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Talk One - Ben Shilliday - RV Failure

Let a right ventricle go fast if it wants to. Don't try and slow it down. However, sinus rhythm is better than non sinus rhythm.

It's really important to maintain systemic pressure in patients with RV failure. Keeping the systemic pressure high, will increase Right coronary artery pressure, so it will increase RV perfusion, so it will increase RV output.

All RV failure is not the same. It depends on whether you've got a high or a low afterload for the right side. If you've a high afterload, then off load, if you've a low afterload, then challenge. Maybe! The RV is way less tolerant of afterload than LV.

CVP is a brilliant marker of right sided function. CVP is pretty much right ventricular preload. It may be rubbish for left side. But right side is good.

If you need drugs for right heart failure, you want something that will increase cardiac infex, decrease pulm artery pressure, but also keep systemic vascular resistance up. So adrenaline is a good inotrope,but it also increase pulm art pressure, so adrenaline in right heart failure they often use nitric oxide as a pulmonary vasodilator. But it does increase contractility more than it.

If you lose control of CO2 in a patient with RV dysfunction, that can increase vessel dilatation (have I got that the complete wrong way round?), which will increase afterload, which will cause worsening of RV failure.

Talk Two - John Payne - SNAHFS - Who To Refer

DO NOT GIVE PATIENTS IN ACUTE DECOMPENSATED HEART FAILURE B BLOCKERS! IT WILL MAKE THINGS WORSE. (they get it after offloaded)

DIY SUMMARY

  • Stop everything but furosemide -inc ace i, MRA, espec B Blocker
  • Use HR as marker of improvement, not ankle size
  • Furosemide infusion (better than boluses) - This is the commonest thing they need to do in SNAHFS - If in doubt dry them out! (You haven't treated them properly until their urea and creatinine is going up)
  • Start K replacement early
  • LMWH DVT prophylaxis
  • Resist temptation to give any dysrhythmmia with B Blocker!

  • You need to offload the heart to improve the stroke volume, don't withhold furosemide cos the blood pressure's low!

  • They would often add a tiny does of enalpril and eplenerone as second agent after furosemide before second diuretic. Like when you get to 20mg/hr

Indications

  • Severe LVSD
    • Decompensation not responding to usual therapy (furosemide)
    • Cardiogenic Shock or other signs of end organ dysfunction
  • Ischaemic and Non-Ischaemic (Familial, Alcohol, Post Myocarditis)
  • HoCM with HF is a really bad sign. They have a v bad prognosis.

Who Gets Referred

You don't need a cardiologist to see your patient before you refer to the SNAHFS.

Don't rule patients out yourself, unless over 65 years or over 35 BMI. But even then if you want to talk through them do it.

Urgent

  • Often first presentation of acute HF
  • Who aren't progressing
  • Who have resting tachycardia/recurrent pulm oedema/renal dysfunction

Emergency

  • First presentation
  • Cardiogenic shock
  • Dilated cardiomyopathy or post infarct
  • Usually severe LVSD, sometimes just RV

Contraindications (are basically contraindications for transplant)

It's these things that mean, they would do badly.

  • Irreversible renal or hepatic dysfunction
  • Active/Recent Ca
  • Older (>65)
  • Severe lung disease
  • Severe PVD
  • BMI >35
  • Challenging psychological background (psychological resilience needed for mechanical support/post transplant)
  • Severe osteoporosis (cos of steroids afterwards)

But just refer, cos these contraindications are relative

ECMO In Cardiogenic Shock

~50-70% of patients in this situation will survive

Each ECMO run is limited to around 2 to 2.5 weeks, you need an exit strategy for afterwards

Medical Management Of Cardiogenic Failure in SNAHFS

Theres a more aggressive use of furosemide

There's a greater use of things like Swan Ganz for filling status using a wedge pressure

Young patients (less than 60s) rarely get the classical symptoms or signs of heart failure. Rather than breathlessness they get abdominal discomfort (from congested livers/guts).

They often stop the beta blockers, and reintroduce them later on at a smaller dose.

They often use an IABP as a bridge to offloading

Talk Three - Traumatic Brain Injury - Chris Hawthorne

Typical Approach To The TBI

The Guideline Approach

They follow the evidence, but are more specific for the neuro critical management. But the problem is the evidence is pretty ambiguous.

Like Chris has said before. The most important questions in Neuro ICU with patients is at the bedside:

  1. "Do I need to scan them"
  2. "Do I need the surgeons for theatre"

The AAGBI Guidelines

Safe transfer of the brain injured patient: trauma and stroke, 2019. [] // To Read