70. The People’s Ventricle with Dr Matt Siuba

This podcast explores the critical role and often-overlooked nature of the right ventricle (RV) in critical care. Dr. Matt Siuba, a medical intensivist and pulmonary vascular disease expert, joins the hosts to discuss why the RV is "the people's ventricle," drawing parallels to marginalized figures in history due to its underappreciation. The conversation covers the RV's unique physiology compared to the LV, emphasizing its vulnerability to increased afterload and the resulting "death spiral." Dr. Siuba highlights the importance of monitoring RV function in ARDS and septic shock patients, advocating for a "zentensivist" approach that balances minimally invasive techniques with attentive care. The discussion also covers practical aspects of RV monitoring, including echocardiographic measurements and the use of pulmonary artery catheters, as well as treatment strategies.

Outlines

Part 1: Introduction, Context, and Physiology

Part 2: Clinical Contributors and Respiratory Mechanics

Part 3: Monitoring and Diagnostic Tools

Part 4: Pulmonary Artery Catheterization

Part 5: Management Strategies and Hemodynamics

Part 6: Advanced Support and Pharmacology

Part 7: Conclusion

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Critical Care Time

Part 1: Introduction, Context, and Physiology

00:04Introducing the Right Ventricle: The Underappreciated Workhorse of Circulation

Introducing the Right Ventricle: The Underappreciated Workhorse of Circulation

00:42RV Dysfunction: Prevalence, Mortality, and Dr. Siuba's "Hipster" Inclinations

RV Dysfunction: Prevalence, Mortality, and Dr. Siuba's "Hipster" Inclinations

05:02Overlooked Topics: Congestion, Transplants, and the Catastrophic Nature of RV Failure

Overlooked Topics: Congestion, Transplants, and the Catastrophic Nature of RV Failure

07:24RV Dysfunction: A Real Entity Increasing Mortality in Septic Shock and ARDS

RV Dysfunction: A Real Entity Increasing Mortality in Septic Shock and ARDS

09:31RV vs LV: Embryological Differences, Contractility, and Coronary Perfusion

RV vs LV: Embryological Differences, Contractility, and Coronary Perfusion

12:01The RV Death Spiral: Dilation, Tricuspid Regurgitation, and Pericardial Impingement

The RV Death Spiral: Dilation, Tricuspid Regurgitation, and Pericardial Impingement

Part 2: Clinical Contributors and Respiratory Mechanics

14:43Common Medical ICU Contributors to RV Failure: ARDS, Septic Shock, and Pulmonary Embolism

Common Medical ICU Contributors to RV Failure: ARDS, Septic Shock, and Pulmonary Embolism

16:37Differentiating Acute vs Chronic RV Dysfunction: Pressure, Thickness, and Contraction

Differentiating Acute vs Chronic RV Dysfunction: Pressure, Thickness, and Contraction

19:33RV Contraction, Positive Pressure Ventilation, and Pulmonary Afterload

RV Contraction, Positive Pressure Ventilation, and Pulmonary Afterload

21:50The Physiologically Difficult Airway: PVR vs Lung Volume

The Physiologically Difficult Airway: PVR vs Lung Volume

23:31Optimizing PEEP and Pressures: Lung Problems, Body Habitus, and Driving Pressure

Optimizing PEEP and Pressures: Lung Problems, Body Habitus, and Driving Pressure

25:58PEEP, FIO2, and Echo Assessments: Individualized Care for the Failing RV

PEEP, FIO2, and Echo Assessments: Individualized Care for the Failing RV

Part 3: Monitoring and Diagnostic Tools

28:38Monitoring the RV: Balancing Invasiveness and Repeatability

Monitoring the RV: Balancing Invasiveness and Repeatability

29:35Frequency of Monitoring: Non-Invasive vs Invasive Tools

Frequency of Monitoring: Non-Invasive vs Invasive Tools

30:59Difficult Airway Course Advertisement

Difficult Airway Course Advertisement

32:34The Three S's of RV Function: Size, Squeeze, and Septal Kinetics

The Three S's of RV Function: Size, Squeeze, and Septal Kinetics

35:35Septal Kinetics: Systole vs Diastole and Atrial Septum Assessment

Septal Kinetics: Systole vs Diastole and Atrial Septum Assessment

38:10Upping the Ante: Invasive Monitoring and Diagnostic Uncertainty

Upping the Ante: Invasive Monitoring and Diagnostic Uncertainty

40:52Zentensivism: A Holistic Approach to Critical Care

Zentensivism: A Holistic Approach to Critical Care

Part 4: Pulmonary Artery Catheterization

42:29PA Catheters: Useless or Underutilized?

PA Catheters: Useless or Underutilized?

44:57PA Catheter Placement: Tips, Tricks, and Troubleshooting

PA Catheter Placement: Tips, Tricks, and Troubleshooting

47:53Waveform Recognition and the "Blind" Insertion

Waveform Recognition and the "Blind" Insertion

50:09Fluid Boluses, Calcium, and Tricuspid Valve Repairs

Fluid Boluses, Calcium, and Tricuspid Valve Repairs

52:30PA Catheter in Place: Now What?

PA Catheter in Place: Now What?

54:46Cardiac Output, Pulmonary Hypertension, and Hypoperfusion

Cardiac Output, Pulmonary Hypertension, and Hypoperfusion

57:12Cardiac Index, Oxygen Consumption, and the Fick Equation

Cardiac Index, Oxygen Consumption, and the Fick Equation

Part 5: Management Strategies and Hemodynamics

1:00:45Diagnosis, Data, and Management of RV Failure

Diagnosis, Data, and Management of RV Failure

1:02:14Therapeutic Monitoring and Afterload

Therapeutic Monitoring and Afterload

1:04:53Pulmonary Vasodilators: Inhaled Nitric Oxide vs Inhaled Nepoprostanil

Pulmonary Vasodilators: Inhaled Nitric Oxide vs Inhaled Nepoprostanil

1:07:22Measuring Impact: PVR, Stroke Volume, and Right Ventricular Function

Measuring Impact: PVR, Stroke Volume, and Right Ventricular Function

1:09:36Oxygenation and Hyperventilation: Pulmonary Vasodilation Strategies

Oxygenation and Hyperventilation: Pulmonary Vasodilation Strategies

1:12:25Preload: Diuresis, Volume Overload, and RV Geometry

Preload: Diuresis, Volume Overload, and RV Geometry

1:14:25CVP Waveforms: Clues to RV Volume Status

CVP Waveforms: Clues to RV Volume Status

1:17:10Diuretic Resistance, Ultrafiltration, and BNP

Diuretic Resistance, Ultrafiltration, and BNP

Part 6: Advanced Support and Pharmacology

1:19:45Cap Refill, the BUS, and Augmenting Contractility

Cap Refill, the BUS, and Augmenting Contractility

1:21:05Inotropes: Dobutamine, Milrinone, and the Evidence-Sparse Zone

Inotropes: Dobutamine, Milrinone, and the Evidence-Sparse Zone