This document provides an overview of circulatory care and treatments for cardiogenic shock. It discusses: 1. Outcomes of cardiogenic shock, which has high early mortality despite early intervention and is difficult to support medically. 2. Trials of IABP support that have shown no clear benefit on mortality. Ongoing large trials are investigating IABP further. 3. Inconclusive evidence on the benefits of inotropes for cardiogenic shock. 4. Evidence that ECMO can successfully support patients with cardiogenic shock, with survival rates over 50-75% reported for various conditions. Early application of ECMO seems to provide major benefits to patients. 5.

1. Advancing Circulatory
Care (2012 )
Vincent Pellegrino
Victorian Intensive Care Network
August
2012

2. Choice

3. Before I start......

4. 1992: First ICU
Rotation
• 1800-0800 (14 beds) RMO only cover
• Closed loop control of circulation
• Open loop control of feeding
• Open loop control of tonicity

6. 1992: First ICU
Rotation
J Crit Care (1994) 9: 124-133

7. 1992: First ICU
Rotation
10 Patients
APII 30
CRRT-HF
601 hour
417 (L) lost
409 (L) administered
3 survived (hosp discharge)
J Crit Care (1994) 9: 124-133

8. 1992: First ICU
Rotation
Reduced haemodynamic
variability compared to
standard care
J Crit Care (1994) 9: 124-133

9. PAC - Clinical Trials
•
Shoemaker 1988

10. PAC - Clinical Trials
•
Intensive Care 19882006
•
•
•
•
ARDS
General ICU
High Risk Surgery
12 Prospective RCT

11. PAC - Clinical Trials
•
•
•
Evaluated different targets
•
CO / Oxygen Delivery (explicit) or Physician
determined
•
+/- MAP, Urine output, skin changes
Used different guidance (rules)
•
CVP and PAOP (explicit) or Physician determined
Applied different therapy
•
•
Fluids (crystalloids/colloids or RBC)
Drugs (inotropes or pressors)

12. PAC - Clinical Trials
•
•
•
•
•
Intensive Care 1988-2006
ARDS
General ICU
High Risk Surgery
12 Prospective RCT

13. PAC - Clinical Trials
• Various approaches to haemodynamic care in
numerous patient populations using either....
• explicit targeting of cardiac output /
oxygen delivery
• guiding care based on perceived needs
does not improve outcome in a number of high
risk patient groups

14. Where does that leave
us ?

15. Drug Trials
Text
Annane D. Lancet 2007

16. Drug Trials
Myburgh J. ICM 2008

17. Drug Trials
Text
De Becker D. NEJM 2010

18. Fluids - Obsevational
Liberal fluids
associated
with
increased
ICU and
ventilator
time and no
reduction in
renal failure
•
Outcome
Death at 60 days (%)
Ventilator-free days
from day 1 to day 28 
ICU-free days 
Days 1 to 7
Days 1 to 28
Organ-failure-free days 
Days 1 to 7
Cardiovascular failure
CNS failure
Renal failure
Hepatic failure
Coagulation abnormalities
Days 1 to 28
Cardiovascular failure
CNS failure
Renal failure
Hepatic failure
Coagulation abnormalities
Dialysis to day 60
Patients (%)
Days
Conservative Strategy
Liberal Strategy
P Value
25.5
28.4
0.30
14.6 ± 0.5
12.1 ± 0.5
<0.001
0.9 ± 0.1
13.4 ± 0.4
0.6 ± 0.1
11.2 ± 0.4
<0.001
<0.001
3.9 ± 0.1
3.4 ± 0.2
5.5 ± 0.1
5.7 ± 0.1
5.6 ± 0.1
4.2 ± 0.1
2.9 ± 0.2
5.6 ± 0.1
5.5 ± 0.1
5.4 ± 0.1
0.04
0.02
0.45
0.12
0.23
19.0 ± 0.5
18.8 ± 0.5
21.5 ± 0.5
22.0 ± 0.4
22.0 ± 0.4
19.1 ± 0.4
17.2 ± 0.5
21.2 ± 0.5
21.2 ± 0.5
21.5 ± 0.4
0.85
0.03
0.59
0.18
0.37
10
14
0.06
11.0 ± 1.7
10.9 ± 1.4
0.96
ARDS Clinical Trial Network, NEJM 2006

19. Fluids - Observational
After correcting for
age and APACHE II,
positive fluid balance
correlated with
increased mortality
Boyd J.H.et al Crit Care Med 2011

20. Fluids Recommendations
CCM Feb 2011

21. Currently
Low Blood Pressure
Low Blood Pressure
Fluids
Fluids
Low Cardiac Output
Low Cardiac Output
Inotropes
Inotropes
Organ Failure
Organ Failure
Vasopressors
Vasopressors

22. Currently
Low Blood Pressure
Low Blood Pressure
Fluids
Fluids
Low Cardiac Output
Low Cardiac Output
Inotropes
Inotropes
Organ Failure
Organ Failure
Vasopressors
Vasopressors

23. The Future ??
• Each decade we reject a new haemodynamic
variable, on which, to base interventions
• 1980: PAWP
• 1990:VO2-DO2 relationship
• 2000: LVEDV GEDVI
• 2010: Forget about monitoring - just
ECHO everything (over and over)

24. Where does that leave
us ?

25. Where does that leave
us ?
• Prescriptive Approaches
• RELIEF (Restrictive versus Liberal Fluid
Therapy in Major Abdominal Surgery)
• Clinical Trials.gov Id: NCT 01424150
• Random allocation of drugs
• Targeting Fluid Balance

26. A Physiological Approach
• Instead of targeting MAP or CO/O2D indices
• using DEPENDENT circulatory variables
(e.g. CVP, EDV, PPV) to guide therapy
• Target BOTH simultaneously using
• INDEPENDENT circulatory variables
-
Volume state
Cardiac function
Systemic vascular resistance

27. Mean Systemic Filling Pressure

28. Mean Systemic Filling Pressure
Anaesthesia
2009(64):1218-1228

29. Mean Systemic Filling Pressure
• Allows independent assessment of volume
state
and
• Allows independent assessment of cardiac
function

30. Modelling the
circulation

31. Stay with me.......

32. MSFP(modeled)
CO
v MSFP
Press
a

33. Venous compliance
lower than assumed
CO
v MSFP
Press
a

34. Venous compliance
higher than assummed
CO
v
Press
a

35. Independent variables of
the circulation
• MSFP = Volume state
= 0.96(CVP) + 0.04(MAP) + c(CO)
• HP (Heart Performance) = Inotropy state
=(MSFP - RAP) / MSFP
• SVR = Arteriolar tone state
These are the numerical descriptors (indicators) of the circulation

36. Choosing the Target
• Cardiac output
• Mean arterial pressure
• (Cardiac Power = CO x MAP)
• Captures both kinetic and potential energy of
the circulation
• Allows assessment of volume responsiveness

37. Cardiogenic Shock
•
Cardiac Power

38. Cardiogenic Shock
•
Cardiac Power

39. Navigator Guidance
Heart efficiency axis
Mean systemic
filling pressure axis
Data from
Monitors
Target zone
Targets set
by clinician
Other data
Systemic
resistance axis
Main menu
area
Data link
Status area
Patient’s
current position
Arrow shows next therapeutic direction

40. •
Intended Control:
Following the arrow
Vertical Axis Control
If Cardiac Power Low: increase MSFP or
Inotropy (depending on HP)
•
•
•
If Cardiac Power High: decrease MSFP or
Inotropy* (depending on HP)
Horizantal Axis Control
•
If Cardiac Power is not well “geared” (SVR too
high or too low): dilators and constrictors

41. Cardiac Power
Relevance

42. Navigator Screens:
NAV-1
Intervention
(Treatment compliance not required)
Control

43. What we learned
• Even if you know the independent
determinants of circulatory variables (like
CO)......
• Even if you use them to direct therapy to a
meaningful target (like cardiac power).....
• You don’t necessarily know when you
should change the target and when you
should change the treatments

44. Structured approach to circulatory
care using Navigator
1. Medical
assessment
2. Nursing
assessment
3. Continual
maintenance
Determine Targets
Targets attained and
maintained (ASD < 1.5)
within intervention limits
No change
+
Define (allowable)
interventions
Targets not maintained within
intervention limits (ASD >1.5)
New Target
or
New Intervention

45. Circulatory Targeting
Sheet
MAP
HP inotrope trigger
ScvO2 > 70
Card Index
HP medical review trigger
Heart Rate
Volume resuscitation
Colloids = 0
Colloids = < 1000 mls
Colloids = < 2000ms
Vasopressor requirements
Noradren = 0
Noradren = 1 - 10
Noradren = >10
AVP = 0
AVP = 1/hr
AVP 2/hr
GTN = 0
GTN =20 or more
GTN ___ - ___
SNP 10 - 50
SNP 50 - 150
SNP ___ - ___
Adren: = 0
Adren: < 5
Adren: 5- ___
Milrinone = 0
Milrinone = 5
Milrinone = 5 - 20
Vasodilator requirements
Inotrope requirements

46. Improving Circulatory
Care .....
• Further investigations into physiologically
based treatments
• Cannot accept that understanding the
circulation can’t lead to improved care

47. Outcomes of cardiogenic shock (CS)
complicating acute coronary
syndromes/myocardial infarction

48. Outcomes of cardiogenic shock (CS)
complicating acute coronary
syndromes/myocardial infarction

49. Outcomes

50. Cardiogenic Shock
Outcomes
•High early mortality (despite early
intervention)
•Difficult to support medically
•Reasonable quality of life post
•Not invariably associated with irrecoverable myocardial damage

51. IABP
Krischan D. Sjauw
Krischan D. Sjauw
European Heart Journal (2009)
European Heart Journal (2009)
30, 459–468
30, 459–468

52. IABP
Unverzagt S
Unverzagt S
Cochrane Library
Cochrane Library
2011
2011

53. IABP
•Ongoing Trials
•IABP Shock II;
•RECOVER II Trial
•Planned Recruitment
•984

54. Inotropes
Elmir Omerovic
Elmir Omerovic
Vascular Health and Risk
Vascular Health and Risk
Management
Management
2010:6 657–663
2010:6 657–663

56. ECMO
• Extra Corporeal Membrane
Oxygenation is a form of
extracorporeal life support where
an external artificial circuit carries
venous blood from the patient to
a gas exchange device
(oxygenator) where blood
becomes enriched with oxygen
and has carbon dioxide removed.
This blood then re-enters the
patient circulation
• Veno-arterial ECMO
– Percutaneous cardiopulmonary
support (bypass)

57. access
return

58. What’s possible
Lymphocytic
myocarditis
Day 2-3

59. What’s possible……
Day 5
Day 10

65. Christian A. Bermudez
Ann Thorac Surg 2011;92:2125–31

66. ECMO for Cardiac Failure 20032012
Diagnostic
Group
CM/FM
Heart Tx (0-7)
AMI
Heart Tx (late)
Septic Shock
Number Age
(168)
(43)
ECMO Days SW SB
(7.3)
NW Alive
Discharge
40
42
7.8
21
14
5
27(+3) (75%)
46
51
6.6
43
1
2*
33 (72%)
25
52.4
9.1
12
8
5
14 (56%)
10
44
11.9
4
3
3
3 (30%)
7
38
4.9
3
0
4
2 (29%)

67. Alfred CS-AMI
•25 patients (20032012)
•Average Age: 52.4
•Average Days on
Support: 9.14
•56% Survival to
hospital discharge
• 5 NW
• 8 SB
• 12 SW

68. Current Mechanical Treatment
Options for Severe Acute Heart
Failure
•Veno-arterial ECMO
•Centrifugal VAD
• Tandem Heart LVAD
• RVAD, LVAD, BiVAD
•Impella Recover
•B2B (Bridge to Bridge)
•Long term VAD

70. Ischaemic C/M
60 month mortality
50%
Non-Ischaemic C/M
60 month mortality
35%

71. Conclusion
• Cardiogenic shock remains a challenging
syndrome to treat but the early application
of safe ECMO seems possible to provide
major patient benefits
• Simple
• Transferable