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Jun 19, 2023 14 tweets 5 min read Read on X
Randomised clinical trials in cardiogenic shock in the PCI era Image
Treatment considerations for patients with AMI-cardiogenic shock Image
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65) ImageImage
Determination of the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage using the revised SCAI Shock Classification Image
Conceptual model showing the overlap between
different states of hemodynamic compromise. Shock is defined by presence of hypoperfusion; most, but NOT ALL, patients will also be hypotensive. Pts w hemodynamic instability who do not meet criteria for shock are labeled as pre-shock Image
Management algorithm for patients with or at risk for cardiogenic shock (CS) tailored to the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage Image
Framework of clinical parameters to follow in patients with heart failure-related cardiogenic shock in the critical care unit Image
Considerations for invasive hemodynamic assessment in HF-CS Image
Classification and management of HF-CS Image
It seems that the most controversial issue is the use of short-term mechanical circulatory support for cardiogenic shock. So, a very recent publication deals with this: Image
Proposed overview of selection of patients to pVAD based on SCAI shock class A-E Image
Flowchart to identify and handle potential need for escalation of mechanical circulatory support in patients supported by axial flow pump (AFP) Image
Flowchart to identify and handle potential need for venting during V-A ECMO support Image

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More from @IM_Crit_

Jan 23
ICU Hemodynamics:

In this recently published article, the authors propose a classification of different cardiovascular phenotypes potentially observed in septic shock into 3 profiles of LV-centric dysfunction, promptly recognizable by critical care echocardiography (CCE): Image
The figure speaks for itself, but we have to highlight a few points made throughout the paper... Image
1. Cardiovascular profiles are dynamic; patients may move from one to another according to fluid administration, correction of LV afterload & evolution of the disease. Therefore, CCE has to be repeated to personalize therapy
Read 11 tweets
Jan 23
ICU Circulation Secrets:

The phenomenon of "hemodynamic incoherence" is observed when microcirculatory dysfunction persists despite the restoration of macro-circulatory indices

In this case, MAP was 88 mmHg & cardiac index was 2.8 l/min/m2 on a small dose of norepinephrine Image
Despite the apparent normalization of systemic & regional blood flow, sublingual video-microscopy revealed persistent tissue hypoperfusion:
The latest generation of handheld vital microscopes,
uses incident dark field (IDF) illumination & has advanced the field w higher-resolution optics & autofocusing capabilities (3-fold increase in the field of view), allowing more comprehensive microcirculatory assessments
Read 6 tweets
Dec 22, 2024
ICU Snapshots - Ventilator waveforms (from a patient I just saw):

Patient on "volume control" (or: VC-CMVs). Please notice the significant change in the pressure waveforms while the flow waveforms remain "mostly" unchanged

What happened?
What happened between breath (A) and breath (D)? Image
In breath (A), there is severe work shifting (what we called "flow starvation" or "flow asynchrony" or "air hunger") with the pressure falling below the set PEEP level & the pressure waveform being deformed due to the presence of Pmus (patient's effort)
Read 6 tweets
Dec 15, 2024
ICU - Non-Invasive Ventilation (NIV) Secrets:

Did you ever admit to the ICU a patient with COPD exacerbation who came from the ED on NIV? Or who went home on NIV? If you are a pulmonologist, you will not learn anything from this post but the rest of us Image
from different specialties (I am Internal Medicine) should remember that NIV settings are not just inspiratory/expiratory pressure (IPAP/EPAP) and FiO2

We have to admit that not every COPD patient will do well with “10 over 5” *. So what else should we pay attention to? Image
Trigger: beginning of inspiratory support and switch from EPAP to IPAP

Rise time: the time to get from EPAP to IPAP (aka pressurization time)

Inspiratory time: duration of inspiratory support

Cycle: end of inspiratory support and return from IPAP to EPAP Image
Read 14 tweets
Dec 13, 2024
Excerpts from:

Echocardiographic Evaluation of a Patient in Circulatory Shock: A Contemporary Approach

Shock parameters: Image
Evaluation of pericardial effusion and signs of cardiac tamponade: Image
Image
How to measure hemodynamic parameters with the echocardiogram: Image
Read 6 tweets
Dec 10, 2024
ICU Physiology Secrets - Return to Basics Edition:

If you are placing Swan-Ganz (SG) catheters or you like reading/interpreting their waveforms, this is for you:

You walk in a patient’s room exactly when your fellow intensivist tries to “wedge” a newly placed SG catheter: Image
At which point - approximately – do you think that the pulmonary capillary pressure (Pcap) should be measured?

1. Please assume that the recording is taken during an expiratory hold while on mechanical ventilation
2. Please feel free to choose any point other than these choices
Why do we care about pulmonary capillary pressure? Because it is a primary determinant of fluid flux across the pulmonary capillary wall (normal: 8-10 mmHg). It is determined by the mean pulmonary artery pressure, pulmonary vascular resistance, and total blood flow
Read 9 tweets

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