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? 😉


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 – 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



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?

C: Fulminant myocarditis?

Most surviving without need for complex heart surgery/transplant

D: After cardiac surgery?

Old data but benefit —->

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 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 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


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: