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Case Presentation
A 44-year-old woman with a past medical history of hypertension, renal artery stenosis, blood loss anemia from menorrhagia, and idiopathic pulmonary arterial hypertension (PAH) came to the hospital for right heart catheterization (RHC). She was diagnosed with PAH 12 years ago when she was worked up for systemic hypertension. She was found to have systolic pulmonary arterial pressure of 150 mmHg and elevated pulmonary vascular resistance (PVR) of 15 Wood units. Follow-up RHC 4 months ago showed mean pulmonary artery pressure (mPAP) of 53 mmHg and PVR of 18 Wood units. She was on bosentan 125 mg every 12 hours, sildenafil citrate 40 mg every 8 hours, and selexipag 1600 µg every 12 hours. Repeat RHC now showed mPAP of 48 mmHg and PVR of 12 Wood units. After discussion with the patient, the decision was made to titrate down selexipag, switch her to the up-titrating dose of intravenous treprostinil, keep the right heart catheter in place to guide the right dose, and monitor pulmonary artery pressures and other hemodynamic variables. This case shows the importance of RHC in the evaluation and differential diagnosis of pulmonary hypertension and assessment of response to therapies.
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KEY POINTS
Fluid assessment in critically ill patients is the key to improve short- and long-term outcomes.
Invasive and noninvasive modalities are available to guide the fluid assessment and responsiveness of hemodynamically unstable patients.
All information should be used in clinical context to obtain optimal results.
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Fluid assessment in the critical care unit is an important measure to guide management and improve patient outcomes. Current techniques use pressure and volume to estimate fluid status. Various methods have been proposed to provide effective assessment tools, but none of them is specific. Good judgment is required to incorporate the findings into the clinical scenario.
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CENTRAL VENOUS CATHETER
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Central venous catheter (CVC) is an invasive tool traditionally used to care for critically ill patients. Besides measuring central venous pressure (CVP), a pressure in the thoracic vena cava (TVC) near the right atrium, CVC can also help with administering peripherally incompatible infusions, placing devices, parenteral nutrition, and blood sampling.
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A normal CVP ranges between 3 and 8 mmHg, which can fluctuate depending on the patient’s volume status and venous compliance. CVP is an important factor in critical care because it enables estimation of volume status and right ventricle (RV) function and assessment of cardiac function via mixed venous gas. However, there are drawbacks and complications with CVC.
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