Showing posts with label cardiogenic shock. Show all posts
Showing posts with label cardiogenic shock. Show all posts

Thursday, December 12, 2019

Impella Stuff

This is my first of many posts on the Impella system by Abiomed. It is going to be part of my "Cardiogenic Shock: Rise of the Machines" lecture for Portland in August 2020.

I am planning on covering LVADs, RVADs, ECMO, TandemHeart, etc. in the upcoming months but one does not need to work at an ECMO or transplant hospital to see an Impella. This post is targeted for the clinician or nurse who is caring for the patient and is curious as to what’s the next step. Not intended for repositioning the device or criteria for installing it. I’ll get there. Give me time. Besides, I took a break from the Ketamine for this today.

When managing a patient on the Impella, whichever of their devices, a question always comes up when the patient becomes hypotensive. Do they need vasopressors or ionotropes? This algorithm from the Detroit Cardiogenic Shock Initiative is a helpful guide, definitely not an end-all-be-all but it’s better than flying without any instruments. Every patient with an Impella NEEDS a swan. You need to be able to measure the right heart pressures appropriately. You also need to be able to have an idea of what your SVR is. Without these parameters handy, you’re in the blind and clueless. Honestly, you should consider transferring the patient out to another shop before they get too sick to salvage.

Calculating the CPO and PAPI is something that nurses do and let the physicians know when things are going south. My favorite is to get the call followed by a suggestion to start a new med. that shows they’re vested and I love that.

Even though I do not run ECMO or have an LVAD program at my shop, I’m fortunate that I have colleagues at nearby hospitals who respond to my texts promptly and are around to help. It’s a blessing. My fellowship training provided me with a great amount of experience to where I do what I know how to do and when I need to make that call, I make it. No shame. Patients come over ego.

-EJ

LINK TO PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Monday, November 25, 2019

Cardiogenic Shock: NICOM vs. Swan-Ganz Catheter

There are four types of shock: cardiogenic, distributive, obstructive, and hypovolemic.

I routinely make a big deal of volume resuscitation regarding septic shock which obviously falls under the distributive shock type. Part of the problem is that with all these well intentioned "Surviving Sepsis Campaigns", I feel that we are under-recognizing cardiogenic shock which can also present with hypotension and an elevated lactic acid. When you provide 30cc/kg of IVF arbitrarily because the "sepsis screen" pops up on your EMR forcing you to give the fluids, you end up causing harm to your patients.

This is where the history and physical plays a huge role. The physical should include a quick targeted POCUS/bedside echo to make sure you're not missing anything that's staring you in the face. If you see an RVOT on the parasternal long axis that's the size of a tennis ball, you're not dealing with sepsis. If you see an LV on the apical four chamber that is barely moving, you're likely not dealing with sepsis. Remember, if the patient is in septic shock, the systemic vascular resistance (SVR) hits the ground. There's no afterload for the LV to deal with. The LV will be clapping happily like a bodybuilder curling a 10lb weight. The "eyeball test" on POCUS is widely criticized but it has some uses.

But once you make the diagnosis of cardiogenic shock, how do you manage that patient? This is where I feel you may have some value in trending a CVP. I know Swan-Ganz catheters are out of favor, but I feel they're very useful if you know what to do with the numbers. Knowing how to apply the numbers clinically, though, takes some practice. Like everything else, you need to get your reps in. I'm fortunate that I trained at an institution where all the post-op hearts came out with a Swan. It was very helpful in my training and allowed me the opportunity to see the value in it rather than just being a nay-sayer. The Swan does have its limitations, though. It's not the easiest procedure to perform and it comes with some potential cardiac risks that I am not going to list here for the sake of my sanity. Is there something that we can use instead?

I will admit that I personally do not have any experience with the NICOM device. I look forward to playing with the technology one day. I like non-invasive things for my patients. I typically use another device which I will not name but I feel it is very helpful when used appropriately. No technology is perfect, not even the Swan. I was excited when I read this article because I was hoping for an out to not have to float Swans in this patient population. I also very much enjoyed how the authors conducted the study. Simultaneous measurements on the same patient was definitely the way to go and I applaud them on that.

Without boring you all with the details, the authors found that the NICOM correlates poorly with indirect Fick and therm-dilution measurements of cardiac output. The authors attribute it to the biorreactance technology being interfered with by pulmonary and interstitial edema. Makes sense to me. They also listed other factors as well which are on the full article. Nonetheless, what method do you use at your institution to manage cardiogenic shock?

-EJ



Link to Abstract

Rali, A. S., Buechler, T., Van Gotten, B., Waters, A., Shah, Z., Haglund, N., & Sauer, A. (2019). Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock – The NICOMTM Study. Journal of Cardiac Failure.

Great article for indirect Fick
De Maria AN, Raisinghani A. Comparative overview of cardiac output measurement methods: Has impedance cardiography come of age? Congestive Heart Failure. 2000;6:60–73.

Indirect Fick Abstract

Indirect Fick PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.