Chapters Transcript Video Does Your Hospital Have a Cardiogenic Shock Team? Dr. Amit Badiye explains cardiogenic shock and support for team based standardized care. Another complex topic in cardiology and very dear to me is cardiogenic shock. And that's why I framed this talk. Does your hospital have a cardiogenic shock team? And those who all work in Centra, they know that we do so good job and those who are not in center, how many of here are not from Centra system? Quite a few? That's great. So this will focus on why to have a cardiogenic shock team. What does it even mean to have a cardiogenic shock team? And what we see when we see this patient? So that's kind of where we are at. Financial disclosures have no relevance. So cardiogenic shock is a spiral, right? I mean, you have a patient shock which is hypertensive, they are hyper perfused and then there is congestion there. And then if you don't act, then it starts a spiral of service. And you know, you start treating them with fluids. If they're hypovolemic shock, if they're in cardiogenic shock, you start inotropes, you think about devices and you know, if you're not able to meet your goal, patient can die, right? And mortality is very high upwards of 50 per cent and this is in hospital mortality, patients who had deno heart failure or patients who have chronic heart failure or acute all lead to Rome. So this is how it is everything cardiology ends with cardiogen shock, right? If you are not able to control the disease process, we saw this morning in a patients, right? How they develop cardiomyopathy patients who had improperly placed or patients who are dependent on RV pacing, they develop cardiomyopathy and when they get into this chronic disease state, they can end up in your hospital with cardiogenic shock. And these patients are one of the sickest, right? I mean, look at the gall of complications they go through when they're in the hospital, right? In the hemodynamic talk by Dr Ali Mad. We saw a larger board, the device, you have extensive vascular complication, hematological complication, neurological complication, infections from just being in the hospital, mechanical complications. I mean, you name it right? And it's there and there are pitfalls in diagnosis and management of shock patient, right? Because the shock presentation can be deceiving. Not every patient presents classic like, oh, they had an led infer their blood pressure is low. They tachycardia, you can see their not perfusing well and they're restless and whatnot. There is something known as normal tens of shock. We see this all the time. We think that they're just admitted with heart failure, exacerbation and you go home and then you come back next day and the guy is not there on the floor and then you check your list and they are in the ICU. What happened? They had an MRT they coded and you know, this was the normal TENS shock which is missed. There are people who are very a diary shock, right? So they are warm. So you examine them, they feel warm and well perfused but they are not, these are pain invasor dilatory. They're patient with mix shock, chronic heart failure, shock, I call them anaerobes. I see these patients especially and all of my partners in advanced heart failure, they are in this chronic state of shock. They can you touch them and they can next day and I you right, we see that our gas lab staff knows them right? They come for just a right heart cat or just a heart cat and then we are struggling to get them out of the gas lab. And then there is RV shock doctor saw is expert on pulmonary hypertension and he sees this all the time. This is like right, ventricle is the most ignored ventricle in the heart and these patients are very difficult to manage. So the pitfalls in diagnosing and recognizing shock and there are issues with assessment assessment of these patients because not everybody believes in using Swan's catheters to look at the data. I mean, I would not like to drive in New York downtown without GPS, right? Or maps. And that's how I feel like taking care of this patient without S guns catheters. And there are hazards associated with transporting this as a cardiogenic shock team. When we accept this patient, they are not the same as you see on the shock call. You know, it's completely different like oh my God, this is not what you promised me. You know, you completely walking in a disaster and things happen, right? Devices move endotrachial tubes, move impella balloon pump, whatever device they had during transport can move. So by the time you get the patient, the balloon pump may be in the knee or something like that, right? So there are a lot of hazards when your choice and then and the choices of treatment are so heterogeneous like which device shall I put a balloon on this guy or shall I put an ECMO or? Oh no, I love impel. I'm going to do that. So how do you decide that all these pitfalls? And that's why we need a common language when we see a shark patient, right? I have a sick guy for you. What does it even mean? I have a guy who is not doing well. What data you got from this? Right? And that's why the sky shock classification has been made. So that we have a common language of shock where a is a patient who is at risk of shock, B is beginning of shock, C is a classic shock D is who is deteriorating and are the patient who is in extremist house on fire kind of a state and the acronym A for cardiac Rs and all these stages as you know, they have their own issues. But someone calls me and says that, hey, I have a sky stage. E now I know that as soon as the transfer center tells me that the patient is going to be here, my team is ready as opposed to someone who is in sky stage, say for example, a you know, and time and again, we know that escalating pharmacological therapy alone doin is not working, then I added me on then does that, you know this Jenga game is not good for this Carro shock patients, they have higher mortality, the moment you start adding more and more agents. And you know, this is exactly what I was talking about. So many studies showing that as the sky stage progresses, the mortality increases, right, 80 per cent or more in state. So once I know that this patient is, I know exactly what I'm dealing with, right? So it helps to have a common language and we talked about Gasca. Look at this study, what happened when you have no Swan Gans Catheter and you have Swan Gasca but incomplete data and only thing was missing, right? April pressure. So congestion is still hallmark of shock, right? And