Right then – last session on other techniques/approaches to managing shock…..
Mechanical assist devices – Alain Combes
Classical indications for mechanical assistance:
INTERMACS classification of indications for mechanical assist devices
LVADs should be for stable patients – not for acute cardiogenic shock
IABP
What about IABP? SHOCK-2 trial Lancet 2013 —> no difference between control/balloon
Indication downgraded from I —> III: no indication for routine use in cardiogenic shock
Should it now be in the “Museum of Medicine” — along with the iron lung and swan ganz? 😉
ESC/ – evidence now low
Tandem heart pVAFD
Not available in Europe – only US
Difficult transeptal cannulation – fair number of issues with this device to be fair
Impella miniature intraaortic pump
Available in Europe
Up to 4L/min (Impella 5.0)
Issues
- Cost – 10-15K euros for few days use
- Concerns about haemolysis
Recent study – IABP v Impella —-> No difference in mortality
HeartMate PHP
No data as of today for this pump
Major issues – only drain LV. Not of use in RV. New Impella for RV but cost ~20K euros
VA-ECMO
Worth remembering that it’s low cost compared to Impella (but still 8-9K Euros per patient….)
Accepted indications:
A: ST-elevation with profound cardiogenic shock?
Paper —-> ST-elevation with profound cardiogenic shock
Close to 50% survival and 68% weaning in survivors
B: End stage DCM?
https://www.ncbi.nlm.nih.gov/pubmed/28471885
C: Fulminant myocarditis?
https://www.ncbi.nlm.nih.gov/pubmed/21336134
Most surviving without need for complex heart surgery/transplant
D: After cardiac surgery?
Old data but benefit —-> https://www.ncbi.nlm.nih.gov/pubmed/20106393
E: Post cardiac transplant?
https://www.ncbi.nlm.nih.gov/pubmed/21414795
What are the trends/emerging indications?
1. Septic shock with severe LV failure
Small study (n=14) but very unwell – SOFA score 18 with LVEF 16 and mean lactate 10
2. Pulmonary embolism
3. Post-cardiac arrest
Post-resuscitation syndrome
Conflicting data on E-CPR —> benefit or no benefit
4. Combination – ECMO + Impella
Take home messages:
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Cristalloids or colloids? Balanced or not? – Luciano Gattinoni
Why do we give fluids?
Review from 2013 in NEJM on resuscitation fluids —> here
So which fluid and what is the price to pay in terms of “health”?
Low pressure
Mechanics of fluid – no difference. Volume that creates a pressure
Issue is what price we pay by giving different fluids
CHEST trial – small differences in Cr. No standard deviations. Be careful interpreting data
CONCLUSIONS:
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Individualising haemodynamic targets – Bernd Saugel
Precision medicine popular term – as is personalised medicine
e.g
http://www.nejm.org/doi/full/10.1056/NEJMp1500523#t=article
https://link.springer.com/article/10.1007/s00134-016-4471-8
https://www.ncbi.nlm.nih.gov/pubmed/26928384
Personalised medicine approach can be applied to haemodynamic management of ICU patients
https://www.ncbi.nlm.nih.gov/pubmed/28562384
Does personalising BP in the operating room improve outcomes?
https://www.ncbi.nlm.nih.gov/labs/articles/27792044/
Seems not to be important at first glance —-> MAP > 65 as food as one based on percentage reduction from baseline
But BP does not mean perfusion —-> autoregulation
https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-015-0085-5
SSC recommends target of 65 BUT state ” when a better understanding of any pts condition obtained, BP target should be individualised”
Asfar et al NEJM 2014 – here
No difference in high v low target BP
BUT —-> Patients with chronic HT in the low target group = increased RRT
What about SV/CO etc?
Pearse et al. Cardiac output guided management —> here
Maximisation of SV may not equate to optimisation
DO2 targeted?
Achievement of preoperative DO2 value associated with reduction in morbidity —> here
How to combine PERSONALISED treatment approached with PROTOCOLISED care?
What is the future?
Smaller sensors to record biosignals without heavy monitors/machines/cables
“Wearables”
Take home messages: