Episode 98: RV failure in the MICU

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We chat about managing a complex MICU patient with RV failure in the setting of renal failure and sepsis, with Amos Dodi, nocturnal intensivist at Einstein/Montefiore and author of a recent narrative review on the RV.

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CHEST’s Procedural Skills for the Critical Care Clinician, April 23-24 2026

References

1. Amos’s RV failure review: Dodi, A.E., Jacobs, M. Acute Right Ventricular Failure in the Medical ICU. Lung 203, 107 (2025). https://doi.org/10.1007/s00408-025-00862-y

Takeaway pearls

1. Distinguishing the cause of shock in a patient with chronic PH is always challenging. Echo can be harder to interpret, but extremes can be called: frank hypovolemia, frank RV failure. Don’t forget to correlate clinically, eg feeling the extremities to estimate SVR.
2. Measuring CVP can be very valuable in these patients. The spot value can be hard to interpret, but trends can be revealing; if the CVP suddenly jumps, consider the RV is giving up.
3. Response to therapy can also be a potent diagnostic tool, such as the response to inotropy, or a fluid challenge.
4. Avoid hypoxemia, hypercarbia, hypotension, acidosis, all of which increase the PVR and hence RV strain. Limit fluid inputs from drips.
5. Favor vasopressin as a PVR-sparing pressor, perhaps with low-dose epinephrine as a titratable inopressor, though caution with vaso causing coronary ischemia in an RV already at risk of it due to dilation.
6. Intubating the RV failure patient should be done with great caution and respect, and really, deferred if possible. The team should proceed with awareness of the risk of hemodynamic decompensation (ideally one provider tasked to this purpose peri-intubation). Induction agents should be hemodynamically stable, preoxygenation should be optimal, and be delicate with BVM use to limit intrathoracic pressure.
7. A PA catheter has potential utility, although expertise has dwindled these days. It is not impossible that placing a foreign body across the TV, through the RV into the PAs could even worsen RV function somewhat. Non-invasive cardiac output monitors may have a role as well although the benefit has not be clearly shown.
8. Volume management and diuresis can sometimes be guided by the urine sodium.