[HSF] RV failure management strategies

[Michael Firstenberg]

Something does not quiet sound right with his hemodynamics - and  
maybe I need to think about this more and look at the actual numbers.
But, if your RV is failing - which it sounds like it is, then you  
would have low preload delivered to the left heart and this should  
(please all corrected me if I am wrong) result in a higher SVR as a  
systemic compensatory measure.

Coming into this a little late (missed some of the other comments)
1) Is your patient septic - and maybe the overall cardiac function  
can not keep up enough
     there may be a little zosyo-penia or the vanco receptors may not  
be adequately saturated.
2) What is the renal function?
     From what you are describing, probably poor - are you on CVVH yet?
     If not - I am a firm believer of the voodoo of dialysis of "evil  
humors"
     If this is truly right heart failure - maybe getting volume off  
acutely (even on tons of drugs) may bring you to a more favorable  
part of the Starling curve
     I have a little experience with acute ultra-filtration  (even  
with "marginal urine output") is sucking some of these people dry  
which works!
        May cause ARF (which should improve with time?) - but your  
current path will most likely knock out the beans forever
        (better to have a live patient on dialysis than a potential  
kidney donor?)
3) You said "open chest" and patient actually woke up.
      Is it correct to assume that he/she is pharm. paralyized?
     I have also seen more than a few patients with "lap-pad"  
tamponade.  Even though the chest is open, there are too many or a  
few stratigically placed pads (particularly if they are placed for  
bleeding) than compress the RV.
4) Fixed-dilated pupils?
     Hmmm - no idea, but it aint over til its over
    I am sure we have all seen comatose patients wake up quite  
contrary to the Glascow data (which I am sure have a reprint  
somewhere knowing you - read: compliment)
5) Acute adrenal insuff.  ->  when in doubt, steroids
     I had a medical school professor who said that no one should die  
without the benefits of steroids.

There seems to be a lot going on with your very sick patient and I  
tossed out a few "kitchen" sink ideas.
      yes, a RVAD/Ecmo may help - but does not solve all of your problem
     though with an open chest an RA-RV circuit with stuff you have  
around may be enough.

I have seen a few recent "mazes" in otherwise healthy hearts have  
similar problems - not sure what to make of it - anyone else?



Good luck - keep us up to date


-michael



On Nov 30, 2006, at 9:40 PM, prasannasimha wrote:

> Can the list members enumerate their management strategies for RV  
> failure.
> This is for two reasons. _ one for th3e Wiki and presently
> I have  a patient who was in low output  and taken for a semi  
> emergency MVR with maze with TV plasty. Patient had RV dysfunction  
> and congestive hepatopathy. Had a difficult wean - LV good but RV  
> function was pretty poor. Patient is in coagulopathy which seems to  
> have decreased .No mechanical problem on epicardial echo.
> Patient has an open chest and has adequate CI (PA cath with CCO)  
> has a high PVR and low SVR and is requiring multiple inotropes  
> (Dopa = Dobut +Adrenaline + Norad +Milrinone and Vasopressin on one  
> hand and multiple vasodilators on the other (getting constrictors  
> via the central lumen of the IABP and dilators via the PA  
> catheter) . I put the IABP as the patient has OK CI but low  
> pressures due to a vasoplegic state and was worried that the  
> coronary flow may not be adequate creating a vicious spiral 9and is  
> helping in maintaining pressures).
> Funny thing is patient has bilateral dilated and fixed pupils but  
> has actually woken up once !! (On an infusion of morphine + Ketamine)
> Prasanna
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