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This week we'll be discussing EmCrit's Podcast 181 - Pulmonary Hypertension and Right Ventricular Failure with Susan Wilcox

Check it out at emcrit.org/181

The RV gets no respect, but it's a source of clean kills in the ED and ICU. This is a powerhouse episode on RV failure and pulmonary hypertension that is a MUST listen for all of us working in pulmonary and critical care medicine

Take a listen & share your thoughts in the comments section below. Please also review the shownotes (link above), specifically the "six step to management of acute RV failure" and "intubating patients with acute RV failure." For your convenience we have included this information below -- but please review the full show notes page!

You will receive a notification when another group member has responded - our hope is to spur some healthy debate.

Stream from the link below or directly from iTunes.


The Six Step Approach to management of acute RV failure

Step 1: Optimize volume status

  • Lasix vs. fluids, use PSAX echo view to decide
  • Err on the side of volume constriction, they are often overloaded unless the patient has a known source of volume loss
  • Passive Leg Raising is probably a clever move before each small fluid bolus
  • See: Diuretics in Normotensive Patients With Acute Pulmonary Embolism and Right Ventricular Dilatation (Circ J, 2013; 77: 2612–2618)

Step 2: Maintain coronary perfusion to limit RV ischemia (Keep MAPS up)

  • Common final pathway in acute RV failure associated with pulm HTN is RV ischemia
  • Also dilated RV = increased wall tension = decreased coronary perfusion
  • Important to maintain SVR >> PVR to maintain R coronary perfusion pressure à Use pressors (norepi, vaso) not volume or chronotropes
  • The pathophysiology of failure in acute right ventricular hypertension: hemodynamic and biochemical correlations. (Circulation. 1981 Jan;63(1):87-95)
  • Treatment of shock in a canine model of pulmonary embolism. (Am Rev Respir Dis 1984, 130:870-874)
  • Volume expansion versus norepinephrine in treatment of a low cardiac output complicating an acute increase in right ventricular afterload in dogs. (Anesthesiology 1984, 60:132-13)

Step 3: Enhance RV inotropy

  • Dobutamine
  • Milrinone
    • Dobutamine and milrinone may need to be combined with vasoconstrictor (norepi or vaso) to counteract systemic hypotension
  • Epinephrine
  • (Levosimendan)

Step 4: Reduce RV afterload

  • Inhaled pulmonary vasodilators (iNO, epoprostenol, iloprost)
    • Dilates pulmonary vasculature in only ventilated areas – improves V/Q mismatch and oxygenation, decreases PVR
  • Systemic pulmonary vasodilators (IV and po) – avoid in critically ill unless Group I already on the med, causes systemic hypotension and worsens oxygenation
  • Oral PAH therapy – no role in critically ill

Step 5: Support Oxygenation and Ventilation

  • Hypoxic vasoconstriction – normal physiologic response to unventilated lung segments, causes increased PVR
  • Positive pressure ventilation – increased RV afterload and decreased RV preload may worsen RV failure
  • Improved oxygenation with PPV may improve hypoxic vasoconstriction and decrease PVR, sum of effect of PPV in RV failure unpredictable
  • Hypercapnea causes pulmonary vasoconstriction and increased PVR
  • Low-tidal volume ventilation to keep plateau pressures low
  • Intensive care med 2009 11 pts, PPV with plateau maintained
  • acidosis and hypercapnea induced

Step 6: Treat the underlying cause

Rescue therapies


Intubating patients with acute RV failure


  • If urgent/semi-emergent intubation

    • Place arterial line, obtain good vascular access
    • Optimize volume status
    • Consider awake intubation or awake fiberoptic intubation
      • May help minimize hemodynamic perturbation
      • Use topical lido + small dose of safe sedative
    • Utilize video laryngoscopy
    • Most experienced intubator
  • If emergent intubation

    • RSI with etomidate
    • Anticipate hemodynamic collapse – use push-dose epinephrine, have norepinephrine or epinephrine drip already hanging
    • I will “premedicate” pts with RV failure with push dose of 10-20mcg of epinephrine and 1-2U of vasopressin just prior to induction even if they aren’t hypotensive
  • Re-evaluate volume status following intubation

Share your thoughts!