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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_

Apr 10
Refresher on Swan-Ganz catheter: Image
Comparison of pulmonary artery catheterisation with different cardiac output monitoring devices: Image
Anatomy and description of a pulmonary artery catheter: Image
Read 10 tweets
Apr 6
ICU Hemodynamics:

If you are managing patients with #vasoplegicshock, this is a nice review article: Image
Vasoplegic shock (VS) is common, contributing up to two-thirds of cases of shock admitted to the ICU

The two most common VS causes: septic shock & vasoplegic shock after cardiopulmonary bypass

There is NO consensus definition of vasoplegic shock
If you like the pathophysiology "stuff": Image
Image
Read 7 tweets
Mar 22
ICU Stories:

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 Image
Image
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
Read 26 tweets
Mar 20
ICU Hemodynamics:

Assessment of the efficacy (stroke volume) and tolerance (left ventricular filling pressures) of blood volume expansion using Doppler echocardiography: Image
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
Read 4 tweets
Mar 16
ICU Hemodynamic Secrets – The role of ScvO2:

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;
Read 18 tweets
Mar 16
ICU #POCUS:

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: Image
It is a 40+ pages' document, so I will just highlight some of the most useful points: Image
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 Image
Read 34 tweets

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