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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_

Feb 28
ICU Mechanical Ventilation Secrets:

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... Image
Image
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 Image
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 Image
Read 5 tweets
Feb 15
ICU Pharmacology Secrets:

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 Image
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"
Read 17 tweets
Feb 12
ICU Pulmonary Embolism Review:

Kudos to the authors for reviewing PE management strategies: Image
An abbreviated spiral of death: Image
And the goals of interventions: Image
Read 16 tweets
Feb 9
ICU Hemodynamics

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 Image
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: Image
The conceptual model of mixed shock etiology & pathogenesis describes "two-hit" & "single insult" scenarios: Image
Read 7 tweets
Feb 8
ICU Hemodynamics

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?

Welcome to the CLEAR strategy Image
The C.L.E.A.R. strategy tries to:

Customize targets
Limit catecholamines
Enhance flow
Adjust fluid balance
Resolve underlying conditions Image
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
Read 5 tweets
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

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