Outline the key issues in the management of acute right ventricular failure in an ICU patient with moderate to severe pulmonary hypertension.

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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
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
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.