Cardiogenic Shock Algorithm and Case Presentation SCAI SHOCK - 2018 Jaya Mallidi, MD, MHS, FACC, FSCAI Interventional Cardiologist, St Joseph Memorial Hospital & Sutter Regional Hospital, Santa Rosa, CA
Disclosures • No disclosures
Statistics – April 2017 to March 2018 Total Population Served: 655,202 Total Percutaneous Coronary Interventions: 610 Total STEMIs: 181 Cardiogenic Shock at start of PCI: 11
Case Presentation • Mr. S is a 63 year old gentleman, no known prior history, presented with outside hospital Cardiac arrest. • V – fib arrest while driving his car. EMS – Vfib, shocks X 3 in the field. EKG after ROSC – Inferior ST segment elevation. Total Code time on field – 15 minutes
Emergency Room • Patient was tachycardic (110 beats / minute) and hypotensive (SBP - 60 mm Hg). He was unresponsive to verbal and painful stimulus • Early Identification of SHOCK • CATH LAB / SHOCK TEAM activated • Phenylephrine and dopamine IV given to improve blood prior to intubation • Targeted temperature protocol management initiated • Initial Lactate level – 5 mmol / L
Cardiac Intensive Care Unit • Echocardiogram – EF 20% • Continuous hemodynamic monitoring with q 3 hrly check of Cardiac power output and Pulmonary artery pulsatality index done. • Weaned all pressors and impella taken out at 24 hours
Intensive Care Unit • Targeted Temperature Protocol followed • Good neurological recovery • No significant end organ dysfunction. • Day 5 of hospital admission – Echocardiogram – EF 45 – 50 %. Discharged home on DAPT, statins, ACE and beta blockers. Stopped smoking.
Nationwide Temporal Trends Among Patients Undergoing PCI for Cardiogenic Shock in Acute Myocardial Infarction 2005 -06 2006-08 2009-10 2011-13 (n=5658) (n=10337) (n=13562) (n=26,940) Hospital Type Private / Community 91.6 90.2 90.4 89.6 University 8.4 9.8 9.6 10.4 Fellowship 49.4 46.0 44.2 42.3 Annual Average PCI volume <500 30.7 34.6 43.7 48.1 500 – 1000 40.4 37.3 35.9 33.5 1000 – 1500 16.9 16.2 13.9 12.6 1500-2000 7.3 7.3 3.8 3.4 >2000 4.7 4.6 2.6 2.3 ALL ARE PERCENTAGE VALUES Ref: Wayangankar SA, Bangalore S, McCoy LA, Jneid H, Latif F, Karrowni W, Charitakis K, Feldman DN, Dakik HA, Mauri L, Peterson ED. Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry. JACC: Cardiovascular Interventions. 2016 Feb 22;9(4):341-51.
CARDIAC CATH LAB • Ultrasound and Fluoroscopy guided Vascular Access (Radial / Fem vs. Bilateral fem) • CHECK ABG – Adjust positive pressure / vent setting to treat acidosis • Obtain LVEDP and perform Diagnostic Angiogram Acute Coronary Syndrome Non Acute Coronary Syndrome LVEDP > 18 mm Hg LVEDP > 18 mm hg Significant MV / LM disease Right heart catheterization Favorable peripheral vascular anatomy Favorable peripheral vascular anatomy Consider MCS device before PCI MCS if CI <2.2 l/ min/sq m INTERVENE ON CULPRIT VESSEL Consider / defer non culprit vessel PCI CARDIAC INTENSIVE CARE UNIT (CICU) Right heart cath after PCI EMERGENCY DEPARTMENT • Open Communication Channel with Tertiary center • Suture MCS Device and Swan Ganz catheter appropriately in place, check for any vascular • Basics: ABCs, IV, Supplemental O2, Cardiac monitoring, 12 complications prior to transport. Lead EKG, Chest X ray, Labs • Continuous hemodynamic monitoring with every 2-4 hr • Confirm Dual Antiplatelet Agent Therapy and appropriate anticoagulation for MCS device calculation of cardiac power output (CPO) and Pulmonary • Early Identification – SHOCK CRITERIA ( Systolic blood Artery Pulsatality Index (PaPi). Evaluate for weaning / pressure < 90 mm Hg for more than 30 minutes or use of escalation of support based on hemodynamic parameters vasopressors ; clinical signs of end organ hypoperfusion – and improvement / worsening of end organ perfusion cool extremities, oliguria, lethargy; labs – lactic acidosis) parameters (urine output, lactic acidosis)* • ACTIVATE CATH LAB / SHOCK TEAM (Interventional a) CPO >0.6 and PaPi >0.9 – Wean off pressors