Randomised clinical trials in cardiogenic shock in the PCI era
Treatment considerations for patients with AMI-cardiogenic shock
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65)
Determination of the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage using the revised SCAI Shock Classification
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
Management algorithm for patients with or at risk for cardiogenic shock (CS) tailored to the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage
Framework of clinical parameters to follow in patients with heart failure-related cardiogenic shock in the critical care unit
Considerations for invasive hemodynamic assessment in HF-CS
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:
Proposed overview of selection of patients to pVAD based on SCAI shock class A-E
Flowchart to identify and handle potential need for escalation of mechanical circulatory support in patients supported by axial flow pump (AFP)
Flowchart to identify and handle potential need for venting during V-A ECMO support
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You can call me lazy but if a patient is admitted to the ICU with pneumonia (& this CXR), is diaphoretic, breathing 50/min, has HR 150/min & O2 Sat 88% on "FiO2 100%", I don't calculate the ROX index or the HACOR score. I just intubate...
The ROX (Respiratory rate-OXygenation) index was introduced in 2016 as a prediction tool to identify the need for IMV in pneumonia patients w AHRF treated wHFNC. It's calculated as [(SpO2/FiO2)/Respiratory Rate] & is typically assessed at 2, 6, & 12 hours after HFNC initiation
The HACOR (Heart rate, Acidosis, Consciousness, Oxygenation, & Respiratory rate) score is a tool for predicting NIV failure in pts with AHRF. It demonstrates good predictive power for NIV failure, w higher scores (>5) having a strong diagnostic accuracy in predicting NIV failure
Dexmedetomidine (D) (Precedex in 🇺🇸) is one of my favorite ICU drugs. It is a highly selective α-2 adrenoreceptor agonist, w sedative/analgesic/ anxiolytic properties & minimal resp depression. Its main side effects are hypotension & bradycardia
Herein I chose 10 less known D's effects/associations with:
1. Hypertension (the opposite from what you would expect): likely due to initial stimulation of peripheral a-1 or a-2b receptors. It is usually transient, mild, & does not require treatment. However, I have seen severe
D withdrawal after abrupt stop of prolonged infusion presenting w severe hypertension (plus tachycardia / diaphoresis / agitation). It went unrecognized for a while & was attributed to "prolonged alcohol withdrawal"
We divide patients with circulatory shock into 3 primary hemodynamic phenotypes, namely hypovolemic, vasodilatory/distributive, & cardiogenic (including obstructive)
But we all witness/manage "mixed" shock, an entity lacking a uniform, evidence-based definition
By analogy to the cardiorenal syndromes, Jentzer et al categorize mixed shock into 3 principal groups, each defined by the sequence & nature of the insult (ie, primary vs secondary hemodynamic process): cardiogenic-vasodilatory, vasodilatory-cardiogenic, & primary mixed shock:
The conceptual model of mixed shock etiology & pathogenesis describes "two-hit" & "single insult" scenarios:
We are all familiar w the concept of "protective ventilation": aiming for normal blood gases entails significant risk
What if we apply the same idea in hemodynamics & try to limit the damage associated w excessive vasoconstriction?
The CLEAR approach is not intended to be a series of
sequential steps but rather key elements that should be addressed simultaneously, depending on the clinical context and patient’s needs
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):
The figure speaks for itself, but we have to highlight a few points made throughout the paper...
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