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

1. Cost – 10-15K euros for few days use
2. 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:

Vasopressors (A Gordon)

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Authors Authors and affiliations

Comparison of Dopamine and Norepinephrine in the Treatment of Shock

Vasopressors for hypotensive shock (Cochrane review)

Catecholamines for shock – equally good or equally bad? – Singer

Issue with adrenaline is that lactate becomes hard to use as a target for therapy.

Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock

Vasopressin in shock – vasoconstrictor, V1 receptor on vascular smooth muscle, binds to V2 and oxytocin receptor. Septic shock – relative vasopressin deficiency

The VANISH Randomized Clinical Trial

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial

Future trials on – angiotensin II, selepressin

Gordon – 1st line = noradrenaline. Will escalate to vasopressin (up to 0.06U/min). No dopamine.

Inotropes (A Mebazaa)

Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance

• the guidance advocates the use of lung ultrasound in the acute phase to help guide therapy

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

The Effectiveness of Inodilators in Reducing Short Term Mortality among Patient with Severe Cardiogenic Shock: A Propensity-Based Analysis

• The initial use of inopressors alone appears to be associated with a poorer prognosis compared to a regimen of inopressors and inodilators in patients who are admitted for cardiogenic shock.

Pulmonary hypertension management (S Orfanos)

PULMONARY HYPERTENSION (GUIDELINES ON DIAGNOSIS AND TREATMENT OF)

Comprehensive Invasive and Noninvasive Approach to the Right Ventricle–Pulmonary Circulation Unit

Prognostic factors and outcomes of patients with pulmonary hypertension admitted to the intensive care unit

Prostacyclin can reduce PVR and improve RV function but caution in LV failure. It can exacerbate V/Q mismatch leading to worsening gas exchange and hypoxaemia

Inhaled NO potent pulmonary vasodilator

Is there a safe plateau pressure in ARDS? The right heart only knows.

Echocardiography (D Matamis)

Echo is not a haemodynamic monitoring tool – controversial. The speaker does feel that it is an excellent diagnostic tool.

Cases of pts with COPD and HCM with failure to wean from mechanical ventilator discussed. The managements were progressed using echocardiography.

Targeting occult heart failure in intensive care unit patients with acute chronic obstructive pulmonary disease exacerbation: Effect on outcome and quality of life

Takotsubo Cardiomyopathy

With the PAC (A Armaganidis)

The Pulmonary Artery Catheter A Critical Reappraisal

Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial.

Pulmonary artery catheters for adult patients in intensive care

Volume status and fluid responsiveness (S Myatra)

Dynamic measures to guide fluid therapy

Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients.

How to do a tidal volume challenge (video from Prof Sheila Myatra) #athens17 pic.twitter.com/WFhHa9rMom

— Matt Rowland (@matthewjrowland) June 16, 2017

Volumetric variables including extravascular lung water (JL Teboul)

Comparison of values in critically ill patients for global end-diastolic volume and extravascular lung water measured by transcardiopulmonary thermodilution: a meta-analysis of the literature.

GEDV could overestimate LV preload in case of dilated RV

Extravascular lung water in critical care: recent advances and clinical applications

Less invasive hemodynamic monitoring in critically ill patients

First session this morning. Talks focusing on SvO2, ScvO2, PCO2 gap, lacate and measurement/assessment of peripheral perfusion

Again a fair amount of focus on the microcirculation…..

Massimo Antonelli – SvO2/ScvO2, PCO2 gap

• SvO2 = VO2 from the whole body, ScvO2 = VO2 from mostly brain and upper arms
• Absolute values are not interchangeable but trends over time are the same
• Sedation may influence both measurements
• Septic patients may have abnormally high measurements

1. CO is not sufficient under conditions of suspected tissue hypoxia
2. Microcirculatory flow is not high enough or adequately distributed to clear the CO2 excess even in the presence of a normal CO

“PCO2 gap should be considered as a marker of the ability of an adequate venous blood flow to remove the CO2 excess rather than as a marker of tissue hypoxia”

Mallet et al. Minerva Anesth 2015

1. DO2 is important when O2 consumption is dependent on it
2. Very low SvO2/ScvO2 are markers of tissue hypoxia and should be corrected
3. Sepsis alters normal DO2/VO2 relationship such that ScvO2 may not always be a good marker of tissue hypoxia
4. CO2 gap may unmask those patients who are going to develop tissue hypoxia and should be considered a marker of low flow state

Interesting question from the floor:

Q: Should we be worried about patients post-CABG with low SvO2 (e.g. PAC-measured)?

A: Low SvO2 not always a marker patient is unwell e.g. when exercising, SvO2 can drop to 25%. So need to assess on case-by-case basis

Andrew Rhodes – Lactate as a marker of perfusion

Sepsis remains a huge problem – recent paper this year: bit.ly/sepsisjama

 Surviving Sepsis Campaign (SSC) targets:

• CVP
• MAP
• UO
• ScvO2

1. Lactate remains the best biomarker for risk assessment
2. Low lactate clearance is a good predictor of mortality
3. At the present time, lactate clearance alone has not been proven to be an adequate end point for resuscitation
4. Further trials are needed to demonstrate the efficacy of lactate clearance as a primary endpoint in the resuscitation of severe sepsis or septic shock

Jacques Duranteau – Peripheral perfusion

Again – emphasis on the importance of the microcirculation

Need real-time measurement of peripheral perfusion

Mottling score predicts survival in septic shock —-> https://t.co/4rWohL2jPn