Intraoperative hypotension with presumed right heart failure/dysfunction: Approach after initial evaluation and management
Intraoperative hypotension with presumed right heart failure/dysfunction: Approach after initial evaluation and management
This algorithm presents an approach to hypotension with presumed right heart failure after initial evaluation and management has been completed.
For initial management, refer to the algorithm on the initial approach to intraoperative hypotension.
Hypotension is defined as an MAP <60 mmHg or SBP <100 mmHg when <90% of baseline.
Signs of right heart failure include CVP >10 mmHg, RV dilation, and RV focal or global wall motion abnormalities.
Right heart failure is commonly caused by left heart failure which is associated with PCWP >18 mmHg. If PCWP is >18 mmHg or there are other signs of left heart failure, refer to the algorithm on the approach to intraoperative hypotension with presumed left heart failure/dysfunction.
For patients with persistent hypotension and/or acute heart failure, the risk/benefit of continuing, modifying or aborting the planned procedure is assessed.
RV: right ventricular; IV: intravenous; PVR: pulmonary vascular resistance; ICU: intensive care unit; ECMO: extracorporeal membrane oxygenation; MCS: mechanical circulatory support (such as ventricular assist devices); MAP: mean arterial pressure; SBP: systolic blood pressure; CVP: central venous pressure; PCWP: pulmonary capillary wedge pressure; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; LV: left ventricular. * TEE or TTE signs of RV systolic dysfunction include RV dilation and/or RV focal or global hypokinesis. RV infarction should be suspected in patients with hypotension, CVP >10 mmHg, ST elevation in inferior and right-sided leads, and LV inferior wall and RV wall motion abnormality on TEE or TTE. ¶ Causes of RV dysfunction include hypoxemia, hypercarbia, acidosis, increased symptomathetic tone (due to pain and stress), RV ischemia/infarction, and pulmonary embolus. Δ Refer to UpToDate content on intraoperative vasopressor use in the treatment of right heart failure. ◊ Hypovolemia should be identified and treated prior to use of an inotrope. Refer to UpToDate content on intraoperative management of right heart failure. § Refer to UpToDate content on intraoperative management of pulmonary hypertension. Pulmonary vasodilator therapy is generally contraindicated in patients with pulmonary hypertension due to left heart failure. Refer to UpToDate content on management of pulmonary hypertension due to left heart disease. ¥ Refer to UpToDate content regarding ECMO and MCS.
