Pulmonary hypertension in critical careintensivistenopleiding.org/downloads-19/files/RV failure en...
Transcript of Pulmonary hypertension in critical careintensivistenopleiding.org/downloads-19/files/RV failure en...
PHT in critical careAcute/acute-on-chronic venous PHT
Secondary to LV failure with left atrial hypertension
Acute-on-chronic arterial PHT
Worsening of preexisting PHT due to natural progression, sepsis, ARDS, PE, drugs
Acute arterial PHT
Massive PE, ARDS, sepsis, drugs
Gayat E. Curr Opin Crit Care 2011;17:439-448
Normal RV
End-diastolic volume index 64 ± 13 ml/m2
Stroke volume index 43 ± 13 ml/m2
RVEF 62 ± 8 %
Redington AN. Br Heart J 1988;59:23-30
PEEP
0
5
10
15
Step 1
Step 2
Step 3
Air-filled pericardial balloon
REF thermodilution catheter
Pinsky MR. Am Rev Respir Dis 1992;146:681-687
12 patients after cardiac surgery
mL
0
35
70
105
140
PEEP (cm H2O)
0 5 10 15 0
EDV ESV
L/m
in
0
1
2
3
4
5
PEEP (cm H2O)
0 5 10 15 0
COm
mH
g
0
10
20
30
40
PEEP (cm H2O)
0 5 10 15 0
Pra (tm) SPpa (tm)
RVEF
0
0,1
0,2
0,3
0,4
0,5
PEEP (cm H2O)
0 5 10 15 0
RVEF
First conclusion• In normal right ventricle changes in EDV occur
below RV stressed volume
• Conformational changes in RV shape rather than myocardial fiber stretch
• RV preload (= RV wall stretch) is constant with variation in RVEDV) meaning RV preload is independent of RV EDV
Important consequence
• If increasing RV volume increases RV preload and thus RV distending pressure, the RV is either hypertrophied with diastolic dysfunction or over distend as in acute cor pulmonale
Implications• CVP can never be used to predict fluid responsiveness
• Changes in CVP are an excellent measure to show that fluid resuscitation has exceeded the normal RV unstressed volume operating range
• If cardiac output increases by Starling mechanism, RV ESV must also increase which by pericardial constraint limits the effect of volume resuscitation
• Nothing beneficial with RV hypertrophy
Clinical implications• Central venous pressure is only elevated in disease
• If CVP rises after a fluid challenge and remains so: STOP - think about ACP
• For an increase in CO the RV must dilate - this limits the effect of fluid resuscitation
• RV hypertrophy is a deal with the devil
Normal RV P-V relationVo
lum
e (c
c)Pr
essu
re (
mm
Hg) Pr
essu
re (
mm
Hg)
Volume (cc × 10-1)Time (s)
Time (s)
Redington AN. Br Heart J 1988;59:23-30
39 ± 4% of SV ejected before peak RV pressure Poorly defined isovolumetric contraction phase
43 ± 9% of SV ejected during pressure fall Poorly defined isovolumetric relaxation phase
Normal LV PV relation
Volume (cc × 10-1)
Pres
sure
(×
10-1
mm
Hg
)
Redington AN. Br Heart J 1988;59:23-30
30 - 40% of RV output results from LV contraction
RV P-V relation with PHT
Pres
sure
(m
mH
g)
0
20
40
60
80
16080Volume (cc)
•Shape resembles normal LV •Decreased ejection during pressure rise and fall
Redington AN. Br Heart J 1990;63:45-49
PAP increase
RVEF ⬇ RV dilatation
Isovol. CP ⬆ Ejection time ⬆
MVO2 ⬆
RV ischemia
RCA mainly perfused in diastole
RV output ⬇
T3 insufficiency
LV preload ⬇
Cardiac output ⬇
Organ failure
Septal displacement
Right ventricular pressure ⬆
Open FO
Hypoxemia
RC blood flow with PHT
Zong PU. Basic Res Cardiol 2002;97:392-398
Without NO blocked increase in MvO2 82% covered by increased flow
Mild PHT induces LV diastolic dysfunction
E/E’
(lat
eral
)0
5
9
14
18
Control DD IPAH
** **
Kasner m. Am J Respir Crit Care Med 2012;186:181-189
TreatmentTreat or avoid RVF (main cause of death)
Treat underlying cause of PHT
No guidelines for the ICU!
