RVSP/Pulmonary Hypertension Workup – Quick Reference

RVSP / PH Workup – Quick Reference

Enter what you have (TR Vmax and RAP, or RVSP and RAP). The tool will solve the missing value, classify PH likelihood, and suggest next steps.

Inputs

TR Vmax

m/s

RAP

mmHg

RVSP

mmHg

Assume no RVOT/PR obstruction (PASP ≈ RVSP)

Formula: RVSP = 4 × (TR Vmax)² + RAP

Supportive Echo Signs (check what’s present)

Category A – RV/RA

RV basal diameter > 41 mm
RA area > 18 cm²
TAPSE < 17 mm
S′ (TDI) < 9.5 cm/s
RV FAC < 35%

Category B – Septum/LV

Septal flattening (D-shaped LV)
LV eccentricity index > 1.1

Category C – PA/IVC

PA diameter > 25 mm
IVC > 21 mm with poor collapse
PAAT < 105 ms (if available)

Symptoms / Context (optional)

Unexplained dyspnea
Syncope/presyncope
Signs of right-sided congestion

Risk for CTEPH (prior PE/DVT)
Connective tissue disease, portal HTN, HIV, drugs/toxins
Chronic lung/OSA/ILD

Results

Enter values and click Calculate.

Suggested Next Step

Action — will populate after calculation —

Reference cutoffs & logic (tap to view)

• TR Vmax ≤ 2.8 m/s (RVSP ≲ 36 mmHg with RAP 3–5): PH unlikely.
• TR Vmax 2.9–3.4 m/s (RVSP ~ 37–50 mmHg): PH possible.
• TR Vmax > 3.4 m/s (RVSP > 50 mmHg): PH likely.
• Upgrade suspicion if ≥2 supportive signs across ≥2 categories (A/B/C).
• Assume PASP ≈ RVSP only if no RVOT obstruction or significant PR.

Ketamine

Ketamine in the ICU – quick reference

Adult dosing; light background for readability. Use with your fentanyl ± dexmedetomidine plan; avoid large rapid boluses if hypertension is a concern.

Indications (ICU and ED)

• Analgesia Sub-dissociative opioid-sparing pain control in trauma, burns, post-op abdominal pain, opioid tolerance/hyperalgesia, neuropathic pain.
• Sickle crisis Vaso-occlusive crisis pain when opioid-sparing is needed or allodynia limits opioid escalation.
• Procedural sedation Short painful procedures, dressing changes, reductions.
• RSI/induction Especially in hypotensive trauma or with bronchospasm.
• ICU sedation Analgosedation adjunct or alternative to propofol/benzodiazepines.
• Status asthmaticus Bronchodilation and improved ventilation.
• Refractory status epilepticus NMDA antagonism for seizure control.
• Severe agitation Excited delirium rescue with airway-ready monitoring.
• Status migrainosus Rescue in selected protocols.
• Alcohol withdrawal Refractory cases as adjunct to standard care.
• Psychiatry Treatment-resistant depression (protocolized settings).

Dosing cheat sheet

• Analgesia (sub-dissociative): bolus 0.1–0.3 mg/kg IV given slowly; infusion 0.1–0.3 mg/kg/hr (≈1.7–5 mcg/kg/min). Titrate by 0.05–0.1 mg/kg/hr q15–30 min.
• Sickle cell VOC pain: same sub-dissociative dosing; avoid large/rapid boluses if BP/HR sensitive.
• Procedural sedation: 0.5–1 mg/kg IV over 1–2 min, then 0.25–0.5 mg/kg IV q5–10 min PRN. IM 3–5 mg/kg if no IV.
• RSI/induction: 1–2 mg/kg IV once (lower end if shocked/on pressors).
• ICU maintenance sedation: 0.3–1 mg/kg/hr; short-term up to 2 mg/kg/hr with close monitoring.
• Status asthmaticus: 0.5–1 mg/kg IV once, then 0.5–1 mg/kg/hr.
• Refractory status epilepticus: load 1–2 mg/kg IV, then 1–5 mg/kg/hr (protocols up to 10 mg/kg/hr to EEG target).
• Severe agitation/excited delirium: 4–5 mg/kg IM or 1–2 mg/kg IV with airway-ready monitoring.
• Status migrainosus: 0.2–0.3 mg/kg IV once or infusion 0.1–0.3 mg/kg/hr for 3–6 hr.
• Refractory alcohol withdrawal: 0.3 mg/kg IV then 0.3–0.5 mg/kg/hr as adjunct to standard therapy.

Units crosswalk: 0.1 mg/kg/hr ≈ 1.7 mcg/kg/min. Use kg weight and round to practical infusion rates.

Practical pearls and safety

• Hemodynamics: mild–moderate ↑BP/↑HR, most after bolus; prefer slow small boluses or start a low infusion if hypertension is a concern.
• Catecholamine depletion: late sepsis/critical illness can unmask myocardial depression → BP may fall; start low and be ready to support.
• Airway/secretions: hypersalivation common → suction first; consider glycopyrrolate 0.2 mg IV PRN.
• CNS: dysphoria/emergence reactions are dose/rate-related; avoid rapid pushes; tiny GABAergic rescue if needed.
• Gut: generally motility-neutral—useful when ileus risk makes anticholinergics undesirable.
• Combinations: plays well with opioids; dexmedetomidine offsets tachy/HTN and improves sleep continuity.
• Titration: adjust q15–30 min to pain/RASS/BP/HR; continuous ECG/SpO₂; capnography preferred with opioids.
• Renal/hepatic: no renal adjustment; go slow in hepatic impairment/cirrhosis.

Contraindications and cautions

• Absolute: known ketamine or formulation allergy.
• Strong cautions: uncontrolled HTN; acute aortic dissection; active ischemia/severe CAD; tachyarrhythmias; severe pulmonary HTN; ICH/SAH where BP surges are hazardous.
• Neuropsychiatric: severe psychosis/mania—use only if benefits outweigh risks with close monitoring.
• Endocrine: pheochromocytoma or untreated thyrotoxicosis → exaggerated sympathetic response.
• Pregnancy: use only when benefits outweigh risks and after OB consult.
• Peri-MI/HOCM: avoid large boluses; prefer slow titration.

If severe hypertension, chest pain, ischemic ECG changes, or distressing dysphoria occurs, pause and treat; resume at a lower rate or consider an alternative.

Monitoring and hold parameters

• Continuous ECG and pulse oximetry; use capnography when combined with opioids.
• Check BP/HR every 5 min during bolus and every 15 min during titration.
• Hold or reduce for: new chest pain/ischemic ECG, severe uncontrolled HTN, sustained HR above target, intolerable dysphoria, or SpO₂ < 92% despite support.

Indications and Dosing Ketamine

Ketamine in the ICU – quick reference

Adult dosing, scoped for your blog’s dark theme. Aim for analgesia first, sleep with dexmedetomidine if desired, and avoid large rapid boluses when hypertension is a concern.

Indications (ICU and ED)

• Analgesia Sub-dissociative opioid-sparing pain control in trauma, burns, post-op abdominal pain, opioid tolerance or hyperalgesia, neuropathic pain.
• Sickle crisis Vaso-occlusive crisis pain when opioid-sparing is needed or allodynia limits opioid escalation.
• Procedural sedation Short painful procedures, dressing changes, reductions.
• RSI/induction Especially in hypotensive trauma or when bronchospasm is present.
• ICU sedation Analgosedation adjunct or alternative to propofol/benzodiazepines.
• Status asthmaticus Bronchodilation and improved ventilation.
• Refractory status epilepticus NMDA antagonism for seizure control.
• Severe agitation Excited delirium rescue with airway-ready monitoring.
• Status migrainosus Rescue in selected protocols.
• Alcohol withdrawal Refractory cases as adjunct to standard care.
• Psychiatry Treatment-resistant depression (protocolized settings).

