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:

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INTERMACS classification of indications for mechanical assist devices

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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? 馃槈

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ESC/ – evidence now low

Tandem heart pVAFD

Not available in Europe – only US

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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聽– IABP v Impella —->聽No difference in mortality

HeartMate PHP

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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

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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?

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 —->聽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

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3. Post-cardiac arrest

Post-resuscitation syndrome

Conflicting data on E-CPR —> benefit or聽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?

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Review from 2013 in NEJM on resuscitation fluids —> here

So which fluid and what is the price to pay in terms of “health”?

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Low pressure

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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

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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聽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

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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

“Wearables”

 

Take home messages:

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