severe pHTN for TKA

[coffeebythelake]

60 y.o. female, morbidly obese (BMI 43), severe pHTN (PASP 65-70 mm Hg), mild-mod RV dysfunction, HTN, COPD on home O2, CHFpEF (LVEF 65%, mild TR, no aortic or mitral valvular abnormalities, grade 2 DD) here for TKA. Etiology of pHTN uncertain, but believed to be from COPD and possibly from OSA as well. Seen by pulmonologist several months ago, on COPD rx and not a candidate for pulmonary vasodilator therapy. Pulmonologist thought sleep study not necessary. Seen by perioperative hospitalist who quoted patient MICA score of 0.7% and hence was not worried. Hopefully the hospitalist didn't convey this number to the patient, because I told patient her risk was substantially higher.

Patient at her baseline cardiopulmonary status at time of your evaluation.
She was recently started on spiriva which she states has improved her breathing to the point that she doesn't need to use home O2 as frequently. She is compliant with her COPD rx, and took her metoprolol this am, but was instructed not to take her spironolactone and HCTZ. HR is 70. Her BP 210/100, although her base line BP is ~130-140/80's. SpO2 is 95% on RA.

How are you going to do the anesthetic?
What if this is for a hip replacement?

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[pgg]

I have a hard time believing her BP went from chronically well controlled in the 130s/80s to 210/100 because she skipped her diuretic this morning. But assuming I could be convinced the case should go at all, I guess I'd just do an isobaric bupivacaine spinal and an adductor canal block, minimal or no sedation.

 

[Psai]

sounds elective
no sedation
maybe a small amount of ketamine if necessary
for knee fem sciatic
for hip cse
oxygen
keep albuterol and nitric close by
raise back of table

 

[sbhfl]

Admit to ED for HTN emergency.

 

[Arch Guillotti]

Spinal. Sedation as needed. Next.

 

[nimbus]

She has pulm htn but it is not scary high. Her RV appears to have compensated. Those of us who routinely insert PA catheters see those numbers from time to time and the patients do fine. Also PAP is dynamic and everything we do during a GA tends to drive those numbers down. I’d have no problem doing this case with an ACB/IPACK, preinduction Aline, ga/ett.

 

[getdown]

I would also do isobaric spinal and minimal sedation. Adductor canal catheter postop if pt's staying in house for several days. If GA then pre induction Aline.

 

[BLADEMDA]

She has pulm htn but it is not scary high. Her RV appears to have compensated. Those of us who routinely insert PA catheters see those numbers from time to time and the patients do fine. Also PAP is dynamic and everything we do during a GA tends to drive those numbers down. I’d have no problem doing this case with an ACB/IPACK, preinduction Aline, ga/ett.

I'm pretty sure she will "decline" the Regional plus SAB with no sedation and go your route. Despite all her medical issues she will likely believe that her condition "isn't that bad" and she can tolerate a GA.

Post op I would want decent pain control with avoidance of opioids as much as possible to keep her Pulm HTN under control. If I knew the surgeon well then I'd decide between Fem/Popliteal vs Adductor Canal/Ipack. I'd likely be conservative with this patient and opt for Femoral/Popliteal blocks which will give the best post-op pain control.

 

[Arch Guillotti]

No sedation will be awful for everyone involvd in the case. Sedate within reason with whatever you want and whatever the patient tolerates.

 

[Psai]

Admit to ED for HTN emergency.

It's hypertensive urgency, not emergency and the ED will discharge with outpatient followup.

 

[coffeebythelake]

1. No we didn't send to ED for HTN emergency. BP was likely combo of missed antihypertensives PLUS pt quite anxious. we gave a little versed which helped tremendously. you're right, unsure whether pt was normally well controlled but this was what was documented in records. i wasn't completely certain pt was euvolemic or close to it, was concerned of potential significant hemodynamic swings.

2. Goal was to maintain hemodynamic stability, not to quickly drop SVR and preload, not to cause tachycardia, adequate volume status. after d/w block team decided not to do straight spinal -- too high risk. We decided between CSE w low dose spinal vs straight epidural vs GA. each with pros vs cons. We chose CSE w low dose spinal, which ended up working maybe too well as even 7.5 mg isobaric bupi caused MAPs to drop 40-50 mm Hg and gave us a T6 level. Also did an AC block for postop pain control. About 1 hour into case we started epidural bupi 0.5% at 20 mg/hour, stopped 30 minute before case end.

