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Cardiogenic Shock Algorithm and Case Presentation SCAI SHOCK - 2018 Jaya Mallidi, MD, MHS, FACC, FSCAI Interventional Cardiologist, St Joseph Memorial Hospital & Sutter Regional Hospital, Santa Rosa, CA
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Page 1: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

Cardiogenic Shock Algorithm and Case Presentation

SCAI SHOCK - 2018

Jaya Mallidi, MD, MHS, FACC, FSCAIInterventional Cardiologist, St Joseph Memorial Hospital & Sutter Regional Hospital, Santa Rosa, CA

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Disclosures

• No disclosures

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Statistics – April 2017 to March 2018

Total Population Served: 655,202

Total Percutaneous Coronary Interventions: 610

Total STEMIs: 181

Cardiogenic Shock at start of PCI: 11

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Case Presentation• Mr. S is a 63 year old gentleman, no known prior history,

presented with outside hospital Cardiac arrest.

• V – fib arrest while driving his car.EMS – Vfib, shocks X 3 in the field. EKG after ROSC – Inferior ST

segment elevation. Total Code time on field – 15 minutes

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Emergency Room • Patient was tachycardic (110 beats / minute) and hypotensive (SBP - 60 mm Hg).

He was unresponsive to verbal and painful stimulus

• Early Identification of SHOCK

• CATH LAB / SHOCK TEAM activated

• Phenylephrine and dopamine IV given to improve blood prior to intubation

• Targeted temperature protocol management initiated

• Initial Lactate level – 5 mmol / L

Page 7: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 8: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 9: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 10: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 11: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 12: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 13: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 14: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
Page 15: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
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Cardiac Intensive Care Unit

• Echocardiogram – EF 20%

• Continuous hemodynamic monitoring with q 3 hrly check of Cardiac power output and Pulmonary artery pulsatality index done.

• Weaned all pressors and impella taken out at 24 hours

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Intensive Care Unit

• Targeted Temperature Protocol followed

• Good neurological recovery

• No significant end organ dysfunction.

• Day 5 of hospital admission – Echocardiogram – EF 45 – 50 %. Discharged home on DAPT, statins, ACE and beta blockers. Stopped smoking.

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Nationwide Temporal Trends Among Patients Undergoing PCI for Cardiogenic Shock in Acute Myocardial Infarction

2005 -06(n=5658)

2006-08(n=10337)

2009-10(n=13562)

2011-13(n=26,940)

Hospital Type

Private / Community 91.6 90.2 90.4 89.6

University 8.4 9.8 9.6 10.4

Fellowship 49.4 46.0 44.2 42.3

Annual Average PCI volume

<500 30.7 34.6 43.7 48.1

500 – 1000 40.4 37.3 35.9 33.5

1000 – 1500 16.9 16.2 13.9 12.6

1500-2000 7.3 7.3 3.8 3.4

>2000 4.7 4.6 2.6 2.3

ALL ARE PERCENTAGE VALUESRef: Wayangankar SA, Bangalore S, McCoy LA, Jneid H, Latif F, Karrowni W, Charitakis K, Feldman DN, Dakik HA, Mauri L, Peterson ED. Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry. JACC: Cardiovascular Interventions. 2016 Feb 22;9(4):341-51.

Page 19: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

CARDIAC CATH LAB

• Ultrasound and Fluoroscopy guided Vascular Access (Radial / Fem vs. Bilateral fem)

• CHECK ABG – Adjust positive pressure / vent setting to treat acidosis

• Obtain LVEDP and perform Diagnostic Angiogram

Acute Coronary Syndrome Non Acute Coronary Syndrome

LVEDP > 18 mm Hg LVEDP > 18 mm hgSignificant MV / LM disease Right heart catheterizationFavorable peripheral vascular anatomy Favorable peripheral vascular anatomyConsider MCS device before PCI MCS if CI <2.2 l/ min/sq mINTERVENE ON CULPRIT VESSEL Consider / defer non culprit vessel PCIRight heart cath after PCI

• Suture MCS Device and Swan Ganz catheter appropriately in place, check for any vascular complications prior to transport.

• Confirm Dual Antiplatelet Agent Therapy and appropriate anticoagulation for MCS device

CARDIAC INTENSIVE CARE UNIT (CICU)

• Open Communication Channel with Tertiary center

• Continuous hemodynamic monitoring with every 2-4 hrcalculation of cardiac power output (CPO) and Pulmonary Artery Pulsatality Index (PaPi). Evaluate for weaning / escalation of support based on hemodynamic parameters and improvement / worsening of end organ perfusion parameters (urine output, lactic acidosis)*

a) CPO >0.6 and PaPi >0.9 – Wean off pressors and then Mechanical support device b) CPO <0.6 and PaPi <0.9 consider need of right sided support – TRANSFER TO TERTIARY CENTERc) CPO <0.6 and PaPi>0.9 – inability to wean – TRANSFER TO TERTIARY CENTER

• Comprehensive vascular assessment and monitoring for bleeding complications.

• Monitor MCS device position as necessary

• Targeted temperature protocol management for patients with cardiac arrest and unknown neurological recovery

• Comprehensive system wise assessment of problems and outline of plan based on multi disciplinary rounds

• Is palliative care an appropriate option?

