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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Elderly patient with multiple medical problems (HFpEF / A fib / HTN / PE / obesity etc) was admitted w CHF exacerbation. Improved w diuresis but developed left upper extremity edema; diagnosed with extensive DVT for which Interventional Radiology (IR) was consulted
IR found severe L subclavian stenosis at the intersection of the clavicle & 2nd rib & upstream LUE extensive DVT. Performed successful image-guided LUE DVT mechanical thrombectomy & stenotic site angioplasty with near complete resolution of clot burden & improvement of stenosis
Towards the last hour of the procedure, patient developed hypotension that did not improve with fluid boluses. Had received fentanyl & midazolam & and this was thought to play a role. Transferred to the ICU and
Assessment of the efficacy (stroke volume) and tolerance (left ventricular filling pressures) of blood volume expansion using Doppler echocardiography:
The 1st fluid challenge resulted in a large ⬆️ in LV stroke volume (38 to 65 mL), whereas the 2nd was unsuccessful (65 to 69 mL). The mitral Doppler profile progressed from “abnormal relaxation” to “restriction to filling” consistent with a gradual ⬆️ in left cardiac pressures
From:
Philippe Vignon and Michel Slama in:
"Hemodynamic Monitoring Using Echocardiography in the Critically Ill"; DOI 10.1007/978-3-540-87956-5
There is not such a thing as a “normal” cardiac output (CO). A CO of 3.5 l/min may be adequate for a 90 years’ old, 100 pounds sedated patient but inadequate for a 40 years’ old, 250 pounds patient with septic ARDS. Ideally,
any CO value should be accompanied by an assessment of the adequacy of perfusion (clinical: mental status, urine output etc or laboratory: central venous O2 saturation, lactate etc)
Many times, we don’t time/energy/means to measure CO, and we employ workarounds to convince ourselves that CO is adequate even when we don’t know what its actual value is. One of them is ScvO2, the O2 saturation in a venous blood sample drawn from a catheter in the SVC;
This is a recently published, information-dense document. It may be a bit technical for the average POCUS user but if you manage patients who harbor a right heart, consider reading it:
It is a 40+ pages' document, so I will just highlight some of the most useful points:
Approach to acquisition of the RA- & RV-focused views:
To obtain the RV-focused apical 4Ch view, place the transducer @ the apex, & rotate until the maximal RV chamber dimension is obtained. Often, the transducer must be positioned more laterally & tilted upward toward the RV