3. arterial line was placed. 1 large bore IV. no other invasive monitors needed

4. Maintained sedation intraop with precedex, dosed 0.5 mcg/kg over 10 minutes, then maintenance at 0.3 mcg/kg/hr. we stopped infusion 30 minutes prior to surgical end. minimal supplemental oxygen provided to keep SpO2 above 95%. couldn't get good waveforms for EtCO2 but pt did not appear obstructing and was easily arousable throughout


thoughts?

 

[Arch Guillotti]

1. No we didn't send to ED for HTN emergency. BP was likely combo of missed antihypertensives PLUS pt quite anxious. we gave a little versed which helped tremendously. you're right, unsure whether pt was normally well controlled but this was what was documented in records. i wasn't completely certain pt was euvolemic or close to it, was concerned of potential significant hemodynamic swings.

2. Goal was to maintain hemodynamic stability, not to quickly drop SVR and preload, not to cause tachycardia, adequate volume status. after d/w block team decided not to do straight spinal -- too high risk. We decided between CSE w low dose spinal vs straight epidural vs GA. each with pros vs benefits. We chose CSE w low dose spinal, which ended up working maybe too well as even 7.5 mg isobaric bupi caused MAPs to drop 40-50 mm Hg and gave us a T6 level. Also did an AC block for postop pain control. About 1 hour into case we started epidural bupi 0.5% at 20 mg/hour, stopped 30 minute before case end.

3. arterial line was placed. 1 large bore IV. no other invasive monitors needed

4. Maintained sedation intraop with precedex, dosed 0.5 mcg/kg over 10 minutes, then maintenance at 0.3 mcg/kg/hr. we stopped infusion 30 minutes prior to surgical end. minimal supplemental oxygen provided to keep SpO2 above 95%. couldn't get good waveforms for EtCO2 but pt did not appear obstructing and was easily arousable throughout


thoughts?

Not bad. I would have skipped the art line and just done a spinal.

 

[coffeebythelake]

Not bad. I would have skipped the art line and just done a spinal.

curious -- at what point would u have said no to straight spinal?

 

[MoMoGesiologist]

Not bad. I would have skipped the art line and just done a spinal.

So what precautions do you take for patients with severe pHTH or RV dysfunction? Sounds like you wouldn't treat this case any different than a healthy person.

 

[nimbus]

So what precautions do you take for patients with severe pHTH or RV dysfunction? Sounds like you wouldn't treat this case any different than a healthy person.

I prefer GA with controlled ventilation for these patients specifically so I can prevent hypoxemia and hypercarbia and so I can run some volatile agent.

 

[fakin' the funk]

So what precautions do you take for patients with severe pHTH or RV dysfunction? Sounds like you wouldn't treat this case any different than a healthy person.

Yeah. That's the usual vibe here.

 

[anbuitachi]

def put an arterial line. benefit > risk in my opinion. have seen enough M&Ms of severe HTN similar to the one in this patient, and mod decreased RV function, get very low dose sedation and die. like someone else said, its dynamic, echo may not accurately reflect the cardiopulmonary status on day of surgery.

 

[narcusprince]

We are missing a few things here. And its the surgical side? How fast is orthopod? 45min for a total knee no tourniquet then spinal/cse no aline. If slow surgeon case greater then 2hrs long tourniquet times aline cse higher potential for worsening acid/base status. Precedex sedation is slick. Total hip depends too anterior versus posterior approach. Have vasopressin ready to bolus in case of hypotension, warm fluids(cold can worsen pulm htn). Im not worried about sedation( she doesnt go into a pulmonary htn crisis at home when she sleeps at night).

 

[Planktonmd]

The best plan is the simplest plan.
This sounds like secondary pulmonary HTN from COPD and OSA Which is very common. Her BP is elevated because of anxiety + maybe skipping meds.
All the options are OK: Spinal, GA, or just blocks.
An LMA might be worth a try too, if it seats well then you don't even need to intubate her.

 

[dhb]

I prefer GA with controlled ventilation for these patients specifically so I can prevent hypoxemia and hypercarbia and so I can run some volatile agent.

Yes but what happens to her pCO2 once you extubate?

 

[MoMoGesiologist]

Ooh I didn't even think about a tourniquet... all that CO2 and H+ when tourniquet comes down could spell death...

 

[coffeebythelake]

We are missing a few things here. And its the surgical side? How fast is orthopod? 45min for a total knee no tourniquet then spinal/cse no aline. If slow surgeon case greater then 2hrs long tourniquet times aline cse higher potential for worsening acid/base status. Precedex sedation is slick. Total hip depends too anterior versus posterior approach. Have vasopressin ready to bolus in case of hypotension, warm fluids(cold can worsen pulm htn). Im not worried about sedation( she doesnt go into a pulmonary htn crisis at home when she sleeps at night).

Typical surgical times around 2-3 hours. Uses tourniquet. Sedation, esp heavier sedation, isn't the same as sleep in terms of oxygenation/ventilation

 

[Noyac]

Admit to ED for HTN emergency.

This is a joke, right?

 

[Noyac]

We see a lot of PHTN in my practice. These cases can be tricky for sure.
The CSE was a good plan esp’ly if the surgeon is slower.
I like blocks in these pts. And like Blade said, I prefer the FNB/Sciatic (popliteal) for ultimate pain control. But I do worry about this pts ability to ambulated POD#1 with a FNB due to her obesity. I might have done the ACB instead and if it didn’t cover the pain well enough then FNB to limit narc’s. Also, be sure to continue multimodal pain therapy throughout the hospital course.

I disliked a few comments.
- send to ER is just being obstructionistic. You are a physician I assume so treatthe HTN. It is most definitely anxiety. Versed is magic.
- ketamine alone for sedation also made my eyes roll. This pt is already severely anxious (see above). Are you gonna give some ketamine in preop holding for the anxiety induced HTN? If not, then your plan is already changing.

My approach would have been:
-anxiolytics with versed. No antihylrtensive meds since my spinal will take care of this and I don’t want it be chasing my arse BC I gave some labetolol or something.
- gentle preload with about 500 cc LR i preop or why blocking.
- ACB/IPACK
- +/- Aline depending on anatomy of her arm and ability to trust cuff
- spinal with isobaric marcaine 10mg (ish).
- sedation of choice but not straight Ketamine. I find small amounts of versed do the trick 90%of the time. Precedex is a good alternative
- bonus LR just before dropping the tourniquet. If surgeon slow and tourniquet time > 45 min then I give1-2u vasopressin prior to dropping.
- turn off sedation early and assess status.

If I were an academic attending supervising a resident then we would:
- preop the same
- blocks the same
- GETA followed by Swan and A line.
- transfer to ICU

 

[Ezekiel2517]

This doesn't sound like severe enough pulm htn to make me really concerned. There's levels to this. Unless the patient is decompensating or actively symptomatic, block, spinal, some sedation. This is a straightforward case IMO

 

[OB1🤙]

This patient doesn't sound that bad to be honest.

When I do these kinds of cases (usually worse numbers than in this patient), I like to put in a spinal catheter. Dose it slowly with isobaric bupi a little at a time, until level and hemodynamics are where you need them to be. It's a very elegant technique. Keeps their physiologic milieu as close to baseline as possible.

Then for sedation, if they are robust enough to tolerate sedation, I'll sprinkle a little propofol on them. If they aren't, I get them noise cancelling headphones and let them watch a show on Netflix.

 

[dhb]

ACB/IPACK

Uh Oh going all fancy Mr Nerve Stimulator

 

[woopedazz]

In the US is it normal for a patient to be placed on home O2 prior to commencing a first line inhaler for known COPD?

 

[Twiggidy]

I'm assuming most of you on here are really good at blocks. I'm will admit that I'm terrible at blocks (fine with spinal / epidurals). For a 3 hr case giving the history it would've been a valiant attempt at a CSE with GA as backup (LMA if seats well. Tube if it doesn't). Probably an A-line in both anesthetics

 

[Twiggidy]

This patient doesn't sound that bad to be honest.

When I do these kinds of cases (usually worse numbers than in this patient), I like to put in a spinal catheter. Dose it slowly with isobaric bupi a little at a time, until level and hemodynamics are where you need them to be. It's a very elegant technique. Keeps their physiologic milieu as close to baseline as possible.

Then for sedation, if they are robust enough to tolerate sedation, I'll sprinkle a little propofol on them. If they aren't, I get them noise cancelling headphones and let them watch a show on Netflix.

Baller move.

