Outline the advantages and limitations of the various therapeutic options available for the treatment of right ventricular dysfunction.
Therapy |
Advantages |
Disadvantages |
Volume |
Effective, as RV needs a |
Determination of preload |
Inotropes and vasopressors |
-May be of benefit in RV |
No large scale published |
Afterload manipulation |
reduce PA pressures |
Optimal target levels unclear. |
Prostaglandins |
Reduce pulmonary |
May cause systemic |
NO |
Improves VQ matching, |
Met Hb, platelet |
Bosentan |
Reduce pulmonary |
No large scale data |
Phosphodiesterase |
Reduce pulmonary |
No large scale data |
Pacing to improve A-V |
Improves preload |
|
Mechanical ventilation |
May improve oxygenation |
Deleterious effects of |
This paper was issued to candidates late in 2009. A pity, because an excellent article on this topic came out in Critical Care in 2010.
I will summarise the suggestions made therein.
Volume management: a weak recommendation to closely monitor the effects of fluid challenge (seeing as conventional methods of assessing fluid responsiveness are quite useless in RV failure)
Afterload management: a weak recommendation to use noradrenaline and vasopressin, because they will only affect pulmonary arteries in very high doses.
Contractility enhancement: milrinone earns a strong promotion, but dobutamine and levosimendan only merit a lukewarm recommendation for lack of good quality evidence.
Afterload reduction: the authors strongly suggest that inhaled pulmonary vasodilators are used, rather than the IV forms. Inhaled NO and prostaglandin are strongly promoted, but oral sildenafil only gets a weak recommendation.
Bosentan and pacing are not mentioned. Mechanical ventilation is promoted as a means of avoiding atelectasis and hypoxic vasoconstriction.
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.