Critical Care Scenarios Episode 99: RV failure in the MICU
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Mar 11, 2026 Amos Dodi, nocturnal intensivist at Einstein/Montefiore and author on right ventricular failure, joins to unpack management of RV failure in the MICU. They walk through bedside ultrasound use, interpreting chronic versus acute RV findings, practical hemodynamic monitoring, vasopressor and inotrope choices, and high-risk intubation and fluid removal strategies. Practical, case-driven clinical talk.
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Use Ultrasound To Rule Out Extremes Of Volume
- Use point-of-care ultrasound immediately to distinguish an empty hyperdynamic heart from a full, dilated RV in suspected shock.
- Look for RV larger than LV and a plethoric IVC to identify elevated filling pressures and steer away from fluid boluses.
Support Broadly Then Use Trends To Narrow Diagnosis
- When data are ambiguous, rule out extremes and support multiple possible causes while watching response over hours.
- Use small inotrope trials and mini-fluid challenges or passive leg raise to convert uncertainty into actionable trend data.
Remove Things That Raise Pulmonary Afterload
- Stop interventions that raise pulmonary vascular resistance and optimize oxygenation, ventilation, and acid-base before escalating other therapies.
- Avoid hypoxia, hypercapnia, and acidosis because each independently increases RV afterload and can precipitate collapse.