How to manage sepsis in a patient with pulmonary hypertension?

Management of Sepsis in Patients with Pulmonary Hypertension

In patients with pulmonary hypertension who develop sepsis, a conservative fluid strategy combined with careful hemodynamic monitoring is essential to prevent right ventricular failure and improve outcomes. 1, 2

Pathophysiological Considerations

• Pulmonary hypertension (PH) patients are at high risk during sepsis due to limited ability of the right ventricle to increase cardiac output, making oxygen delivery to tissues challenging 2
• Severity of PH correlates with mortality in sepsis, with reported hospital mortality rates of 28% in mild PH, 67% in moderate PH, and 80% in severe PH 3
• The combination of sepsis and PH creates a dangerous synergy that can lead to:
  • Right ventricular failure due to increased afterload 4
  • Thrombotic events in pulmonary microcirculation 5
  • Worsening inflammation affecting pulmonary mechanics 5

Hemodynamic Management

Fluid Management

• Implement a conservative rather than liberal fluid strategy for patients with established sepsis who have PH, especially if they don't have evidence of tissue hypoperfusion 1
• Carefully assess volume status before fluid administration, as excessive fluids can worsen right ventricular function in PH 4
• Optimize right ventricular preload through judicious fluid administration with close monitoring 2

Vasopressor Support

• Maintain systemic blood pressure to ensure coronary perfusion to the right ventricle 4
• Norepinephrine is commonly used (65% of cases in one study) but multiple agents may be required 3
• Longer duration of vasopressor support is associated with increased mortality in PH patients with sepsis 3

Monitoring

• Implement invasive hemodynamic monitoring to guide therapy 4
• Avoid routine use of pulmonary artery catheters in sepsis-induced ARDS 1
• Monitor for development of atrial fibrillation, which is associated with a 6.5-fold increase in mortality when it occurs in PH patients with sepsis 3

Respiratory Management

Ventilation Strategies

• Use a target tidal volume of 6 mL/kg predicted body weight in sepsis-induced ARDS 1
• Maintain plateau pressures ≤30 cm H₂O, as higher pressures are associated with increased mortality 1, 3
• Consider higher PEEP levels in moderate to severe ARDS 1
• Position the head of the bed at 30-45 degrees to prevent ventilator-associated pneumonia 1

Advanced Respiratory Support

• Consider prone positioning for patients with severe hypoxemia (PaO₂/FiO₂ ratio <150) 1
• Use recruitment maneuvers in cases of severe refractory hypoxemia 1
• Consider short-course neuromuscular blockade (≤48 hours) for patients with early sepsis-induced ARDS and PaO₂/FiO₂ ratio <150 mm Hg 1
• Avoid β-2 agonists unless specifically indicated for bronchospasm 1

Additional Management Considerations

Sedation Management

• Minimize continuous or intermittent sedation in mechanically ventilated patients 1
• Target specific sedation endpoints to avoid oversedation 1

Weaning from Mechanical Ventilation

• Implement a structured weaning protocol 1
• Perform regular spontaneous breathing trials when patients meet criteria: arousable, hemodynamically stable without vasopressors, no new serious conditions, low ventilatory requirements, and low FiO₂ requirements 1

Monitoring for Complications

• Be vigilant for new-onset atrial fibrillation, which significantly increases mortality risk 3
• Monitor for signs of right ventricular failure, which can rapidly lead to hemodynamic collapse 4

Pitfalls and Caveats

• Avoid excessive fluid administration which can precipitate right heart failure in PH patients 4, 2
• Avoid high plateau pressures during mechanical ventilation as they are associated with increased mortality in PH patients with sepsis 3
• Be cautious with vasopressors that can increase pulmonary vascular resistance and worsen right ventricular afterload 2
• Monitor closely for new-onset arrhythmias, particularly atrial fibrillation, which is associated with poor outcomes 3