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The Pump

cardiac assessment and resuscitation in the peri-intubation period

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Your need to intubate may have a negative impact on a cardiovascular system that is already in shock. Learn how to assess and support heart function BEFORE intubation to avoid cardiovascular collapse in the peri-intubation period and beyond.


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AfterloadPracticeWhat’s Next
at the intersection of cardiac physiology & Intubation
The impact of positive pressure

How will your decision to intubate impact the heart of a critically ill patient? In order to be prepared for the consequences of the procedure of intubation you need to first know what effect that procedure will have. We explain it here.


Apical 4 Chamber View

To evaluate RV contractility, the first step is to get a good apical four chamber view. Is the RV bigger than the LV?


Assessing Volume Status

A plethoric IVC suggests a volume overload state or obstructive pathology (tamponade, PE). >50% collapse with inspiration or compression suggests euvolemia or hypovolemia. The RV is preload dependent to an extent, but excess fluid can quickly overload the RV and worsen RV dysfunction–so consider vasopressors early.

Venous Congestion

The Vexus Score

Not convinced by your IVC ultrasound? The Venous Excess Ultrasound grading system can help provide additional information to evaluate fluid status.


how bad & acute or chronic

POCUS can be used to quickly evaluate for RV dysfunction and potential cardiovascular collapse in the peri-intubation period. The apical 4-chamber view and TAPSE are key components of assessing the RV.

measuring tapse

Tricuspid annular plane systolic excursion or (TAPSE) has a strange name but is simple to measure. It’s done in the apical 4 chamber view using m-mode. We show you how to do it here. Is the measurement less than 1.6cm? That means poor contractility.


Decreased RV contractility and poor systemic perfusion despite optimizing preload and using vasopressors? Consider adding an inotrope.


pH, PaO2, and PCO2

Pulmonary vasodilation, or decreased PVR, will reduce afterload for the right ventricle. Oxygen is a potent pulmonary vasodilator, meaning pre-oxygenation should be optimized for patients with RV failure in the peri-intubation period. Hypercapnia will increase PVR and RV afterload. NIPPV can be used to improve both oxygenation and ventilation peri-intubation, but beware of using excess PEEP.

Pulmonary Vasodilators

Oxygen is the ultimate pulmonary vasodilator, but O2 isn’t enough there are pharmacologic options that can be considered to decrease pulmonary vascular resistance (PVR).


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