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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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
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
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
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)?
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)
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
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?
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
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:
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