Short Topics in Intensive Care Medicine

• Cardiogenic shock • Cardiac output monitoring • Haemofiltration & haemodialysis • Lactate

Cardiogenic Shock in 10 mins
• Definition • Incidence • Aetiology • Pathophysiology • Therapy

Cardiogenic Shock in 10 mins
Clinical: Definition • Hypotension i.e. SBP below 90 mmHg Incidence • Impaired tissue perfusion • After correction of non-cardiac factors Aetiology Pathophysiology Haemodynamic: • Cardiac index < 2.2 litres/min/m Therapy • Systolic blood pressure < 90 mm Hg

• LAP/RAP > 18 mm Hg or PCWP > 16 • Urine output < 20 ml/hr • SVR > 2100 dynes-sec·cm–5

Incidence & Mortality
Study CREATE-ECLA [1] NRMI [2] COMMIT [3] Incidence 6.5% 8.6% 4.4% 5.0% 3.9% SHOCK [4] 20% 80% Mortality 68% 47.9% 68% 68% 72% 75% 56% Patient group STEMI STEMI AMI (93% STEMI) Metoprolol Plcaebo CS on admission Delayed CS USA/Belgium Country China, India, Pakistan USA China

[1] The CREATE-ECLA Trial Group. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA Randomized Controlled Trial. JAMA 2005; 293: 437– 446. [2] Babaev A, Frederick PD, Pasta DJ, et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 2005; 294:448–454. [3] Jeger RV, Harkness SM, Ramanathan K, et al. Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry. Eur Heart J 2006; 27:664–670. [4] Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomized placebo controlled trial. Lancet 2005; 366:1622–1632.

Echo indicators of mortality

Cardiogenic Shock in 10 mins
Definition Incidence Aetiology Pathophysiology Therapy
Cause of CS LV failure post-MI (8.5% of STEMI, 2.5% of NSTEMI) Acute severe mitral regurgitation Ventricular septal rupture Isolated RV failure Ventricular free-wall rupture or Cardiac tamponade Myocardial contusion LVOT obstruction (AS/HOCM) End-stage cardiomyopathy Obstructed LV filling (MS) Myocarditis Proportion 70-75% 8.3% 4.6% 3.4% 1.7%

Cardiogenic Shock Pathophysiology

Cardiogenic Shock Pathophysiology

Target for therapy?

At least 20% of CS patients have SIRS and low SVR

Therapy - Reducing iNOS: L-NMMA
Effect of Tilarginine Acetate in Patients With Acute Myocardial Infarction and Cardiogenic Shock - The TRIUMPH Randomized Controlled Trial. JAMA 2007;297:1657-1666

“Excessive NOS results in high levels of nitric oxide that, in turn, lead to inappropriate systemic vasodilatation, progressive systemic and coronary hypoperfusion, and myocardial depression”

Cardiogenic Shock Therapy
• Optimise volume / oxygenation / rhythm • Inotropic agents & vasopressors  β agonists  a agonists  PDE III inhibitors  LEVOSIMENDAN
sensitizes myocardial contractile proteins to calcium independent of sympathetic NS and so NO increase in MVO2 Prolonged action beyond infusion duration


Cardiac Output Monitoring
• Oesophageal doppler • Fick-based methods e.g. NICO • Pulse contour analysis • Pulse power analysis e.g. LiDCO • Impedance cardiography e.g. NICCOMO

Oesophageal Doppler
• Measures blood flow velocity in descending aorta • Doppler transducer (continuous or pulsed wave) • Uses VTI x Area (measured with M-mode or estimated) • Assumptions:

– – –

accurate descending aortic blood flow velocity estimated aortic CSA near mean value during systole constant division of flow between descending aorta (70%) and brachiocephalic / coronary arteries (30%) – negligible diastolic flow in the descending aorta Limits of agreement between thermodilution and OD = +2 l/min to -1.5 l/min

Oesophageal Doppler

Applies Fick principle to CO2 intermittent partial rebreathing through disposable rebreathing loop Components
– CO2 sensor (infrared light absorption) – disposable airflow sensor (differential pressure pneumotachometer) – pulse oximeter

Impedance cardiography – how?
An alternating current is transmitted through the chest. The current takes path of least resistance: the blood filled aorta. Baseline impedance to current is measured. Blood volume and velocity in aorta change with each heartbeat. Corresponding changes in impedance are used with ECG to give haemodynamic parameters.
Kubicek NASA 1960 started development of modern equations relating SV to maximum value of the first derivative of the impedance waveform (dZ/dtmax) and the left ventricular ejection time (LVET)

Impedance cardiography – how?

Impedance cardiography – what?
Stroke Volume/Index (SV/SVI) Cardiac Output/Index (CO/CI) Systemic Vascular Resistance/Index (SVR/SVRI) Velocity Index (VI) Thoracic Fluid Content (TFC) Systolic Time Ratio (STR) Left Ventricular Ejection Time (LVET) Pre-Ejection Period (PEP) Left Cardiac Work/Index (LCW/LCWI) Heart Rate