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

• r,

, Cardiac diac Catheteri erization tion Laborat

• rator
• ry

Direc ector

• r,

, Hyper ertr trop

• phic

hic Cardiom diomyop

• pat

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.

Where e is the problem? em? (Rate-lim imit iting ng step in normalizati ization

• n
• f CO/CI

/CI)

Intersection of Key Considerations in the Diagnosis and Management of CS

What t are our suppo port t optio ions? ns? (press ssor

• rs, MCS)

Is this s actual tually CS and how bad is bad? It all starts ts here

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

• n

(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

• ther

ermia mia Signs s of Hypoper erfusi fusion

• n

(Lacta ctate e > 7-8, ph ph 7.1-7.2)

• 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

An Updated Lexicon: SCAI SHOCK Stages

Inter erv Cardi diol

• logy
• gy

Heart Failure ure / Tx Tx Critica ical C / Cardi diol

• logy
• gy

Emerg Medici edicine ne Critica ical Care Nursin ing Cardi diac ac 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

• r 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

• n 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

• stic

tic discrimi riminat nator

• ry

y pot

• tent

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

• t 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

• stic po

power er and d ea ease-of

• f-use

use in in da databases es 3.

• 3. Driv

ive e ea earlie ier rec ecog

• gni

nition ion of shock

• ck 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

• n

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