Oren Friedman - Hemodynamic Management of Crashing PE
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Transcript of Oren Friedman - Hemodynamic Management of Crashing PE
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Management of the crashing RV failure patient with acute PE
Oren Friedman MD
Pulmonary and Critical Care
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• Pathophysiology
• Clot Reduction
• Intubation
• Vasopressors
• Ecmo
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From 2014 ESC PE Guidelines European Heart Journal (2014)
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Wood Chest 2002
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Degree of Clot obstruction
Pu
lmo
nar
y V
ascu
lar
Re
sist
ance
Wood Chest 2002
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The RV is much more sensitive to Increases In Afterload than the LV
Vascular Pressure in mmHg
Stro
ke V
olu
me
( %
of
con
tro
l)
Right Ventricle Left Ventricle
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Wood Chest 2002
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Interventricular Dependence
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Wood Chest 2002
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The RV is normally perfused during systole AND diastole
Ao
PA
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DecreasePVR
Increase Systemic
BP
OptimizePreload
Improve Contractility
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Game On
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Clinical Assessment
and Risk of bleeding
Catheter Directed Lysis
Systemic Lysis
ECMO/Surgical Thrombectomy
Big PE
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DecreasePVR
Increase Systemic
BP
OptimizePreload
Improve Contractility
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There is rationale for using Nitric Oxide as a pulmonary vasodilator in acute pulmonary embolism
Trummer Annals of Thorac Surg 2002Schenk AnnEmergMed 1999Bottiger Chest 1999
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-Induction medications : vasodilation/hypotension-Acute preload reduction to the RV -Positive Pressure has a complicated influence on PVR
Intubation and positive pressure can have deleterious and even devastating hemodynamic
effects
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Ventetuolo Management of Acute RV failure in the ICU Annals ATS June 2014
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When it comes to tidal volume, you have
to aim for the “ sweet spot”
West J, Essential Physiology, 10th edition
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-100
0
100
200
300
400
500
600
700
0 20 40 60 80 100 120
% In
cre
ase
PV
R
PO2
Acidosis and Hypoxia Increase PVR
pH 7.4
pH 7.3
pH 7.2
pH 7.1
Adapted from Ventetuolo and Klinger Ann Am Thorac Soc 2014
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Low TVNormoxia
NormocapneaPEEP limitation
Cardiostable Induction
Pre-induction A line
How do I intubate a patient without killing them?
Pressors/iNOReady to go
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DecreasePVR
Increase Systemic
BP
OptimizePreload
Improve Contractility
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Volume loading can paradoxically worsen LV filling
Ventetuolo Management of Acute RV failure in the ICU Annals ATS June 2014
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DecreasePVR
Increase Systemic
BP
OptimizePreload
Improve Contractility
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NorepinephrineVasopressinPhenylephrine
Increase Systemic BP to improve coronary perfusion and prevent RV myocardial
ischemia
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Hirsch et al Norepinrpehrine and phenylephrine effects on RV function Chest 1991
Both Norepinephrine and Phenylephrine can restore systemic pressure in acute PE
Control PE Phenylephrine Norepinephrine
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Norepi has much more robust effect on cardiac output than Phe in acute PE
Hirsch et al Norepinrpehrine and phenylephrine effects on RV function chest 1991
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Hirsch et al Norepinrpehrine and phenylephrine effects on RV function Chest 1991
Norepi increased myocardial blood flow in acute PE model
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DecreasePVR
Increase Systemic
BP
OptimizePreload
Improve Contractility
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Enhancing Contractility of RV may improve the hemodynamic profile
Dobutamine
EpinephrineMilrinone
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AGENT CO PVR SVR
Norepinephrine + +/- ++
Phenylephrine - + +
Vasopressin - - ++
Dobutamine ++ - -
Epinephrine ++ - +
Milrinone ++ - - -
Adapted and modified from Price et al., Critical Care, 2010
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Central Access is sketchy
Do you really need that central line?Don’t stop the heparin for a central line
Do try to get line in before lyticsDon’t mess it up
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Stand alone treatment for shock from PE or bridge to catheter directed lysis or surgical thrombectomy
VA ECMO
Adapted from Westaby, cardiogenic shock in ACS Nature Reviews Cardiology 2012
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Intubation: caution, aim for normoxia, normocapnea, low TV
Recognize: RV death spiral : septal D-ing, RV ischemiaGet early and frequent echo
1.PVR: Rapidly assess for declotting( lysis/thrombectomy) iNO2. For shock: norepi/ dobuta
Ecmo
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References
• Bottiger, Bernd W., et al. "Inhaled nitric oxide selectively decreases pulmonary artery pressure and pulmonary vascular resistance following acute massive pulmonary microembolism in piglets." CHEST Journal 110.4 (1996): 1041-1047.
• Dalen, James E. "Pulmonary embolism: what have we learned since Virchow? Natural history, pathophysiology, and diagnosis." CHEST Journal 122.4 (2002): 1440-1456.
• Hirsch, L. J., et al. "Norepinephrine and phenylephrine effects on right ventricular function in experimental canine pulmonary embolism." CHEST Journal 100.3 (1991): 796-801.
• Konstantinides, Stavros V., et al. "2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism." European Heart Journal (2014): ehu283.
• McGlothlin, Dana, Natalia Ivascu, and Paul M. Heerdt. "Anesthesia and pulmonary hypertension." Progress in cardiovascular diseases 55.2 (2012): 199-217.
• Poor, Hooman D., and Corey E. Ventetuolo. "Pulmonary hypertension in the intensive care unit." Progress in cardiovascular diseases 55.2 (2012): 187-198.
• Price, Laura C., et al. "Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review." Crit Care 14.5 (2010): R169.
• Rich, Stuart, S. Gubin, and K. Hart. "The effects of phenylephrine on right ventricular performance in patients with pulmonary hypertension." CHEST Journal 98.5 (1990): 1102-1106.
• Schenk, Peter, Christoph Mittermayer, and Klaus Ratheiser. "Inhaled nitric oxide in a patient with severe pulmonary embolism." Annals of emergency medicine 33.6 (1999): 710-714.
• Trummer, Georg, et al. "Successful treatment of pulmonary hypertension with inhaled nitric oxide after pulmonary embolectomy." The Annals of thoracic surgery 73.4 (2002): 1299-1301.
• Tapson, Victor F. "Acute pulmonary embolism." New England Journal of Medicine 358.10 (2008): 1037-1052.
• Ventetuolo and Klinger, james ‘ Management of Acute Right Ventricular Failure in the Intensive Care Unit” Ann Am Thorac Soc Vol 11, No 5 Jun 2014
• Wood, Kenneth E. "Major pulmonary embolismReview of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism." CHEST Journal 121.3 (2002): 877-905.
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RV strain
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RV strain “septal D-ing”
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Intubation: caution, aim for normoxia, normocapnea, low TV
Recognize: RV death spiral : septal D-ing, RV ischemiaGet early and frequent echo
1.PVR: Rapidly assess for declotting( lysis/thrombectomy) iNO2. For shock: norepi/ dobuta
Ecmo