and then cardiologist + ICU Attending) Mechanical support device PATIENT FOCUSED GOALS OF CARE b) CPO <0.6 and PaPi <0.9 consider need of right sided support • Challenging intubation because of hypotension, acidosis – TRANSFER TO TERTIARY CENTER and hypoxia. Maximize pre intubation hemodynamics. • Early Identification c) CPO <0.6 and PaPi>0.9 – inability to wean – TRANSFER TO Consider push dose pressors. Be weary of worsening TERTIARY CENTER • Appropriate selection of patients for early hemodynamics during intubation attempts invasive intervention • Comprehensive vascular assessment and monitoring for • Bedside echocardiogram – rule out mechanical • Multi- disciplinary team based approach bleeding complications. complications of MI as cause for cardiogenic shock and • REDUCE 3 Ms - MORTALITY, MORBIDITY, large LV thrombus. • Monitor MCS device position as necessary MODS (Multi – organ Dysfunction ) • Avoid beta blockers . Tachycardia is acceptable. • Targeted temperature protocol management for patients with cardiac arrest and unknown neurological recovery • Accurate and quick neurological assessment and initiation of targeted temperature protocol management if • Comprehensive system wise assessment of problems and appropriate after ROSC in case of cardiac arrest. PALLIATIVE CARE CONSIDERATIONS outline of plan based on multi disciplinary rounds • Is palliative care an appropriate option? • Advanced dementia • Is palliative care an appropriate option? • Terminal illness with life expectancy of less than 1 year • Advanced age with poor baseline functional status with multiple co morbidities * CPO – Cardiac Power Output : MAP X CO / 451 • Patients wishes PaPi– Pulmonary Artery Pulsatality Index: s PAP – d PAP / RA • Prolonged downtime with poor neurological recovery • No myocardial recovery and not a candidate for LVAD / transplant
PATIENT FOCUSED GOALS OF CARE • Early Identification • Appropriate selection of patients for early invasive intervention • Multi- disciplinary team based approach • REDUCE 3 Ms - MORTALITY, MORBIDITY, MODS (Multi – organ Dysfunction )
EMERGENCY DEPARTMENT • Basics: ABCs, IV, Supplemental O2, Cardiac monitoring, 12 Lead EKG, Chest X ray, Labs • Early Identification – SHOCK CRITERIA ( Systolic blood pressure < 90 mm Hg for more than 30 minutes or use of vasopressors ; clinical signs of end organ hypoperfusion – cool extremities, oliguria, lethargy; labs – lactic acidosis) • ACTIVATE CATH LAB / SHOCK TEAM (Interventional cardiologist + ICU Attending) • Challenging intubation because of hypotension, acidosis and hypoxia. Maximize pre intubation hemodynamics. Consider push dose pressors. Be weary of worsening hemodynamics during intubation attempts • Bedside echocardiogram – rule out mechanical complications of MI as cause for cardiogenic shock and large LV thrombus. • Avoid beta blockers . Tachycardia is acceptable. • Accurate and quick neurological assessment and initiation of targeted temperature protocol management if appropriate after ROSC in case of cardiac arrest. • Is palliative care an appropriate option?
CARDIAC CATH LAB • Ultrasound and Fluoroscopy guided Vascular Access (Radial / Fem vs. Bilateral fem) • CHECK ABG – Adjust positive pressure / vent setting to treat acidosis • Obtain LVEDP and perform Diagnostic Angiogram Acute Coronary Syndrome Non Acute Coronary Syndrome LVEDP > 18 mm Hg LVEDP > 18 mm hg Significant MV / LM disease Right heart catheterization Favorable peripheral vascular anatomy Favorable peripheral vascular anatomy Consider MCS device before PCI MCS if CI <2.2 l/ min/sq m INTERVENE ON CULPRIT VESSEL Consider / defer non culprit vessel PCI Right heart cath after PCI • Suture MCS Device and Swan Ganz catheter appropriately in place, check for any vascular complications prior to transport. • Confirm Dual Antiplatelet Agent Therapy and appropriate anticoagulation for MCS device
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