Dosing cheat sheet

• Analgesia (sub-dissociative): bolus 0.1 to 0.3 mg/kg IV given slowly; infusion 0.1 to 0.3 mg/kg/hr (about 1.7 to 5 mcg/kg/min). Titrate by 0.05 to 0.1 mg/kg/hr every 15 to 30 min.
• Sickle cell VOC pain: same sub-dissociative dosing as above; consider avoiding large boluses to limit blood pressure and heart rate rise.
• Procedural sedation: 0.5 to 1 mg/kg IV over 1 to 2 min, then 0.25 to 0.5 mg/kg IV every 5 to 10 min as needed. IM 3 to 5 mg/kg when no IV.
• RSI/induction: 1 to 2 mg/kg IV once (use lower end if in shock or on vasopressors).
• ICU maintenance sedation: 0.3 to 1 mg/kg/hr; short-term up to 2 mg/kg/hr with EEG or close monitoring when needed.
• Status asthmaticus: 0.5 to 1 mg/kg IV once, then 0.5 to 1 mg/kg/hr.
• Refractory status epilepticus: load 1 to 2 mg/kg IV, then 1 to 5 mg/kg/hr (some protocols allow up to 10 mg/kg/hr) to EEG target.
• Severe agitation/excited delirium: 4 to 5 mg/kg IM or 1 to 2 mg/kg IV with airway-ready monitoring.
• Status migrainosus: 0.2 to 0.3 mg/kg IV once or infusion 0.1 to 0.3 mg/kg/hr for 3 to 6 hr.
• Refractory alcohol withdrawal: 0.3 mg/kg IV then 0.3 to 0.5 mg/kg/hr as adjunct to standard therapy.

Units crosswalk: 0.1 mg/kg/hr equals about 1.7 mcg/kg/min. Use weight in kilograms and round to practical infusion rates.

Practical pearls and safety

• Hemodynamics: expect mild to moderate rise in blood pressure and heart rate, most noticeable after bolus. Prefer slow small boluses or start a low infusion if hypertension is a concern.
• Catecholamine depletion: in late sepsis or prolonged critical illness, direct myocardial depression can dominate and blood pressure may fall. Start low and be ready to support.
• Airway and secretions: hypersalivation is common. Glycopyrrolate 0.2 mg IV can be used if needed. Laryngospasm is rare and usually linked to large rapid pushes.
• CNS effects: dysphoria or emergence reactions are dose and rate related. Reduce risk by avoiding rapid pushes; a small dose of a GABAergic agent can help if required.
• Gut: generally neutral for motility and a useful adjunct when ileus risk makes anticholinergic sedatives undesirable.
• Combinations: pairs well with opioids for analgesia. Dexmedetomidine can offset tachycardia and hypertension and improve sleep continuity.
• Titration: adjust every 15 to 30 min based on pain scores, RASS, blood pressure, and heart rate. Use continuous cardiac and pulse oximetry monitoring. Capnography is preferred when also using opioids.
• Renal and hepatic: no renal adjustment; in hepatic impairment or cirrhosis use lower doses and slower titration.

Contraindications and cautions

• Absolute: known ketamine or formulation allergy.
• Strong cautions: uncontrolled hypertension; acute aortic dissection; severe coronary disease with active ischemia; tachyarrhythmias; severe pulmonary hypertension; intracranial hemorrhage or subarachnoid hemorrhage where blood pressure surges are hazardous.
• Neuropsychiatric: history of severe psychosis or mania may worsen; use only if benefits outweigh risks with close monitoring.
• Endocrine: pheochromocytoma or untreated thyrotoxicosis can have exaggerated sympathetic responses.
• Pregnancy: use only when benefits outweigh risks and after obstetric consultation.
• Peri-MI and HOCM: avoid large boluses; prefer slow titration to limit demand ischemia or dynamic obstruction.

If severe hypertension, chest pain, ischemic ECG changes, or distressing dysphoria occurs, pause titration and treat the cause. Resume at a lower rate or consider an alternative.

Monitoring and hold parameters

• Continuous ECG and pulse oximetry. Use capnography when combined with opioids.
• Blood pressure and heart rate at least every 5 min during bolus and every 15 min during titration.
• Hold or reduce for: new chest pain or ischemic ECG changes; severe uncontrolled hypertension; sustained heart rate above target; intolerable dysphoria; oxygen saturation under 92 percent despite support.