Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review
IntroductionPulmonary vascular dysfunction, pulmonary hypertension (PH) and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR).
We therefore planned to provide a detailed update on the management of PH and RV failure in adult critical care.
Methods: A systematic review was performed, based on a search of the literature from 1980-2010, using pre-specified search terms. Relevant studies were subjected to analysis based on the GRADE methodology.
Results: Clinical studies of intensive care management of pulmonary vascular dysfunction were identified describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators and mechanical devices.
The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1: A weak recommendation (very low quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance. 2: A weak recommendation (low quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients, and that 3: low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock.
4: A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5: A strong recommendation (moderate quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent.
6: A weak recommendation (low quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7: A strong recommendation (moderate quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction following cardiac surgery, and that the side effect profile is reduced using inhaled rather than systemic agents.
8: A weak recommendation (very low quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.
Conclusions: This systematic review highlights that although some recommendations can be made to guide the management of pulmonary vascular and right ventricular dysfunction, within the limitations of the this review and the GRADE methodology, the quality of the evidence base is generally low and further high quality research is needed.
Published on: 2010-09-21