Outline the key issues in the management of acute right ventricular failure in an ICU patient with moderate to severe pulmonary hypertension.
College Answer
| Goal / Principle | Additional detail to be provided |
| Treat triggering factors | Infection, anaemia, arrhythmias, comorbidities, PE, MI, acidosis |
| Maintain oxygenation | Supplemental Oxygen to maintain sats >90% Avoid Intubation if possible. Consider Echo +/ - PA Catheter risks |
| Establish adequate monitoring |
ECG, Arterial line, Oxygen Sats, CVP, Echocardiography vs PA Catheter Kidney function: Urine Catheter, Serum Creatinine, Liver congestion: AST, ALT, Bilirubin, Lactate |
| Optimise fluid balance | Fluids if hypovolaemia is present , diuretics if excess fluid is present |
| Reduce RV afterload | IV Prostanoids: Epoprostinil, iloprost IV or Oral PDE-5 inhibitors (sildenafil) Inhaled vasodilators (nitric oxide) Endothelin receptor antagonists (ERAs) eg bosantan |
| Optimise Cardiac output | Milrinone, Levosimendan, |
| Optimise Systemic perfusion pressure |
Norepinephrine or Vasopressin |
| Liaison with Pulmonary Hypertension Centre |
Surgical options: Pulmonary thrombendarterectomy / balloon atrial septostomy / ECMO / Ventricular assist device / Heart/lung transplant / Palliation |
Additional comments:
Candidates who scored well showed an in-depth understanding of the applied physiology and consequences of the various therapeutic options. Candidates who scored poorly omitted key points.