article
4-Year Results of a RCT of Percutaneous Repair Versus Surgery for Mitral Regurgitation – http://content.onlinejacc.org/article.aspx?articleID=1687961