ESICM Regional Conference Athens 2017: Management of Shock – Others

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? 馃槈


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)


  1. Cost – 10-15K euros for few days use
  2. Concerns about haemolysis

Recent study聽– IABP v Impella —->聽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



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聽—->聽ST-elevation with profound cardiogenic shock

Close to 50% survival and聽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 —->聽

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

Post-resuscitation syndrome

Conflicting data on E-CPR —> benefit or聽no benefit

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”?


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





Individualising haemodynamic targets – Bernd Saugel

Precision medicine popular term – as is personalised medicine



Personalised medicine聽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 聽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



Take home messages: