Definition of Shock: Is More Clarity Needed? Introducing the SCAI - PowerPoint PPT Presentation

Definition of Shock: Is More Clarity Needed? Introducing the SCAI SHOCK Classification Srihari hari S. Naid idu, u, MD, FACC CC, , FAHA HA, , FSCAI CAI Direc ector or, , Cardiac diac Catheteri erization tion Laborat orator ory Direc ector or, , Hyper ertr trop ophic hic Cardiom diomyop opat athy y Center er of Excellen llence Westchest ster Medical l Center, , Valhalla, lla, New York rk Profes essor sor of Medicin ine, e, New York k Medical al College lege On Behal alf f of the SCAI AI SHOCK CK Clinica ical Exper ert t Consensus nsensus Docume ument nt Writing ing Group

Disclosures: ▪ I have nothing to disclose.

Intersection of Key Considerations in the Diagnosis and Management of CS It all starts ts here Where e is the What t are our problem? em? Is this s actual tually CS suppo port t optio ions? ns? (Rate-lim imit iting ng step and how bad is (press ssor ors, MCS) in normalizati ization on bad? of CO/CI /CI)

Is This CS and How Bad is Bad?

Simple/Traditional Definition of CS Persistent SBP < 90 mm Hg not responsive to fluid administration alone Secondary to cardiac dysfunction Associated with signs of hypoperfusion or a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg

Problem with “One Size Fits All” IABP P SHOCK HOCK II Trial ial SBP < 90 for 30 mins Pressor sors to SBP > 90 Pulm Conges estion tion Signs s of Hypoper erfusi fusion on (Lacta ctate e > 2, Alt MS or Ur Urine Output put < 30 /hour) IMPRESS RESS Trial ial SBP < 90 for 30 mins Pressor sors to SBP > 90 All pts intubat ubated ed 90% cardia iac c arr rrest st 20 minut utes es to ROSC 70 70-80% % hypoth other ermia mia Signs s of Hypoper erfusi fusion on (Lacta ctate e > 7-8, ph ph 7.1-7.2)

An Updated Lexicon: SCAI SHOCK Stages • SCAI Clin inic ical Expe pert t Consen ensus us Stateme ement t on Def efin inin ing g the e Spe pectrum trum of Car ardi dioge genic ic Shock ck ✓ Simulta ultaneous neous Publication cation at SCAI I 2019 9 Meeti eting ✓ Endorsed ed by AHA, , ACC, STS and SCCM Inter erv Heart Critica ical C / Emerg Critica ical Care Cardi diac ac Cardi diol ology ogy Failure ure / Tx Tx Cardi diol ology ogy Medici edicine ne Nursin ing Surgery Naidu S Baran D Hollenb nberg erg S Ornato J Stellin ing K Pa Pagani ni F* F* O’Neill W Ha Hall S Van Diepen en S Grines es C Ka Kapur N Burkhof hoff D Henry T Bailey S Thiele e H

Goals of a New SHOCK Definition 1. 1. Simpl ple and intuitiv uitive witho thout ut the need for calcul ulation ation 2. 2. Adds s needed granula nularit rity y in the severity ty of shock 3. 3. Suitab table e for rapid id assessme sment nt at the bedside de 4. 4. Allows s for frequent ent reassessme sment nt and reclassif sificatio ication 5. 5. Can be a appl plied ied to retr etrospe pecti tive datasets asets or p prior or trial als s to re- examine mine outcomes, mes, and future ure tri rial als to b bett etter r define ne the included uded populati ation 6. 6. Provide ide new lexicon on for communic unicatio ation n betwee etween n provider iders, s, includi uding ng facil ilitating itating multidis idisciplinar ciplinary y communi unication ation within hin a hospital ital and betwee etween n hospital itals s (hub and spoke model) 7. 7. Prognos ostic tic discrimi riminat nator ory y pot otent ntial ial for morbidit dity and mortal ality ity 8. 8. Easy to remember nomencl clature ature (model INTERMACS) CS)

Risk Modifier for Cardiac Arrest • Any cardi diac c arres est t however er brie ief (Def efib ib or CPR) ✓ SCAI I SHOC OCK K B(A) ) = A patient tient with h relativ ive hypot potens ension ion or tachycar cardia dia without hout hypo pope perfusio fusion who suffers s a witnes nessed d VF success ssful fully ly defibril rillat lated ed and remains ins without hout signs s of hypo pope perfus fusion ion ✓ If signs s of hypo pope perfusio fusion develop p after the arrest, t, this s patie ient nt wou would d be SCAI I SHOC OCK C(A), , and in need of initia tial efforts ts to improve perfusio usion; n; if those efforts ts do not ot work work, , the patie ient nt is now SCAI I SHOC OCK K D(A)

Courtesy Tim Henry, MD

Where do we go from here? 1. 1. Pres esen ent, t, pu publis ish h and d spr prea ead d the e word d to the e wid ider er car ardi diovascular ascular an and c d crit itical ical car are e communi mmuniti ties es 2. 2. Valid idate e the c e class ssif ific ication ation by evaluati ting g it its pr progn gnostic ostic po power er and d ea ease-of of-use use in in da databases es 3. 3. Driv ive e ea earlie ier rec ecog ogni nition ion of shock ock an and d the e more e pr prec ecis ise e stage ge, to gu guid ide app e appropr pria iate e and t d tim imel ely y es escalation ation of care e in includi ding g transfer er to cen enter ers s more re fully ly equi equipp pped ed 4. 4. Ut Util iliz ize e the e stag ages es to bett etter er de defin ine e pr prospe pecti ctivel ely y the e value e of MCS/ECMO MO and d other er ther erapi pies es

THAN ANK YOU! • SCAI AI leade dersh ship p including ding pub ublica cati tion on comm mmitt ttee ee • SCAI AI pub ublic icat ation ion and mark rketi ting ng staff • Collea leagues es on the e writi ting ng group, up, espec pecially ially co co-Cha Chair r David d Baran an, , Cindy dy Grines nes and Tim Henr nry • En Endor dorsing ing soci cieti ties es (AH AHA, , ACC, , STS and SCCM) M) • Wider der cardio iovascular scular community mmunity