Volume managementVolume overload is common and may aggravate RV dysfunction
With a dilated RV and IV septum shift first try iv diuretics followed by hemofiltration often under inotropic support
VasopressorsNorepinephrine in case of severe systemic hypotension to improve RCA perfusion
Car
diac
Out
put (
L)
0,00
1,25
2,50
3,75
5,00
Baseline Pulmonary HT After fluid challenge After NE infusion
Bloo
d pr
essu
re
0
40
80
120
160
Baseline Pulmonary HT After fluid challenge After NE infusion
Ghignone M. Anesthesiology 1984;60:132-135
VasopressorsSBP
(mmHg)MPAP
(mmHg)PVRI
(D.s.cmMPAP/MAP
(%)PVRI/SVRI
(%)
Baseline 91 ± 11.8 31.4 ± 5.3 257.8 ± 84.4 44.2 ± 5.3 12.4 ± 4.8
NE dose 1 (30% ⬆ SAP) 131.0 ± 4 37.3 ± 7 340.9 ± 78.4 38.1 ± 9.9 11.7 ± 5.9
NE dose 2 (50% ⬆ SAP) 152 ± 3.2 41.3 ± 7.8 442 ± 228.3 37.7 ± 8.6 13.3 ± 4.3
N = 10 - cardiac surgery and pulmonary hypertensionKwak YL. Anaesthesia 2002;57:9-14
InotropesPDE inhibitors - strong recommendation
Levosimendan - only case records
Rieg AD. PLoS ONE 2013;8:e66195
Pre-constricted
Levosimendan and ARDS after sepsis
RCT Levosimendan (N=18) versus placebo (N=17)
Patients with septic ARDS (< 3 D)
Dose 0.2 μg/kg/min for 24 hours without loading dose
Primary endpoint ∆ RVEF after 24 hours
Morelli A. Crit Care Med 2006;34:2287-2293
PHT in patients with ARDSLung damage per se (capillary destruction and obstruction by clots)
Muscularization by hypoxemia and hyper- capnia
Mechanical ventilation with increased alveolar distending pressures
Mechanical ventilationPrevent hypoxia, hypercapnia and high transalveolar pressures
Low tidal volume ventilation with low levels of PEEP unless a severe reduction in FRC is present
Low Tv and RV functionARDS (N = 145) with PAC
RVF defined as MPAP > 25 mmHg, CVP > PCWP and SV < 30 ml/m2
Tv 8.8 ± 1.9 ml/kg and Pplat 26 ± 6 cmH2O
RVF in 9.6% - no mortality difference (68%)
RVF No RVF P-valueTv (ml/kg) 9.7 ± 2.8 8.6 ± 1.8 < 0.05P 28 ± 6 25 ± 6 0.41
Osman D. Intensive Care Med 2009;35:69-76
Tv and RV function
0
20
40
60
80
Plateau pressure Day 1 (cm H2O)
18-26 27-35 > 35
56
32
13
Mortality (%) RVF (%)
Mor
talit
y (%
)0
25
50
75
100
Plateau pressure Day 1 (cm H2O)
18-26 27-35 > 35
Normal RVF
ARDS (N = 352)Jardin F. Intensive Care Med 2007;33:444-447
TV and RV function
Intensive Care Med. 2013 Oct;39(10):1725-33
Inci
denc
e A
cute
Cor
Pu
lmon
ale
(%)
0
10
20
30
Boissier 2013 Lhéritier 2013Intensive Care Med. 2013 Oct;39(10):1734-42
Moderate to severe ARDS
N = 226 N = 200Risk: driving pressure ≥ 17 Risk: PaCO2 ≥ 60 mmHg
ACP is RV enlargement combined with systolic paradoxical septal motion
PVR and FRC
PVR may ↓ with recruitment (low FRC)
PVR may ↓ with abolishment of HPV
PVR may ↓ with PaCO2 ↓
Hypercapnia and ARDS
N = 11 Severe ARDS
22 - 23
PaCO2 52 pH 7.30
PaCO2 71 pH 7.17
PaCO2 75 pH 7.20
0
0,5
1
1,5
LP HP/HR HP/LR
1,281,19
1,11
0,85
0,64
RV/LV area ratioES eccentricity index
** ** ** **
pH only factor independently associated with RV/LV area ratio and ES EI
Mekontso Dessap A. Intensive Care Med 2009;35:1850-1858
Vasodilators
IV vasodilators (NTG, Nitroprusside, PGE1) not recommended
Inhaled nitric oxide, prostacyclin (derivatives)
Sildenafil
NO or Iloprost inhalation?M
PAP
(mm
Hg)
30
40
50
60
70
80
Baseline 1 NO (40 ppm) Baseline 2 Iloprost (14-17 mcg)
CO
(l/m
in)
0
1
2
3
4
5
6
Baseline 1 NO (40 ppm) Baseline 2 Iloprost (14-17 mcg)
PVR
(dyn
es*s
ec*c
m-5
)
0
500
1000
1500
2000
Baseline 1 NO (40 ppm) Baseline 2 Iloprost (14-17 mcg)
Prostacyclin compared to NO significantly lowers MPAP and PVR
significantly increases CO
Hoeper MM. J Am Coll Cardiol 2000;35:176-182
Nebulized iloprost
Sawheny E. Chest 2013;144:55-62
ARDS (N = 20)
No effect on hemodynamic or pulmonary mechanics