How to manage a patient with right heart failure, hypotension, and intubation?

Management of Right Heart Failure with Hypotension in Intubated Patients

In an intubated patient with right heart failure and hypotension, prioritize maintaining systemic arterial pressure near RV systolic pressure using vasopressors (norepinephrine preferred), employ dobutamine for inotropic support, use inhaled nitric oxide to reduce RV afterload without systemic hypotension, and optimize mechanical ventilation with low tidal volumes (6 mL/kg) and minimal PEEP (≤10 cmH2O) while avoiding hypercapnea and hypoxia. 1, 2

Critical Hemodynamic Principles

The failing right ventricle requires a delicate balance where systemic arterial pressure must be maintained close to or above RV systolic pressure to ensure adequate RV perfusion 3. When pulmonary artery systolic pressure exceeds systemic systolic pressure, RV ischemia occurs because RV perfusion happens during both systole and diastole 1.

Immediate Ventilator Management

After intubation, implement lung-protective ventilation immediately:

• Use tidal volumes of approximately 6 mL/kg lean body weight to minimize increases in RV afterload 1
• Keep peak airway pressures <30 cmH2O 1
• Limit positive end-expiratory pressure to ≤10 cmH2O if oxygenation allows 1
• Avoid permissive hypercapnea as acidosis and hypercapnea acutely increase pulmonary vascular resistance 1
• Maintain oxygen saturation ≥90% (target 94-98%) as hypoxia increases PVR 1, 4, 2

Vasopressor and Inotropic Support

First-Line Vasopressor

Norepinephrine (0.2-1.0 μg/kg/min) is the preferred vasopressor for maintaining systemic arterial pressure in cardiogenic shock with RV failure 4, 2.

Inotropic Support

Dobutamine is the preferred inotrope for RV failure:

• Start at 2.5-5.0 μg/kg/min and titrate up to 10 μg/kg/min based on hemodynamic response 1, 2
• Dobutamine is preferred over milrinone due to its shorter half-life in the face of hypotension risk 1
• Consider milrinone (0.25-0.75 μg/kg/min) as an alternative for its additional pulmonary vasodilatory effects, but monitor closely for hypotension 2

Vasopressin Adjunct

Consider replacement-dose vasopressin to offset the potential drop in systemic vascular resistance from inotropes, particularly in septic patients or those with liver disease where vasopressin deficiency is common 1.

Pulmonary Vasodilator Therapy

Inhaled nitric oxide (iNO) at 20 parts per million is routinely employed in hypotensive patients with RV failure 1:

• Acutely decreases PVR and improves cardiac output without detrimental effects on systemic vascular resistance 1
• Improves oxygenation through ventilation-perfusion matching 1
• Unloads the acutely failing right ventricle 1
• Upon weaning iNO, start or restart a phosphodiesterase inhibitor (such as sildenafil 20 mg three times daily) to prevent rebound pulmonary hypertension 1, 2

Fluid Management

Fluid management in RV failure requires careful assessment:

• If central venous pressure is low, consider a modest fluid challenge (≤500 mL) 4, 2
• Avoid aggressive volume expansion as it worsens RV function by increasing RV distention and compromising left ventricular filling 4, 2
• If fluid overload is present, loop diuretics (furosemide) are essential for symptomatic treatment 2
• Consider doubling the diuretic dose up to furosemide 500 mg equivalent if no initial response 2

Hemodynamic Monitoring

Pulmonary artery catheterization should be considered in patients who are refractory to pharmacological treatment, persistently hypotensive, or have uncertain left ventricular filling pressure 2:

• Target pulmonary wedge pressure <20 mmHg 1
• Target cardiac index >2 L/min/m² 1
• Aim for filling pressure (pulmonary wedge) of at least 15 mmHg 1

Bedside echocardiography is essential to assess RV function, differentiate causes of shock, and guide therapy 4, 5.

Common Pitfalls to Avoid

• Excessive PEEP and high tidal volumes increase RV afterload and worsen failure 1
• Aggressive fluid resuscitation in a massively dilated RV increases distention and reduces cardiac output 4, 2
• Allowing hypoxia or hypercapnea acutely increases pulmonary vascular resistance 1
• Abrupt discontinuation of inhaled nitric oxide without replacement therapy causes rebound pulmonary hypertension 1
• Using inotropes that drop systemic vascular resistance without vasopressor support risks RV ischemia 1

Mechanical Support Considerations

If medical management fails, consider mechanical circulatory support:

• Intra-aortic balloon pump or other mechanical support devices should be considered in patients without contraindications 2
• Extracorporeal life support is increasingly used for acute RV failure refractory to medical management 3

Monitoring and Reassessment

Continuous monitoring for at least the first 24 hours of heart rate, rhythm, blood pressure, and oxygen saturation is essential 2. Reassess hemodynamics frequently and adjust therapy based on response, using echocardiography to guide management decisions 5, 6.