[HSF] RV failure management strategies
Michael Firstenberg
msfirst at gmail.com
Fri Dec 1 12:18:45 EST 2006
I my limited experience - it is never too late.
We had a young adult on an LVAD with a failing right heart and all of
the systemic end-organ problems (and then some) to go along with it.
We took him a week after his LVAD for a RVAD which helped greatly.
Your lady didnt have a PE?
interesting with right heart failure - usually the PA pressures
drop as the CVP goes up. High PA pressures are not always bad as
they tend to show some degree of functional reserve - although for
how long, is unclear.
but you said she was oxygenating and ventilating ok?
hmmmm - very tough case
m
On Dec 1, 2006, at 12:13 PM, prasannasimha wrote:
> Lost the battle. Was planning starting mechanical support when
> patients PA pressures shot up and became equisystemic and did not
> respond to iNO etc etc and followed by hemodynamic collapse.
> Incidentally how late is late when starting RVAD. I would say
> earlier the better but how late could it still work ?
> Prasanna
>> It sounds like its going to be mechanical support or death. I
>> understand the reluctance to re-cannulate the right atrium, so use
>> a long venous cannula throught the femoral or jugular vein. I
>> question the fear of cannulating the pulmonary artery with a small
>> bore tube and suitably pledgeted purse string(s). I also think
>> that the RVAD flows don't need to be that high (1-2 liters per
>> minute) with a centrifugal pump. Heparinization at low levels
>> should also be suitable. On the other hand, if this is
>> irreversable pulmonary vascular disease then your goose is cooked
>> (American idiom).
>>
>> Ed Bender, MD
>>
>>
>> ---- prasannasimha <prasannasimha at gmail.com> wrote:
>>> 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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