 

[coffeebythelake]

In the US is it normal for a patient to be placed on home O2 prior to commencing a first line inhaler for known COPD?

Good Q
I'm not sure what the circumstances were and why the patient wasn't put on spiriva earlier.

 

[deleted162650]

In the US is it normal for a patient to be placed on home O2 prior to commencing a first line inhaler for known COPD?

No

 

[narcusprince]

Baller move.

Our wifi wont allow us to stream video......

 

[coffeebythelake]

This patient doesn't sound that bad to be honest.

When I do these kinds of cases (usually worse numbers than in this patient), I like to put in a spinal catheter. Dose it slowly with isobaric bupi a little at a time, until level and hemodynamics are where you need them to be. It's a very elegant technique. Keeps their physiologic milieu as close to baseline as possible.

Then for sedation, if they are robust enough to tolerate sedation, I'll sprinkle a little propofol on them. If they aren't, I get them noise cancelling headphones and let them watch a show on Netflix.

why a spinal catheter? PDPH?
are you using a tuohy or do u have a special kit with small needles for spinal caths?
why not epidural?

 

[psychbender]

why a spinal catheter? PDPH?
are you using a tuohy or do u have a special kit with small needles for spinal caths?
why not epidural?

Allows very precise titration of anesthetic level and hemodynamics. Give 0.5mL isobaric bupi, wait a minute, see how it affects pressure and where you level is. Run volume and/or pressor alongside. Lather, rinse, and repeat until you have an appropriate level, and BP is where you want it. I've done this before for hip fxs with AS and an unfavorable airway, ****ty lungs, or something else that made me think it was a better option than a straight GA with careful induction (also in a more favorable medicolegal environment). I used a regular epidural kit, and just drove through dura. Catheter out at the end of the procedure, so no one mistakes it for an epidural post-op. It's a really slick technique that I discuss with residents as an option.

Sent from my SM-G930V using SDN mobile

 

[coffeebythelake]

Allows very precise titration of anesthetic level and hemodynamics. Give 0.5mL isobaric bupi, wait a minute, see how it affects pressure and where you level is. Run volume and/or pressor alongside. Lather, rinse, and repeat until you have an appropriate level, and BP is where you want it. I've done this before for hip fxs with AS and an unfavorable airway, ****ty lungs, or something else that made me think it was a better option than a straight GA with careful induction (also in a more favorable medicolegal environment). I used a regular epidural kit, and just drove through dura. Catheter out at the end of the procedure, so no one mistakes it for an epidural post-op. It's a really slick technique that I discuss with residents as an option.

Sent from my SM-G930V using SDN mobile

interesting... i'm going to look into this

would you offer this to a reasonably young patient (say 40's) where risk of PDPH is more significant?

 

[Noyac]

interesting... i'm going to look into this

would you offer this to a reasonably young patient (say 40's) where risk of PDPH is more significant?

PDPH’s are not that difficult to deal with “usually”. Many options which have all been discussed as nauseum here. They include some things like:
Caffeine (poor results)
Atropine/neostigmine (fairly good reports of effect)
EBP (gold standard)

I would argue that someone old enough to have a TKA is an extremely low risk Pt for PDPH. These are the perfect pts to use when teaching a young anesthesiologist how to place an epidural because wet taps just don’t cause that many PDPH’s in this population.

 

[Arch Guillotti]

interesting... i'm going to look into this

would you offer this to a reasonably young patient (say 40's) where risk of PDPH is more significant?

I probably wouldn't unless comorbidities dictated otherwise which be sort of unusual at that young of an age.

 

[migm]

Admit to ED for HTN emergency.

Hope you're kidding

 

[deleted162650]

Uh Oh going all fancy Mr Nerve Stimulator

He’s so good he does nerve stim ACB’s:

“Sir, tell me when your shin is tingling”

 

[OB1🤙]

Allows very precise titration of anesthetic level and hemodynamics. Give 0.5mL isobaric bupi, wait a minute, see how it affects pressure and where you level is. Run volume and/or pressor alongside. Lather, rinse, and repeat until you have an appropriate level, and BP is where you want it. I've done this before for hip fxs with AS and an unfavorable airway, ****ty lungs, or something else that made me think it was a better option than a straight GA with careful induction (also in a more favorable medicolegal environment). I used a regular epidural kit, and just drove through dura. Catheter out at the end of the procedure, so no one mistakes it for an epidural post-op. It's a really slick technique that I discuss with residents as an option.