* CPO – Cardiac Power Output : MAP X CO / 451PaPi– Pulmonary Artery Pulsatality Index: s PAP – d PAP / RA

PATIENT FOCUSED GOALS OF CARE

• Early Identification• Appropriate selection of patients for early

invasive intervention• Multi- disciplinary team based approach• REDUCE 3 Ms - MORTALITY, MORBIDITY,

MODS (Multi – organ Dysfunction )

PALLIATIVE CARE CONSIDERATIONS

• Advanced dementia• Terminal illness with life expectancy of less than 1 year• Advanced age with poor baseline functional status with multiple co morbidities• Patients wishes• Prolonged downtime with poor neurological recovery• No myocardial recovery and not a candidate for LVAD / transplant

EMERGENCY DEPARTMENT

• Basics: ABCs, IV, Supplemental O2, Cardiac monitoring, 12 Lead EKG, Chest X ray, Labs

• Early Identification – SHOCK CRITERIA ( Systolic blood pressure < 90 mm Hg for more than 30 minutes or use of vasopressors ; clinical signs of end organ hypoperfusion –cool extremities, oliguria, lethargy; labs – lactic acidosis)

• ACTIVATE CATH LAB / SHOCK TEAM (Interventional cardiologist + ICU Attending)

• Challenging intubation because of hypotension, acidosis and hypoxia. Maximize pre intubation hemodynamics. Consider push dose pressors. Be weary of worsening hemodynamics during intubation attempts

• Bedside echocardiogram – rule out mechanical complications of MI as cause for cardiogenic shock and large LV thrombus.

• Avoid beta blockers. Tachycardia is acceptable.

• Accurate and quick neurological assessment and initiation of targeted temperature protocol management if appropriate after ROSC in case of cardiac arrest.

• Is palliative care an appropriate option?

Page 20: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

PATIENT FOCUSED GOALS OF CARE

• Early Identification

• Appropriate selection of patients for early invasive intervention

• Multi- disciplinary team based approach

• REDUCE 3 Ms - MORTALITY, MORBIDITY, MODS (Multi – organ Dysfunction )

Page 21: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

EMERGENCY DEPARTMENT

• Basics: ABCs, IV, Supplemental O2, Cardiac monitoring, 12 Lead EKG, Chest X ray, Labs

• Early Identification – SHOCK CRITERIA ( Systolic blood pressure < 90 mm Hg for more than 30 minutes or use of vasopressors ; clinical signs of end organ hypoperfusion – cool extremities, oliguria, lethargy; labs – lactic acidosis)

• ACTIVATE CATH LAB / SHOCK TEAM (Interventional cardiologist + ICU Attending)

• Challenging intubation because of hypotension, acidosis and hypoxia. Maximize pre intubation hemodynamics. Consider push dose pressors. Be weary of worsening hemodynamics during intubation attempts

• Bedside echocardiogram – rule out mechanical complications of MI as cause for cardiogenic shock and large LV thrombus.

• Avoid beta blockers. Tachycardia is acceptable.

• Accurate and quick neurological assessment and initiation of targeted temperature protocol management if appropriate after ROSC in case of cardiac arrest.

• Is palliative care an appropriate option?

Page 22: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

CARDIAC CATH LAB

• Ultrasound and Fluoroscopy guided Vascular Access (Radial / Fem vs. Bilateral fem)

• CHECK ABG – Adjust positive pressure / vent setting to treat acidosis

• Obtain LVEDP and perform Diagnostic Angiogram

Acute Coronary Syndrome Non Acute Coronary Syndrome

LVEDP > 18 mm Hg LVEDP > 18 mm hgSignificant MV / LM disease Right heart catheterizationFavorable peripheral vascular anatomy Favorable peripheral vascular anatomyConsider MCS device before PCI MCS if CI <2.2 l/ min/sq mINTERVENE ON CULPRIT VESSEL Consider / defer non culprit vessel PCIRight heart cath after PCI

• Suture MCS Device and Swan Ganz catheter appropriately in place, check for any vascular complications prior to transport.

• Confirm Dual Antiplatelet Agent Therapy and appropriate anticoagulation for MCS device

Page 23: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

CARDIAC INTENSIVE CARE UNIT (CICU)

• Open Communication Channel with Tertiary center

• Continuous hemodynamic monitoring with every 2-4 hr calculation of cardiac power output (CPO) and Pulmonary Artery Pulsatality Index (PaPi). Evaluate for weaning / escalation of support based on hemodynamic parameters and improvement / worsening of end organ perfusion parameters (urine output, lactic acidosis)*

a) CPO >0.6 and PaPi >0.9 – Wean off pressors and then Mechanical support device b) CPO <0.6 and PaPi <0.9 consider need of right sided support – TRANSFER TO TERTIARY CENTERc) CPO <0.6 and PaPi>0.9 – inability to wean – TRANSFER TO TERTIARY CENTER

• Comprehensive vascular assessment and monitoring for bleeding complications.

• Monitor MCS device position as necessary

• Targeted temperature protocol management for patients with cardiac arrest and unknown neurological recovery

• Comprehensive system wise assessment of problems and outline of plan based on multi disciplinary rounds

• Is palliative care an appropriate option?

* CPO – Cardiac Power Output : MAP X CO / 451PaPi– Pulmonary Artery Pulsatality Index: s PAP – d PAP / RA

Page 24: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

PALLIATIVE CARE

• Advanced dementia

• Terminal illness with life expectancy of less than 1 year

• Advanced age with poor baseline functional status with multiple co morbidities

• Patients wishes

• Prolonged downtime with poor neurological recovery

• No myocardial recovery and not a candidate for LVAD / transplant

Page 25: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h

Thank you!

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Page 31: P v ] ^ Z } l o P } ] Z u v W v ] } v ^ / ^,K < r î ì í ô · >s W E í ô u u , P >s W E í ô u u Z P ^ ] P v ] ( ] v Ds l >D ] Z ] P Z Z Z ] Ì ] } v ... •Z h
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Reference: Outcomes of patients with acute MI Cardiogenic Shock supported with Impella. William O ‘ Neil, Henry Ford Hospital, Detroit. Presented at ACC, 2017

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