Fluid management in septic patients with pulmonary hypertension, review of the literature

Abstract

The management of sepsis in patients with pulmonary hypertension (PH) is challenging due to significant conflicting goals of management and complex hemodynamics. As PH progresses, the ability of right heart to perfuse lungs at a normal central venous pressure (CVP) is impaired. Elevated pulmonary vascular pressure, due to pulmonary vasoconstriction and vascular remodeling, opposes blood flow through lungs thus limiting the ability of right ventricle (RV) to increase cardiac output (CO) and maintain adequate oxygen delivery to tissue. In sepsis without PH, avoidance of volume depletion with intravascular volume replacement, followed by vasopressor therapy if hypoperfusion persists, remains the cornerstone of therapy. Intravenous fluid (IVF) resuscitation based on individualized hemodynamic assessment can help improve the prognosis of critically ill patients. This is accomplished by optimizing CO by maintaining adequate preload, afterload and contractility. Particular challenges in patients with PH include RV failure as a result of pressure and volume overload, gas exchange abnormalities, and managing IVF and diuretic use. Suggested approaches to remedy these difficulties include early recognition of symptoms associated with pressure and volume overload, intravascular volume management strategies and serial lab monitoring to assess electrolytes and renal function.

Pulmonary Hypertension and the Risk of 30-Day Postoperative Pulmonary Complications after Gastrointestinal Surgical or Endoscopic Procedures: A Retrospective Propensity Score-Weighted Cohort Analysis

“…Secondly, it may point to a general susceptibility to deleterious fluid shifts in the perioperative period. It is well understood that right ventricular dysfunction is common in PH patients during physiological stress [20,21].…”

“…Secondly, it may point to a general susceptibility to deleterious fluid shifts in the perioperative period. It is well understood that right ventricular dysfunction is common in PH patients during physiological stress [20,21]. Increasing serum natriuretic peptide, a validated measure of HF severity, has been associated with worse weaning outcomes in postoperative patients and is a measure of risk stratification in pulmonary arterial hypertension and a biomarker for PH-related right ventricular dysfunction [22][23][24][25].…”

Evaluation of Electrical Cardiometry to Assess Fluid Responsiveness in Patients with Acute Circulatory Failure: A Comparative Study with Transthoracic Echocardiography

“…Fourth, PH and increased right ventricular (RV) pressure decrease venous return during PLR and may lead to a false negative PLR-response. 36 Although we excluded patients with PH and RV dysfunction, we did not assess pulmonary artery pressure in at-risk patients, (e.g., chronic obstructive pulmonary disease and hypoxemia).…”