The Optimal Team for 24/7 CCU shock management
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1 The Optimal Team for 24/7 CCU shock management Emmanouil S. Brilakis, MD, PhD Minneapolis Heart Institute pm
2 Disclosures Consulting/speaker honoraria: Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Boston Scientific, CSI, Elsevier, GE Healthcare, Medtronic. Research support: Osprey, Regeneron, Siemens. Shareholder: MHI Ventures. Board of Directors: Cardiovascular Innovations Foundation Board of Trustees: Society of Cardiovascular Angiography and Interventions
3 Stages of shock management Entry point Cath Lab CCU Ambulance ED Inpatient Cath Lab Identification DDx Medications MCS Revascularization Intubation Ventilation Medical Rx Weaning MCS Treating comorbidities Disposition
4 Shock management protocol 1. Identification 2. Differential diagnosis Management Cardiac Respiratory RHC Imaging 3. Meds 4. MCS 5. Revasc 6. Intubation 7. Ventilation
5 1. Identification 1. Identification 1. ED 2. Interv cardiologist cath lab tech - RN
6 Case 1 Proximal RCA thrombus
7 Things got worse
8 7 episodes of VF: defibrillation and intubation
9 Case 2 LAD CTO EF=25%
10
11
12
13 Acute vessel closure
14 2. Differential diagnosis 2. Differential diagnosis 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist RHC Imaging
15 Esposito, Kapur F1000 Research 2017, 6(F1000 Faculty Rev):737
16 3. Medications 1. Identification Management 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist Cardiac 3. Meds
17 Case 1 post defibrillation
18 1 mg epinephrine IV Post epinephrine Stopped propofol Called perfusion for Protek Duo
19 Case 1: patient stabilized Epinephrine drip 0.2 mcg/min
20 4. Mechanical circulatory support 1. Identification Management 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist 4. Perfusionist Cardiac 4. MCS
21 Case 2 After circ stenting
22 Case 2 No MCS needed Uneventful recovery CK-MB: 9.2 ng/ml
23 MCS device selection Cardiac arrest VA-ECMO Hypoxemia RV failure LV failure + LV failure Isolated Preshock Severe shock Refractory shock: Protek Duo, Impella RP IABP Impella CP, Tandem Heart
24 Percutaneous ECMO Cannulation Tool Box Fluoroscopy Multipurpose needle Guide wires Dilators Cannulas Stiff guide wires Micropuncture needle Vascular ultrasound Smaller cannulas Provisional distal perfusion catheter Bilateral cannulation
25 5. Revascularization 1. Identification Management 1. Interv cardiologist 2. Cardiac surgeon 3. Advanced heart failure Cardiac 5. Revasc
26 6. Intubation 1. Identification Management Anesthesiologist Respiratory 6. Intubation
27 7. Ventilation 1. Identification Intensivist Management Respiratory 6. Intubation 7. Ventilation
28 Shock management: tasks IC/tech/ RN 1. Identification + AHF Intensivist Cardiac surgery Perfusion Anesthesia Other 2. DDx Sonogra pher 3. Medication management 4. MCS selection, placement, management / Revascularization Intubation + 7. Ventilation +
29 CCU management Advanced Heart Failure Intensivist Perfusionist Cardiac surgery Subspecialty care Heart failure management MCS management + weaning Advanced support options Manage ventilator Non-cardiac issues Manage ECMO Evaluate surgical options (LVAD, etc) As needed
30 CS center characteristics Van Diepen et al. Circulation 2017
31 531 pts Cardiac intensivist and CS mortality Na et al. Intern J Cardiol 2017;244:
32 Conclusions Multiple steps multiple specialties Team approach: Improves decision making Allows parallel processing (hence increases speed) Each does what they do best Facilitates transition of care Can improve patient outcomes
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