Alain Cariou, Cardiogenic shock. Which Monitoring?
Recommendations for management of adult patients with cardiogenic shock
- An arterial catheter should be placed to monitor blood pressure (strong agreement).
- Plasma lactate should be assayed repeatedly (in the absence of epinephrine therapy) to assess the persistence or correction of shock during treatment (strong agreement).
- A CVC should be placed in the SVC for intermittent or continuous measurement of ScvO2
- CVP should not be measured as a weak marker of preload and preload dependency
- In refractory shock CO and ScvO2 should be measured continuously
- Routine echocardiography (transthoracic and/or transesophageal) should be used to identify the cause of (cardiogenic) shock, for later hemodynamic evaluations, and for the detection and treatment of complications (tamponade) (strong agreement).
Use of 72hr TOE probe continuous echo possibly will change continuous cardiac output monitoring. This could be the future
Levy et al. Annals of Intensive Care (2015) 5:17
Intensive Care Med. 2013 Apr;39(4):629-35
Which biomarkers? Alexandre Mebazaa
Lactate not a prognosticator at 24hrs. Good before than. Need other biomarkers.
Adrenomedulline showed good prognostic predcition
75%of pts at 24hrs have a normal lactate in acute cardiogenic shock
Vasopressor therapy: Norad or adrenaline? Levy Bruno
Understand the pharmacology of catecholamines they can be responsible for
- Excessive increase in afterload
- Excessive tachycardia
- Cellular increase in calcium
Norepinephrine should be used to restore perfusion in cardiogenic shock (
Adrenaline can be used instead of dobutmaine and noradrenaline but is associated with a greater risk of arrhythmias, tachycardia and high lactate.
Dobutamine should be used to treat low cardiac output in cardiogenic shock.
PDE inhibitors and levosimendan should not be first line agents.
Levy et al. Annals of Intensive Care (2015) 5:17
Optima CCstudy: RCT adrenaline vs norad in acute cardiogenic shock in AMI. Ends Decmeebr 2015.
Inotropic therapy: Dobutamine and Inodilators S Hollenberg
Negative cycle of cardiogenic shock
Adrenaline worse than norad/dobutmiane (LEVY 2011 Crit Care Med. 2011 Mar;39(3):450-5.)
We need adequate perfusion pressure but not too much
Preference for inodilators over vasopressors makes sense
We must assess perfusion to assess response of therpay
No evidence to show one inotropic regimen better than other
There are some novel inotropes starting to be researched which may offer new avenues for treatment:
- Omecantiv mecarbil
- Energetic modultaors
In essence which inotrope?
“Probably doesn’t matter until it does”.
- Were are you going
- How are you going to measure it
- Watch for complications
Fluid administration in Sepsis: Gernot Marx
Is hypervolaemia bad in sepsis?
SOAP study showed this and also studies in acute lung injury patients.
Less fluid in the recent EGDT compared to RIVERS NEJM paper with better outcomes.
However, there is evidence that early appropriate fluid is beneficial with improved oxygen delivery and cardiac output. The question is how early?
When one looks at studies and in particular at fluid balance and outcomes it is important that you take note of when the patients were enrolled to the study
Early fluid may be useful 0-3 hrs, Aggressive in the initial hours (0-6hrs) then be cautious and restrictive from 12hrs out.
It is important to work out where is the patient on the pathophysiological journey. Be context and time adapted.
High Dose Catecholamines in Sepsis: Claude Martin
Should we target a high blood pressure?
The Asfar study showed no mortality improvement. (N Engl J Med 2014; 370:1583-1593.)
Sub group analysis did show a reduction in RRT in the higher group though. Higher pressures do lead to higher perfusion rate of the microvasculature.
Are we using higher doses because the “drugs don’t work”?
Higher doses of catecholamines are associated with increased SOFA scores and poorer outcomes.
One possible option is to use high dose catecholamine as a stress test and if patient does not respond then there is a poor prognosis.
In septic shock with an infusion rate of 1microgram/kg/min there is a 90% mortality.
Switch to vasopressin or terlipressin as a rescue therapy rather than an other catecholamine as the receptors are down regulated. Methylene blue is also available as a rescue therapy.
Haemodynamics: Individualised care or Guidelines. Richard Beale
Guidelines have been published by societies but there is some reticence:
- Some disagree with the guideline
- Don’t believe the evidence
- Don’t trust the process
The problem is solved now and isn’t an issue now.
Do the recent EGDT trials results mean that guidelines are not necessary now?
IMPRESS-SSC study in 2013 still showed fairly poor compliance to the sepsis care bundles.
Need to use guidelines to ensure the delivery of the basics with high reliability but need to deploy more advanced intervention when still necessary. The two are not dichotomous but need to be used in different circumstances and for different aims.