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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- 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:
It was a retrospective cohort study in the VA system:
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
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
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
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