Cardiogenic shock PPV
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The safety of using high PEEP with cardiogenic shock patient.
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Cardiogenic shock PPV
- 1. The Use Of PEEP With Cardiogenic Shock Patients Aziza Saleh Alamri
- 2. Objectives • Introduction of Cardiogenic shock • Cardiovascular effects of PEEP • Management (VIP) • Mechanical ventilation Use of PEEP
- 3. What is Cardiogenic shock? Is a clinical condition of inadequate tissue perfusion due to cardiac dysfunction. • Myocardial infarction • End-stage cardiomyopathy • Arrhythmias • Low cardiac output
- 4. Cardiovascular effects of PEEP
- 5. People in Shock Must be treated with VIP
- 6. Ventilatory Assistance in Shock • Supplemental Oxygen • CPAP/ BiPAP • Intubation
- 7. 1. A patient came to ER having • Severe dyspnea • Hypoxemia • pH< 7.25 • Decreased LOC
- 8. ؟What is the appropriate action Oxygen NPPV Intubation
- 9. 2. A patient came to ER having • The feel of intense chest pain and tightness • Slightly increased and unlabored RR • Oxygen saturation: 93% (on room air). • Conscious and alert • Restless and anxious • Suspected MI
- 10. 1. Non-rebreather face mask (15 L/min) 2. NPPV 3. Intubation ؟What is the appropriate action
- 11. 1. Chest pain 2. Sweating 3. Fatigue 4. Dyspnea 5. Edema 6. On CxR : it revealed butterfly pulmonary opacities 3. A patient came to ER having
- 12. ؟What is the appropriate action The use of NIV for patients with ACPE is highly supported . Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.
- 13. Importance of Ventilation • To protect the airway and maintain oxygen supply in patients with a deterioration in consciousness or cardiac arrest. • To treat acute respiratory failure, most often due to cardiogenic pulmonary edema. • To raise the arterial pH in metabolic acidosis
- 14. Infusion “Fluid Resuscitation in Shock” • Initial fluid resuscitation • Risk of edema (CHF) • Is my patient's shock fluid responsive? • Determining Fluid Responsiveness in Shock Type of fluid “Crystalloid” How fast to infuse it “300-500mL over 20-30 minutes” Define a positive test: ↑arterial pressure, ↓HR, ↑ urine output Set a safety limit :↑ in CVP by 4 cm H2O “To avoid pulmonary edema”
- 15. Pump “Use of vasoactive Drugs in Shock” • Inotropes Adrenaline, Dobutamine • Vasopressors Noradrenaline, Vasopressin • Dopamine • Aspirin and Heparin • Diuretics
- 16. Use Of PEEP Don’t have an effectDo have an effect ↓ LV oxygen demand and improved oxygen delivery to the ischaemic myocardium ↓Venous return, LV filling, CO and overall organ perfusion ↓ Intracardiac lactate production ↑ RV afterload
- 17. • Improve hemodynamics, respiratory function and oxygenation in patients with acute systolic heart failure and pulmonary oedema compared with oxygen therapy alone. • lower rates of intubation
- 18. • A number of reports in patients with cardiogenic shock suggest that the hemodynamic effects of PEEP may work in favor of the patient with severe left heart failure
- 19. Management of PEEP in cardiogenic shock
- 20. CONCLUSION
- 21. References • UpToDate • http://emedicine.medscape.com/article/155 919-overview • http://www.ncbi.nlm.nih.gov/pubmed/204 39577 • http://www.ncbi.nlm.nih.gov/pubmed/235 39555
Editor's Notes
- is the irreversible necrosis of heart muscle secondary to prolonged ischemia chronic disease of the heartmuscle (myocardium), in which the muscle isabnormally enlarged, thickened, and/or stiffened+loses the ability to pumping + arrhythmias
- External pressure on the IVC (decreased venous return )+(increased right ventricular dilatation)+(decreased left ventricular filling and cardiac output)
- myocardial infarction (MI) with arterial oxygen desaturation
- 1. MI during the first six hours after presentation 2. If respiratory distress, respiratory acidosis, and/or hypoxia persist 3. If pt. deteriorates + decrease LOC or uncooperative
- all patients in shock deserve some initial fluid resuscitation, even if volume overloaded (e.g., end stage CHF), but "too much fluid carries the risk of edema with its unwanted consequences," and the amount of fluid should be "closely monitored.
- 2013 1. PEEP exerted unfavourable haemodynamic effects such as less venous blood return, increasing (RV) afterload, decreasing (LV) filling and depressing CO and overall organ perfusion 2. other studies did not indicate that PPV had detrimental effects on LV function and showed that, conversely, PEEP decreased LV oxygen demand and improved oxygen delivery to the ischaemic myocardium, as evidenced by a decreased intracardiac lactate production.
- PCWP “normal vs. abnormal “ 12 out of 13 patients with a PCWP ≥19 improved CO with peep of 3-8
- As with any intervention, PEEP has a broad spectrum of haemodynamic consequences, which can be alternatively favourable or unfavourable depending on the clinical scenario in which it is used. severe left systolic heart failure, acute MI and cardiogenic shock will always require clinical judgement, we conclude that most patients will benefit from its use RV infarcts or have hypovolaemia, care must be exercised to ensure that cardiac under-filling does not occur with the decreased venous return which accompanies PEEP