Sandbox: Cardiogenic Shock
Template:Cardiogenic Shock - 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
AHA SCIENTIFIC STATEMENT - 2017
Contemporary Management of Cariogenic Shock
Pragmatic and Clinical Trial Definitions of Cardiogenic Shock
| Clinical Definition | SHOCK Trial | IABP-SHOCK II | ESC HF Guidelines |
|---|---|---|---|
| Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion | Clinical criteria:
SBP <90 mmHg for ≥30 min OR Support to maintain SBP ≥90 mmHg AND End-organ hypoperfusion (urine output <30 mL/h or cool extremities) Hemodynamic criteria: CI of ≤2.2 L·min−1·m−2 AND PCWP ≥15 mmHg |
Clinical criteria:
SBP <90 mmHg for ≥30 min OR Catecholamines to maintain SBP >90 mmHg AND Clinical pulmonary congestion AND Impaired end-organ perfusion (altered mental status, cold/clammy skin and extremities, urine output <30 mL/h, or lactate >2.0 mmol/L) |
SBP <90 mmHg with adequate volume and clinical or laboratory signs of hypoperfusion
Clinical hypoperfusion: Cold extremities, oliguria, mental confusion, dizziness, narrow pulse pressure Laboratory hypoperfusion: Metabolic acidosis, elevated serum lactate, elevated serum creatinine |
| CI indicates cardiac index; CS, cardiogenic shock; ESC, European Society of Cardiology; HF, heart failure; IABP-SHOCK II, Intraaortic Balloon Pump in Cardiogenic Shock II; LV, left ventricular; MI, myocardial infarction; PCWP, pulmonary capillary wedge pressure; SBP, systolic blood pressure; and SHOCK, Should We Emergently Revascularize Occluded Coronaries for Cariogenic Shock | |||
Potential Hemodynamic Presentations of Cardiogenic Shock
| Volume Status | |||
| Peripheral Circulation | Cold | Classic Cardiogenic Shock or Mixed Shock (↓Cl; ↑SVRI; ↑PCWP) | Euvolemic Cardiogenic Shock (↓Cl; ↑SVRI;↔PCWP) |
| Warm | Vasodilatory Cardiogenic Shock or Mixed Shock (↓Cl; ↓/↔SVRI;↑PCWP) | Vasodilatory Shock (Not Cardiogenic Shock) (↑Cl; ↓SVRI; ↓PCWP) | |
| CI indicates cardiac index; PCWP, pulmonary capillary wedge pressure; and SVRI, systemic vascular resistance index. | |||
Considerations for Initial Critical Care Monitoring in Patients With Cardiogenic Shock
| Monitoring Parameter | Frequency | Comment/Rationale |
|---|---|---|
| Noninvasive Monitoring | ||
| Telemetry, pulse oximetry, respiratory rate | Continuous | High incidence of arrhythmias, ventilator failure, and pulmonary edema |
| Critical care unit monitoring | 1:1 Nurse-to-patient ratio | High incidence of hemodynamic deterioration and multisystem organ failure |
| Invasive monitoring | ||
| Arterial BP monitoring | Continuous | Consider continuing until vasoactive medications have been discontinued for 12–24 h |
| CVP | Continuous | A central line is required for delivery of vasoactive medications; single-point-in-time CVP measurements may be unreliable measures of uid status, but longitudinal CVP trends may provide information on trends in fluid status |
| Central venous oxygen saturation | Every 4 h | Trends in central venous oxygen saturation in patients with a central line can be used to help monitor trends in cardiac output |
| Urine output | Every hour | Urine output and serum creatinine monitoring are markers of renal perfusion and acute kidney injury |
| PAC or noninvasive cardiac output monitor | Selected use | Consider using early in the treatment course in patients not responsive to initial therapy or in cases of diagnostic or therapeutic uncertainty |
| Laboratory Investigations | ||
| Complete blood counts | Every 12–24 h | Consider more frequently in patients with CS with, or at high risk for, bleeding |
| Serum electrolytes | Every 6–12 h | Frequency should be tailored to risks or presence of renal failure and electrolyte dycrasias |
| Serum creatinine | Every 12–24 h | Urine output and serum creatinine monitoring are markers of renal perfusion and acute kidney injury |
| Liver function tests | Daily | Monitoring for congestive hepatopathy and hypo perfusion |
| Lactate | Every 1–4 h | Lactate clearance is a marker of resolving end-organ hypoperfusion, and lack of clearance is associated with a higher risk of mortality |
| Coagulation laboratories | Every 4–6 h for those on anticoagulants until therapeutically stable, every 24 h if patient is not on anticoagulants | Altered drug elimination and frequent use of mechanical support devices often necessitate antithrombotic monitoring |
| BP indicates blood pressure; CS, cardiogenic shock; CVP, central venous pressure; and PAC, pulmonary artery catheter. | ||
Mechanism of Action and Hemodynamic Effects of Common Vasoactive Medications in Cardiogenic Shock
| Clinical Definition | SHOCK Trial | IABP-SHOCK II | ESC HF Guidelines | SHOCK Trial | IABP-SHOCK II | ESC HF Guidelines |
|---|---|---|---|---|---|---|
| Receptor Binding | ||||||
| Medication | Usual Infusion Dose | α1 | β1 | β2 | Dopamine | Hemodynamic Effects |
| Vasopressor/inotropes | ||||||
| Dopamine | 0.5–2 μg·kg-¹·min−¹ | − | + | − | +++ | ↑CO |
| 5–10 μg·kg-¹·min−¹ | + | +++ | + | ++ | ↑↑CO, ↑SVR | |
| 10–20 μg·kg-¹·min−¹ | +++ | ++ | − | ++ | ↑↑SVR, ↑CO | |
| Norepinephrine | 0.05–0.4 μg·kg-¹·min−¹ | ++++ | ++ | + | − | ↑↑SVR, ↑CO |
| Epinephrine | 0.01–0.5 μg·kg-¹·min−¹ | ++++ | ++++ | +++ | − | ↑↑CO, ↑↑SVR |
| Phenylephrine | 0.1–10 μg·kg-¹·min−¹ | +++ | − | − | − | ↑↑SVR |
| Vasopressin | 0.02–0.04 U/min | Stimulates V1 receptors in vascular smooth muscle | ↑↑SVR, ↔PVR | |||
| Inodilators | ||||||
| Dobutamine | 2.5–20 μg·kg-¹·min−¹ | + | ++++ | ++ | − | ↑↑CO, ↓SVR, ↓PVR |
| Isoproterenol | 2.0–20 μg/min | − | ++++ | +++ | − | ↑↑CO, ↓SVR, ↓PVR |
| Milrinone | 0.125–0.75 μg·kg-¹·min−¹ | PD-3 inhibitor | ↑CO, ↓SVR, ↓PVR | |||
| Enoximone | 2–10 μg·kg-¹·min−¹ | PD-3 inhibitor | ↑CO, ↓SVR, ↓PVR | |||
| Levosimendan | 0.05–0.2 μg·kg-¹·min−¹ | Myo lament Ca²+ sensitizer, PD-3 inhibitor | ↑CO, ↓SVR, ↓PVR | |||
| CO indicates cardiac output; CS, cardiogenic shock; PD-3, phosphodiesterase-3; PVR, pulmonary vascular resistance; and SVR, systemic vascular resistance. | ||||||