Short Topics in
Intensive Care Medicine
Overview
• Cardiogenic shock
• Cardiac output monitoring
• Haemofiltration & haemodialysis
• Lactate
Cardiogenic Shock in 10 mins
• Definition
• Incidence
• Aetiology
• Pathophysiology
• Therapy
Cardiogenic Shock in 10 mins
Definition Clinical:
• 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 2
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 Incidence Mortality Patient group Country
CREATE-ECLA [1] 6.5% 68% STEMI China, India, Pakistan
NRMI [2] 8.6% 47.9% STEMI USA
COMMIT [3] 4.4% 68% AMI (93% STEMI) China
5.0% 68% Metoprolol
3.9% 72% Plcaebo
SHOCK [4] 20% 75% CS on admission USA/Belgium
80% 56% Delayed CS
[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
Cause of CS Proportion
Definition
LV failure post-MI (8.5% of 70-75%
Incidence STEMI, 2.5% of NSTEMI)
Acute severe mitral regurgitation 8.3%
Aetiology
Ventricular septal rupture 4.6%
Pathophysiology
Isolated RV failure 3.4%
Therapy Ventricular free-wall rupture or 1.7%
Cardiac tamponade
Myocardial contusion
LVOT obstruction (AS/HOCM)
End-stage cardiomyopathy
Obstructed LV filling (MS)
Myocarditis
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
• IABP
• PCI
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
NICO
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
