IMCrit Profile picture
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_

Jun 20
ICU scenarios (and pet peeves):

- Hey doc, this patient with ileus in bed 6 has a blood pressure of 186/68. What do you want me to give?
- Any worrisome symptoms with this BP?
- No, I am just worried she will stroke out
- Don't give anything
- No hydralazine then?
- No, please
This is one of the most common management discussions/topics in the wards or in the ICU. This study tried to shed some light: Image
It was a retrospective cohort study in the VA system: Image
Read 8 tweets
Jun 18
ICU Hemodynamics Secrets:

Actually, these are not secrets at all; they reflect common, basic knowledge. But the word “secrets” is more clickbait-y!

Here it begins:

1. You don’t have to check for fluid responsiveness (FR) if the patient is bleeding to death…
2. Preload challenges (eg, end-expiratory occlusion test or tidal volume challenge) are preferable to fluid challenges
3. ~50% of pts do not respond to a fluid challenge (response defined as increase in cardiac output by >10%)

4. Even if the cardiac output ⬆️, this does not guarantee improvement in tissue oxygenation. In fact, only ~50% of those with CO ⬆️ will also show an ⬆️ in O2 consumption
Read 10 tweets
Jun 12
Noninvasive ventilation (NIV) has been standard of care treatment for acute exacerbation of COPD (AECOPD) for > 30 years. In this article, the authors describe an evidence-based algorithm of the initiation, titration, monitoring, and weaning of NIV in AECOPD
NIV initiation: Image
NIV tritration: Image
Read 12 tweets
Jun 10
An interesting study was recently published in @yourICM and the authors made some sensible - IMHO - suggestions about how to use echocardiography to guide fluid management in critically ill patients

They recognized 3 scenarios where echo can predict fluid responsiveness (FR):
1. Do NOT fill

2. Fill

3. Optional fill

I tried to tabulate their scenarios and recommendations/limitations extracting only information from their paper and not adding any thoughts of mine

Here is begins:
1. Do NOT fill when echo shows: Image
Read 13 tweets
Jun 7
ICU ID Secrets (following up on my post* from last week):

Ten things to remember about methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nasal swabs:
1. The MRSA nasal PCR is mostly helpful in patients with pneumonia or at least high suspicion of it since nasal colonization correlates with MRSA presence in the rest of the respiratory tract
2. The MRSA nasal PCR is mostly useful for its high negative predictive value (NPV) for MRSA pneumonia. The NPV number to remember is 95%. The use of MRSA PCR screening in pneumonia can reduce length of stay and antibiotic costs
Read 20 tweets
Jun 3
ICU Snaphots:

Following on my post on underdamping from a couple of days ago: there is a misconception that underdamping is seen only in arterial lines

This 👇 was seen in a central venous catheter today:
This is what I saw when I did the flush (square wave) test: Image
After the flush test, the oscillating wave should fade in 1-2 waveforms. If it takes > 2 = underdamped. If it takes 0-1 = overdamped

No easy way to fix it but sometimes it helps if u add air (not a good idea) or blood in the line. I pulled some blood back from the CVP lumen: Image
Read 6 tweets

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