[HSF] RV failure management strategies

Michael Firstenberg msfirst at gmail.com
Fri Dec 1 09:57:58 EST 2006 

Hmmmm,
Sounds like my kinda case - want to ship her to me?

How come you dont want to run a RA-PV pump?

Low platelets?
HITTs?

Just curious - how are you going to feed her?
    I know a few people who like TPN (yuck yuck yuck) with open  
chests to make nursing care easier and safer.

Although, sounds like you are making progress -> winning the battle,  
stay the course.


-michael



On Dec 1, 2006, at 9:43 AM, prasannasimha wrote:

> Michael,
> She was a case of severe calcific MS with LA clot severe TR with  
> pretty bad RV function. She was on inotropes prior to surgery and  
> was in low output. She had a TIA and so was taken semi-emergently.  
> She could not lie down and was urgently intubated and required   
> rapid institution of CPB. Surgery was pretty uneventful (No clot  
> was seen in the LA and I presume it had embolized during the TIA)  
> and the heart was contracting well as long as not loaded. While  
> loading  The situation was good LV contractility, RV poor EF (on  
> Echo) . Low LAP and high transpulmonary gradient. We initially  
> managed by giving pulmonary vasodilators etc and had to give  
> systemic vasoconstrictors to maintain the SVR which was low Tried  
> to use iNO - did not help . We could wean off CPB and she was  
> pretty coagulopathic and after the usual burn and stitch for a  
> couple of hours (ill advisedly) closed her and had to immediately  
> open her due to tamponade due to a clot over the PA. Kept the chest  
> open.
> At present she is still on multiple inotropes. CI is wavering  
> between 2.4- 3.0. Bleeding seems to have stopped . I had opened up  
> everything and washed the pericardium and sutured a plastic sheet  
> back.
> No evidence of sepsis.
> I also like to "run em dry" and actually the patient is passing  
> good urine and I have a PD catheter with mini-cycling to reduce  
> edema.though she requires a CVP of around 12-14 to maintain  
> hemodynamics. Her creat is pretty normal and her only abnormal  
> parameter  are her platelets and bilirubn which is marginally high  
> (probably going to keep rizing further!!)
> I usually do not paralyze all open chests and keep them on Morphine  
> and Ketamine infusions which usually deeply anesthetises them  
> without the need to paralyze them. I have seen this been done with  
> pediatric patients and they argue that "micromovements" is actually  
> good in mobilizing tissue  edema by lymphatics.
> (Patients actually do not move around when on the infusion but have  
> preserved muscular tone if you get what I mean) though I do give  
> them a relaxant if they breath spontaneously and this causes  
> incoordination which they rarely do. One of my residents had  
> lowered the drug infusion temporarily to see the CNS status !! That  
> is how I know she was "awakable"
> Did give her a shot of Methypred but no use.
> RVAD in her is impractical for "practical" reasons. I have an IABP  
> in place. I cannot do a bail out Glenn because her PVR is high.
> At present following a wait and watch till edema comes down .
> Prasanna
>
>
>
>
> Michael Firstenberg wrote:
>> 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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