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The RV is a low-pressure chamber that doesn’t tolerate acute increases in pulmonary pressures (e.g., ARDS, pulmonary embolism, etc.); acute increases can lead to RV dysfunction / failure
Managing RV dysfunction requires a three-pronged approach:
- Optimize preload – give small fluid boluses (e.g., 250cc) but not too much, because too much can worsen RV function. Use ultrasound to determine volume status
- Optimize RV function – Consider starting inotropes (e.g., dobutamine) for better RV contractility and concurrently start pulmonary vasodilators (e.g., inhaled nitric oxide); also minimize hypoxemia and hypercarbia
- Prevent systemic hypotension – hypotension reduces coronary perfusion that leads to RV ischemia and dysfunction; use norepinephrine to keep blood pressure >65
- Bottom-line: Don't under-estimate the importance of the RV when resuscitating your patients
References
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