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Matt Siuba
Zentensivist. ARDS, Mechanical Ventilation, RV, & Shock Enthusiast.
Brendan Riordan
Left-handed intensivist defending the right side of the heart. Often found ordering diuretics in the Cardiothoracic Surgery ICU or posting cat photos on twitter.
The Pre-brief
Re-join #ThePeoplesVentricle Defense League for Part 2 of acute cor pulmonale in ARDS. If you missed Part 1, get caught up here.
In this segment we discuss diagnostic and therapeutic approaches to ACP management.
Timestamps:
0:21 Introduction: Resistance is Futile
1:15 Prevention of ACP
9:09 Identifying ACP with invasive and non-invasive techniques (including POCUS)
15:42 Treatment of ACP
23:55 What about extracorporeal life support for ACP?
27:33 The Bottom Line
The Debrief
- ACP is best identified with POCUS, whether TTE or TEE. Invasive hemodynamic monitoring may play a role in select circumstances.
- Targets to monitor response to therapy are not well defined
- ACP prevention shares common ground with best practices for ARDS including lung-protective ventilation and prone position ventilation. This can be considered “RV-protective ventilation”.
- Reduction of preload (via diuresis or ultrafiltration) should be considered
- Afterload reduction is more challenging. Treat acid/base and gas exchange abnormalities as able. Inhaled pulmonary vasodilators are a physiologically appealing therapy for ACP but without strong evidence to support it.
- Inotropic therapy may be attempted, but is a bridge at best.
- Consider consultation with an experienced ARDS and extracorporeal life support center if the above was unsuccessful.
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- https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20784/abnormal-central-venous-pressure-waveform-patterns
- https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory-system/Chapter%20064/factors-which-affect-pulmonary-vascular-resistance
