Invasive assessment of optimal amount of intravenous fluid for the management of hypotensive patients with inferior-wall myocardial infarction, complicated by right ventricular infarction.

Sharma, Akhil

Invasive assessment of optimal amount of intravenous fluid for the management of hypotensive patients with inferior-wall myocardial infarction, complicated by right ventricular infarction.

Monday, May 20, 2019

Belmont Ballroom 2-3 (The Cosmopolitan of Las Vegas)

Akhil Kumar Sharma, M.D., D.M. , King George Medical College, Lucknow, Lucknow, India

Sudhanshu Kumar Dwivedi, M.D., D.M.FACC, FSCAI, FESC , King George Medical College, Lucknow, Lucknow, India

Vankar Sameer, M.D., D.M. , Apollo hospital, Secunderabad, India

Sharad Chandra, M.D., D.M.FACC, FSCAI, FESC, FSCAI , None, Lucknow, India

Gaurav Kumar Chaudhary, M.D., D.M. , King George Medical College, Lucknow, Lucknow, India

Rishi Sethi, M.D., D.M.FACC, FSCAI, FESC, FSCAI , King George's Medical University. Lucknow, Lucknow, India

Akshyaya kumar Pradhan, M.D., D.M. , King George Medical College, Lucknow, lucknow, India

Pravesh Vishwakarma, M.D., FSCAI , King George’s Medical University, Lucknow, India

Monika Bhandari, M.D., D.M. , King George's Medical University. Lucknow, Lucknow, India

Varun S. Narain, M.D., D.M.FACC, FESC , King George's Medical University. Lucknow, Lucknow, India

Background
Fluid replacement along with guideline-directed therapy is recommended in patients of inferior-wall myocardial infarction with right ventricular infarction (IW+RVMI) complicated by low cardiac output (CO) state. However, the optimum amount of intravenous (IV) fluid in such patients has not been studied.

Methods
To assess the hemodynamic effect of graded IV fluid infusion and optimal amount of fluid needed to achieve and maintain SBP ≥90 mmHg in hypotensive patients of IWMI with RVMI. In this single-center prospective study conducted from January to December 2017, patients with first episode of IW+RVMI and SBP <90 mm Hg were analyzed. Subclavian venous access was taken for Swan Ganz CCO catheter to measure pulmonary capillary wedge pressure (PCWP) on GE DASH 500 cardiac monitoring system .Femoral artery access was taken to measure CO and cardiac index (CI) using Edwards Life Sciences Vigilance 1000 platform monitor .The hemodynamic parameters such as heart rate, SBP, CO, CI, and PCWP were measured at the baseline and after each 500 ml normal saline over 15 min until SBP ≥ 90 mmHg was attained. The primary objective was to study the change in CO, CI, and PCWP with response to fluid and amount of fluid needed for ≥10% rise in CO and to maintain SBP ≥90 mmHg was also evaluated. The secondary objectives were to study the need for inotropic support, complications such as acute pulmonary edema, local site bleeding and in-hospital mortality.

Results
Twenty two patients were subjected to graded fluid therapy. The mean baseline PCWP, CO and CI was 8.4±3.0 mm Hg, 2.1±0.7 L/min and 1.3±0.3L/min/m2 respectively. Fluid therapy resulted in significant rise in PCWP, CO and CI to 17.6±1.5 mmHg, 3.7±0.7 L/min and 2.4±0.76 L/min/m2 respectively. The average quantity of fluid needed to increase the CO by 10% over the baseline was 865±462 mL. However, optimal amount of fluid needed to maintain SBP ≥90 mmHg was 2,192 ±560 mL. There were no complications such as local site bleeding and hematoma, acute pulmonary edema or in-hospital death.

Conclusions
Less than a liter iv fluid required for 10% improvement in CO but more than 2 liter fluid needed to treat hypotension in patients with IW+RVMI. However, more study with larger number of patients would be needed to confirm the same.