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Beckman S, Lu H, Alsharif P, Qiu L, Ali M, Adrian RJ, Alerhand S. Echocardiographic diagnosis and clinical implications of wide-open tricuspid regurgitation for evaluating right ventricular dysfunction in the emergency department. Am J Emerg Med 2024; 80:227.e7-227.e11. [PMID: 38702221 DOI: 10.1016/j.ajem.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024] Open
Abstract
The tricuspid regurgitation pressure gradient (TRPG) reflects the difference in pressure between the right ventricle and right atrium (ΔPRV-RA). Its estimation by echocardiography correlates well with that obtained using right-heart catheterization. An elevated TRPG is an important marker for identifying right ventricular dysfunction in both the acute and chronic settings. However, in the "wide-open" variant of TR, the TRPG counterintuitively falls. Failure to recognize this potential pitfall and underlying pathophysiology can cause underestimation of the severity of right ventricular dysfunction. This could lead to erroneous fluid tolerance assessments, and potentially harmful resuscitative and airway management strategies. In this manuscript, we illustrate the pathophysiology and potential pitfall of wide-open TR through a series of cases in which emergency physicians made the diagnosis using cardiac point-of-care ultrasound. To our knowledge, this clinical series is the first to demonstrate recognition of the paradoxically-low TRPG of wide-open TR, which guided appropriate management of critically ill patients in the emergency department.
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Affiliation(s)
- Sean Beckman
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Helen Lu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Peter Alsharif
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Linda Qiu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Marwa Ali
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Robert James Adrian
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Chen LL, Zuma D. Right Ventricular Failure: A Concise Review. Crit Care Nurs Q 2024; 47:9-13. [PMID: 38031303 DOI: 10.1097/cnq.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Right ventricular failure (RVF) is a critical condition that significantly impacts morbidity and mortality in affected patients. This review article aims to provide a comprehensive understanding of RVF by discussing its background, etiology, pathophysiology, clinical presentation, diagnostic studies, medical treatment, and mechanical assistive devices.
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Affiliation(s)
- Leon L Chen
- Columbia University School of Nursing, New York City, New York (Drs Chen and Zuma); Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York (Dr Chen); and Department of Medicine, Cardiology, Columbia University Irving Medical Center, New York City, New York (Dr Zuma)
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Hickey AJ, Cummings MJ, Short B, Brodie D, Panzer O, Madahar P, O'Donnell MR. Approach to the Physiologically Challenging Endotracheal Intubation in the Intensive Care Unit. Respir Care 2023; 68:1438-1448. [PMID: 37221087 PMCID: PMC10506638 DOI: 10.4187/respcare.10821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable.
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Affiliation(s)
- Andrew J Hickey
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Oliver Panzer
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York.
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Use of Cardio-Pulmonary Ultrasound in the Neonatal Intensive Care Unit. CHILDREN 2023; 10:children10030462. [PMID: 36980020 PMCID: PMC10047372 DOI: 10.3390/children10030462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/11/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Cardiopulmonary ultrasound (CPUS), the combination of lung ultrasound (LUS) and targeted neonatal echocardiography (TnECHO)AA, may offer a more appropriate approach to the challenging neonatal cardiovascular and respiratory disorders. This paper reviews the possible use of CPUS in the neonatal intensive care unit (NICU).
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Gashler K, Li T, Gonzalez J, Hasoon J, Nguyen A. Anaesthetic considerations: management of pulmonary hypertension and difficult airway in a patient undergoing radical nephrectomy for renal cell carcinoma. Anaesthesiol Intensive Ther 2023; 55:307-309. [PMID: 38084577 PMCID: PMC10691454 DOI: 10.5114/ait.2023.132913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Kyle Gashler
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Tommy Li
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Justo Gonzalez
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, UTHealth, McGovern Medical School, Houston, Texas
| | - Anvinh Nguyen
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
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Crager SE, Humphreys C. Right Ventricular Failure and Pulmonary Hypertension. Emerg Med Clin North Am 2022; 40:519-537. [DOI: 10.1016/j.emc.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chen J, Tian Z, Zhang H, Shi L, Bao W, Huang T, Zhai J, Gao N, Li W. Risks of postoperative respiratory failure in elderly patients after hip surgery: a retrospective study. J Orthop Surg Res 2022; 17:140. [PMID: 35246194 PMCID: PMC8895770 DOI: 10.1186/s13018-022-02909-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background The purpose of this retrospective study was to investigate the determinants of postoperative respiratory failure in elderly patients with hip fracture. Methods The subjects of this study were 663 elderly patients who had hip fracture and had been treated with total hip arthroplasty at our hospital from January 2014 to May 2020. According to the occurrence of postoperative respiratory failure, 626 patients with no respiratory failure were retrospectively included in the control group, and 37 cases combined with respiratory failure were enrolled in the PRF group. The clinical and surgical data of the two groups were collected and analyzed to evaluate the determinants of respiratory failure by logistic regression analysis. Results There were no significant differences in the demographics and baseline variables including age, gender, fracture type and location between the groups (P > 0.05). All patients received hip surgery including total hip arthroplasty (THA), hemiarthroplasty (HA) and internal fixation with PFNA (proximal femoral nail anti-rotation). There were no significant differences in operative time and intraoperative blood loss between the groups (P > 0.05). However, close associations were found between pulmonary hypertension (univariate analysis: OR = 3.792, 95% CI = 1.421–10.203; multivariate analysis: OR = 1.132, 95% CI = 1.003–1.251), obstructive pulmonary disease (OR = 1.119, 95% CI = 1.009–1.238; multivariate analysis: OR = 13.298, 95% CI = 4.021–43.298), bronchiectasis and emphysema (OR = 4.949, 95% CI = 1.919–9.873; multivariate analysis: OR = 11.231, 95% CI = 187.87), and history of respiratory failure (OR = 6.098, 95% CI = 2.012–12.198; multivariate analysis: OR = 8.389, 95% CI = 2.391–21.982) with postoperative respiratory failure (P < 0.05). Conclusion Pulmonary hypertension, abnormal lung texture, obstructive pulmonary disease, bronchiectasis, emphysema, history of respiratory failure, and hypoproteinemia may be risk factors for postoperative respiratory failure in elderly patients with hip fracture.
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Affiliation(s)
- Jia Chen
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Zhi Tian
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Huaxing Zhang
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Lifang Shi
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Wenjuan Bao
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Teng Huang
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Jinshuai Zhai
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China
| | - Nan Gao
- Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Wenyi Li
- Department of Orthopedics, Hebei General Hospital, No. 348 Heping East Road, Shijiazhuang, 050051, Hebei, China.
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