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
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)
- Cost – 10-15K euros for few days use
- Concerns about haemolysis
Recent study – IABP v Impella —-> No difference in mortality
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
Worth remembering that it’s low cost compared to Impella (but still 8-9K Euros per patient….)
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?
C: Fulminant myocarditis?
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?
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
4. Combination – ECMO + Impella
Take home messages:
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”?
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
Individualising haemodynamic targets – Bernd Saugel
Precision medicine popular term – as is personalised medicine
Personalised medicine approach can be applied to haemodynamic management of ICU patients
Does personalising BP in the operating room improve outcomes?
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
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
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
Take home messages: