My friends who cares about the RV what would you do differently #PHT, #RV

Last day in my 7 days stretch The patient extubated on 2L nasal cannula, on combined oral PHT meds and diuretics.

Autoimmune workup, HIV, LUQ ultrasound, portal Doppler, VQ scan, medication & illicit drugs all negative!

Adding Dobutamine 10 mcg/kg/min, Inhaled Epoprostenol and starting aggressive fluid removal by CRRT 18L in 48 hrs 🤩. After 72 hrs I reached the numbers as showing below

RHC at bedside

Unfortunately, next day pt oxygen requirement increased to HFNC 60L and 90% with repeat CT-PE no PE but still dilated RV and RA with signs of pulmonary edema. Repeat POCUS

Before TNK pt had MAP > 65 mmHg and SBP 98 mmHg, with persistent tachycardia and hypoxemia in HFNC 40L and 40% Fio2

After 12hr: (Improvement) NtproBNP ⬇️, LA 2.2, AKI (crea 1.5), oxygen requirement⬇️ NC 5L- Osat 98%, SBP improved 108-115, and Pt feels better.

After consulting with Interventional Radiology about the patient's clinical situation, they did not support the use of CDT or CDE. Following thorough discussions with the patient, we reached a consensus to proceed with a half dose of TNK and aggressive diuresis 🌊

POCUS: severely dilated RV and RA RV/LV > 1, TAPSE 12 mm, TRPG 90, LV moderately reduced EF, flat IVS during Systole and Diastole, PV acceT 57, no pericardial effusion. VEXUS grade III. Low CO and CI (1.8) but the angle was not great 😌 underestimated result is possible

BP improved after 500cc Bolus in the ED 😞. Lab 🧪: -ve high sensitivity trop, ⬆️ NTProBnp 20k, D-Dimer 700s, LA 2.9, AKI (1.9 Creat). CT-PE showed unilateral RLL non obstructive pulmonary embolism 🤔, signs suggesting of pulmonary edema, and severally dilated RV and RA

♂in his mid 30s with no PMH. Presented to the ED c/o progressive dyspnea, Bendopnea and fatigue started couple of months before presentation. ROS -ve. On physical exam was unremarkable except for borderline low BP 100/63 mmHg and irregular irregular tachycardia 123 bpm.