[HSF] RV failure management strategies
prasannasimha
prasannasimha at gmail.com
Fri Dec 1 20:44:08 EST 2006
Why not an RA PA pump - Michael - her RA was plain friable and took
plenty of time just to get hemostasis. (She was having a sky high CVP
with blubbery tissues when I opened her initially itself) . I think I
will have a mess if I touch her RA and PA now. She is still oozing at
her puncture sites so heparinising her would be a big challenge for me.
Blood products are difficult to obtain too so having her on RVAD would
be ending in exsanguinating her in the situation I am in. At least now I
have some things in control even if not really OK.
Prasanna
Michael Firstenberg wrote:
> 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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