Page 126 - Critical Care Notes

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RESP
■ The aims are to decrease pulmonary pressure, remove excessive fluid, and
decrease the risk of clotting.
■ Monitor respiratory, cardiac, and neurological status.
■ Institute ECG and hemodynamic monitoring. Administer antiarrhythmics as
indicated. Cardioversion or radiofrequency ablation may be needed to treat
atrial fibrillation/flutter. A pulmonary artery catheter (Swan Ganz) is generally
indicated.
■ Provide O 2 therapy: cannula, mask, ventilator. Monitor ABGs. Avoid intubation
if possible.
■ Administer bronchodilators as indicated.
■ Consider standby therapeutic phlebotomy if Hct >60%.
■ Maintain Hgb to minimum 10 g/dL.
■ Provide low-sodium diet and fluid restrictions. Correct fluid and electrolyte
and acid-base disturbances. Administer diuretics as needed.
■ Complex management is needed to maintain adequate preload but avoid
overfilling RV → compress LV →↓ cardiac output.
■ Treat hypotension and low cardiac output as needed.
■ The use of calcium channel blockers, steroids, anticoagulation, antiplatelet
drugs, and endothelin receptor antagonists have been found to be more
suited for non–critically ill patients with PAH but may be considered for
critically ill patients as needed. Calcium channel blockers and beta blockers
should be avoided in the critically ill because they reduce cardiac function.
■ Dobutamine preferred if inotropes necessary. Also use of norepinephrine
preferred.
■ Administer digoxin (Lanoxin) as necessary.
■ Administer prostanoids: treprostinil (Remodulin, Tyvaso), epoprostenol
(Flolan), iloprost (Ventavis).
■ Administer endothelin-receptor antagonists: bosentan (Tracleer), sitaxsentan
(Thelin), ambrisentan (Letairis).
■ Administer phosphodiesterase type 5 (PDE5) inhibitors: sildenafil (Viagra),
tadalafil (Cialis), vardenafil (Levitra).
■ Treat pulmonary embolism with thrombolytics or anticoagulants as
appropriate.
■ Surgery (optional): atrial septostomy, pulmonary thromboendarterectomy.
■ Consider ECMO as a bridge to transplantation.
■ Consider lung or heart-lung transplantation because biventricular HF may
develop.
Pulmonary Embolism
Pulmonary embolism is defined as an obstruction of the pulmonary artery or
its branch (pulmonary vasculature) by a thrombus or thrombi (blood clot) that
· ·
originates in the venous circulatory system or the right side of the heart. A V/Q
mismatch → hypoxemia and intrapulmonary shunt.
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