The Optimal Team for 24/7 CCU shock management Emmanouil S. Brilakis, MD, PhD Minneapolis Heart Institute 3.10 3.25 pm
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
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
Shock management protocol 1. Identification 2. Differential diagnosis Management Cardiac Respiratory RHC Imaging 3. Meds 4. MCS 5. Revasc 6. Intubation 7. Ventilation
1. Identification 1. Identification 1. ED 2. Interv cardiologist cath lab tech - RN
Case 1 Proximal RCA thrombus
Things got worse
7 episodes of VF: defibrillation and intubation
Case 2 LAD CTO EF=25%
Acute vessel closure
2. Differential diagnosis 2. Differential diagnosis 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist RHC Imaging
Esposito, Kapur F1000 Research 2017, 6(F1000 Faculty Rev):737
3. Medications 1. Identification Management 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist Cardiac 3. Meds
Case 1 post defibrillation
1 mg epinephrine IV Post epinephrine Stopped propofol Called perfusion for Protek Duo
Case 1: patient stabilized Epinephrine drip 0.2 mcg/min
4. Mechanical circulatory support 1. Identification Management 1. Interv cardiologist 2. Advanced heart failure 3. Intensivist 4. Perfusionist Cardiac 4. MCS
Case 2 After circ stenting
Case 2 No MCS needed Uneventful recovery CK-MB: 9.2 ng/ml
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
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
5. Revascularization 1. Identification Management 1. Interv cardiologist 2. Cardiac surgeon 3. Advanced heart failure Cardiac 5. Revasc
6. Intubation 1. Identification Management Anesthesiologist Respiratory 6. Intubation
7. Ventilation 1. Identification Intensivist Management Respiratory 6. Intubation 7. Ventilation
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 + + + + + +/- + 5. Revascularization + + 6. Intubation + 7. Ventilation +
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
CS center characteristics Van Diepen et al. Circulation 2017
531 pts 2012-2015 Cardiac intensivist and CS mortality Na et al. Intern J Cardiol 2017;244:220-225
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