Sent from my SM-G930V using SDN mobile

Yeah, this.

 

[Twiggidy]

Our wifi wont allow us to stream video......

That's weak



(I'm sure you see what I'm doing there)

 

[Noyac]

He’s so good he does nerve stim ACB’s:

“Sir, tell me when your shin is tingling”

You sir, have no idea!

 

[Dexmetaketapropofol]

Great case and so many ways to skin a cat. Long post, early apologies...If this was just a total knee case with unpredictable surgeon skill and speed...

I would be cautious with all the players who think this is a straightforward/easy case (esp for residents reading this post, if nothing else, consider this for your oral boards). If all goes well and your plan works, then yes, retrospectively it was easy! You can brag to your colleagues how doing the same thing you do for all your patients works for these sickies!

I would consider the pathology and it's spectrum and how the surgery and postop issues will effect this spectrum.

If I may dissect the the original information from the OP it may show the reasons why I would choose a particular technique over another.

1. Mild-mod RV dysfunction with minimal tricuspid regurgitation: This is not a great sign for me. Where did the OP find the RVSP? Usually this is from a TTE. If true, the TR would definitely not be mild. Was the RVSP obtained from a R heart cath? I doubt this, otherwise the OP would have stated other pressures, CVP, etc. What this translates to is that the R heart is not compensating as much for the increase in pulmonary vascular resistance and the patient is closer to experiencing uncompensated symptoms with hypoxia/hypercarbia/pain. Also, why is this patient not a candidate for inodilator or vasodilator therapy???

2. The SVR/afterload is high. Yes, everyone likes to chalk this up to anxiety. And yes, you'd be right in the majority of surgical patients. If I believe the patient and "140s/150s" is true, this could be the case. However, you cannot exclude the possibility that the SVR is attempting to compensate for an above baseline PVR. This patients current PVR:SVR ratio is 1/3. Normal ratio anyone??? Anesthetics obviously can tip the scale unfavorably. Some clues to chronically uncontrolled HTN are the grade II diastolic dysfunction with chronic LA high pressures. I'm sure this plus the increased PVR are worsening the patients R heart function over time.

3. SpO2 of 95% on RA. As you know the oxygen dissociation curve places this patient at a wide range of PAO2s with a steep slope for quick occurring hypoxemia. A piece of information I would have requested would have been an ABG and I'm sure you had the chemistry which shows the bicarb level. I wouldn't be surprised if the bicarb on the chem is 37 plus and the baseline CO2 on ABG is 55 plus. This info can sway your choice for techniques.

I personally would choose:
- Arterial line (able to perform ABGs and titrate meds to maintain SVR during the sympathoplegia you obtain from neuraxial anesthetics)
- Milrinone (to aid RV support, decrease PVR and improve diastology of the LV. This will also help the heart for any insults it may receive. Tourniquet, CO2 load, etc). Vasopressin for SVR maintenance.
- Facemask with strap from the anesthesia machine (this will allow for a more accurate ETCO2 read, and increase the ability to give true 100% FiO2
- Neuraxial of your choosing. CSE works, Spinal works, Spinal cath works as long as you know what you're doing. I personally would choose a CSE. The tuohy would save time with added tactile touch for earlier success IMO. Even if I didn't want to thread a catheter I would still use the tuohy.
- Regional for postop analgesia no brainer
- Sedation of your choice with the obvious goals. Precedex can work, straight versed (flumazenil location available) can work, propofol can work, Ketamine low dose with any of the prior mentioned can work. This matters less than ensuring adequate ventilation and oxygen delivery.

Ok I'm tired of typing

 

[Arch Guillotti]

And like Blade said, I prefer the FNB/Sciatic (popliteal) for ultimate pain control.

Do you routinely do a popliteal block for knee replacement?

 

[Noyac]

Do you routinely do a popliteal block for knee replacement?

Nope!

 

[vector2]

Great case and so many ways to skin a cat. Long post, early apologies...If this was just a total knee case with unpredictable surgeon skill and speed...

I would be cautious with all the players who think this is a straightforward/easy case (esp for residents reading this post, if nothing else, consider this for your oral boards). If all goes well and your plan works, then yes, retrospectively it was easy! You can brag to your colleagues how doing the same thing you do for all your patients works for these sickies!

