Moffitt Report Pearls 4/19 and 4/20: RV failure and Hypercalcemia

Acute RV failure

Management

  1. Reduce RV afterload: supplemental O2, pulmonary vasodilators (e.g. NO)
  2. Decrease RV pressure: gentle diuresis (preload dependent in the RV so don’t want to over-diurese and cause underfilling. In addition, because of RV failure, the LV can be underfilled so over-diuresis be detrimental for this reason as well)
  3. Improve RV contractility:
    1. Inotropic support: dobutamine and milrinone
      1. These agents can cause hypotension so sometimes need to be combined with a pressor like norepinephrine
    2. If not working, consider mechanical support or ECMO!

 

Why is RV failure so dangerous? You have heard of attendings talking about the “death spiral” of RV failure:

RV failure

To read more, check out this excellent paper from which this image was obtained: http://www.ncbi.nlm.nih.gov/pubmed/18158479

 

Hypercalcemia from elevated 1,25 OH Vit-D

  • Lymphoma
  • Granulomatous diseases
    • Fungi (cocci)
    • Sarcoid
    • TB
    • IBD
  • Profound foreign body reactions (rare, availability bias at UCSF since an impressive case of this was presented last year)

Pearl from Mark Anderson: if you have a high suspicion that 1,25-Vit D may be elevated from a clinical perspective, don’t be falsely reassured by a normal range on the lab test. Apparently there is variability of the accuracy of the assay!

For more reading on hypercalcemia, check out these old blog posts!

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