Critical Care Refresher Course 2016: Cardiovascular

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