I would consider the pathology and it's spectrum and how the surgery and postop issues will effect this spectrum.

If I may dissect the the original information from the OP it may show the reasons why I would choose a particular technique over another.

1. Mild-mod RV dysfunction with minimal tricuspid regurgitation: This is not a great sign for me. Where did the OP find the RVSP? Usually this is from a TTE. If true, the TR would definitely not be mild. Was the RVSP obtained from a R heart cath? I doubt this, otherwise the OP would have stated other pressures, CVP, etc. What this translates to is that the R heart is not compensating as much for the increase in pulmonary vascular resistance and the patient is closer to experiencing uncompensated symptoms with hypoxia/hypercarbia/pain. Also, why is this patient not a candidate for inodilator or vasodilator therapy???

2. The SVR/afterload is high. Yes, everyone likes to chalk this up to anxiety. And yes, you'd be right in the majority of surgical patients. If I believe the patient and "140s/150s" is true, this could be the case. However, you cannot exclude the possibility that the SVR is attempting to compensate for an above baseline PVR. This patients current PVR:SVR ratio is 1/3. Normal ratio anyone??? Anesthetics obviously can tip the scale unfavorably. Some clues to chronically uncontrolled HTN are the grade II diastolic dysfunction with chronic LA high pressures. I'm sure this plus the increased PVR are worsening the patients R heart function over time.

3. SpO2 of 95% on RA. As you know the oxygen dissociation curve places this patient at a wide range of PAO2s with a steep slope for quick occurring hypoxemia. A piece of information I would have requested would have been an ABG and I'm sure you had the chemistry which shows the bicarb level. I wouldn't be surprised if the bicarb on the chem is 37 plus and the baseline CO2 on ABG is 55 plus. This info can sway your choice for techniques.

I personally would choose:
- Arterial line (able to perform ABGs and titrate meds to maintain SVR during the sympathoplegia you obtain from neuraxial anesthetics)
- Milrinone (to aid RV support, decrease PVR and improve diastology of the LV. This will also help the heart for any insults it may receive. Tourniquet, CO2 load, etc). Vasopressin for SVR maintenance.
- Facemask with strap from the anesthesia machine (this will allow for a more accurate ETCO2 read, and increase the ability to give true 100% FiO2
- Neuraxial of your choosing. CSE works, Spinal works, Spinal cath works as long as you know what you're doing. I personally would choose a CSE. The tuohy would save time with added tactile touch for earlier success IMO. Even if I didn't want to thread a catheter I would still use the tuohy.
- Regional for postop analgesia no brainer
- Sedation of your choice with the obvious goals. Precedex can work, straight versed (flumazenil location available) can work, propofol can work, Ketamine low dose with any of the prior mentioned can work. This matters less than ensuring adequate ventilation and oxygen delivery.

Ok I'm tired of typing

With mild to moderate RV dysfunction it's still possible the RV has not dilated out yet. In the absence of dilation and significant tricuspid annulus distortion (and assuming the leaflets are normal), the TR could very well still be mild. PHTN secondary to left heart disease (pulmonary venous backpressure) and/or COPD typically doesn't respond that well to vasodilator therapy, although in this pt a RHC, calculation of the wedge and TPG, and a vasodilator challenge may still be appropriate if the picture is cloudy and one suspects there is pulmonary arterial disease as well.

 

[coffeebythelake]

Vasodilator therapy could worsen v/q mismatching in patient with significant copd?

 

[Dexmetaketapropofol]

With mild to moderate RV dysfunction it's still possible the RV has not dilated out yet. In the absence of dilation and significant tricuspid annulus distortion (and assuming the leaflets are normal), the TR could very well still be mild. PHTN secondary to left heart disease (pulmonary venous backpressure) and/or COPD typically doesn't respond that well to vasodilator therapy, although in this pt a RHC, calculation of the wedge and TPG, and a vasodilator challenge may still be appropriate if the picture is cloudy and one suspects there is pulmonary arterial disease as well.

That's true, but then the OP must have gotten the PASP from a RHC and not from Bernoulli's equation on echocardiography. Otherwise the TR Vmax to calculate an RVSP that high would show a decent degree of TR

 

[Dexmetaketapropofol]

Vasodilator therapy could worsen v/q mismatching in patient with significant copd?

Yes, then we are giving COPD the majority of the credit for the patient's R heart dysfunction