when that data was missing, again, mortality was high. And as you have complete assessment of hemodynamic profile of dismiss the survival improves especially sicker are the patients they're more needy, right? So these are the patients you don't want to play the game of? Ok. I think he's OK. No, we need data and Swan gas can provide that data to you. And then we want to know what are the therapeutic targets. When we are trying, trying to take care of this patient, we want to make sure they hemodynamically stable, the myocardial ischemia. If any vascular vascularization is taken care of, if they are struggling, then do we have a strategy to escalate their support? And you know, if they have an organ dysfunction, what's the escape plan? Right. Where do we go from here? Are we now providing fertile care and there's a realm of mechanical circulatory support devices? But are they the answer? If every shark patient comes in, you just flip a coin and put one device, whichever the coin shows is that the answer? But the reality is you want to do this to decrease their pre load, decrease their afterload, augment cardiac output or power to provide an organ perfusion, right? And then the goal with devices is always to either aim for a patient for recovery or to get this patient as a bridge to some destination like transplant. And you know, now there is a paradigm shift of looking at these interventions where time is money just like stemming, the longer you wait in shock for intervention higher is your mortality. So just like we have door to balloon time, the concept of door to support time is coming through. And you know, what do you really want to do in this patient is you want to recognize shock early, right? You want to triage them and then you want to have standardized diagnostic and probably treatment criteria. You have to speak the common language. That's why you have the Sky Shock classification. And then you want to assess them as a multidisciplinary team. And with this early assessment and recognition, you want to treat them aggressively so that you go on the pathway of escalation or recovery, you want to have a constant assessment of these patients and then hope for improved survival outcome and discharge and you don't want to stop there. You really want to go beyond their discharge and see if they have continuous follow up, right? So is this a technology issue just as I said, like you have all the device you need in my hospital, but if you don't have a team, will that technology help your patient? And the answer is look, there are so many randomized controlled trials in circulatory device therapies and none of them showed any mortality benefit, right? And that's the data. No difference. Randomizing this sick patient is challenging. If you look at all these eight trials, either they had low enrollment or they were stopped early or the feasibility of randomizing was really not done and then look at some other trials last 10 years, they're still randomizing, right? And as we talked before, like delay in timing of instituting mcs or any circulatory support worse than survival. But is that is a device answer? Right? And if you extrapolate that to a system with cardiogenic shock team versus no, if you see device utilization, there's really not a big difference, right? There is a higher utilization of balloon pump in no shock team programs. And there is higher utilization of impella in programs with shock teams utilization and surgical bats were the same. So the resource utilization is not different whether you have a shock team or not. But that's when you need to see where this patient travels on this line. From initial assessment to stratification to an intervention to recovery. And that's really when a role of cardiogenic shock team comes in. Because if you see from this paper, only difference between these hospitals and the survival is these hospitals had a cardiogenic shock team, right? And those hospitals where you had shock team look, they had more advanced mcs options, they had swan based guided treatment of this patient, right? And look at their CSU mortality, it was much less than those hospitals where they had no shock team. And you know, teams make dream come true. And that's look at every program who had initiated a shock protocol shock team driven protocol, whether it's national cardiogenic shock initiative, Utah recovery symposium or travel in Canada or I know north of us they all had one team, they had a cardiogenic shock team. So what constitutes a cardiogenic shock team? This is a team is available 24 7, 365 days a year, right? Basically, the core team members are your advanced heart failure, inter international cardiology team, your cardiovascular surgeons and not to forget your intensiveness, right? And more importantly, not to forget your supporting staff. We are blessed to have our cash lab staff, excellent I nurses emergency room, our perfusionist technologies, ecotech, they come in when there is a shock alert. So the whole hospital kind of becomes part of the shock team overall, right? And then how are these pathways to get established? There might be a level one center where I feel myself proud and privileged to work with where we have multiple options for devices. We have VAD and transplant program, we have protocols for this patient. So that becomes like a level one center, but there could be a level three center where they have limited resources or these kind of tools, but you can at least identify this patient early and get them to the next level of care, right? Just like if you're not a STEMI center, you can send this patient to a STEMI hospital rather than keeping them in your institute, right? And then these programs, they have a clear agreement between all the key members, right? They have a 24 7 team and then they have a clear operational manual or pattern, right? And you have location of where these patients need to be hosted, who is going to implant the device, who's going to manage the device, what are the protocols? And then you have to troubleshoot your equipment, make sure the equipment is ready, have constant communication with the team members and then establish your support team to make sure your patient gets the best care, right? And there are different shark team protocols. These are few of them. One is from the National Cardiogenic Shock Initiative and the other is from Innova team. But ultimately, this protocol should help you decide where once you are starting care of this, where do you go? Are you able to escalate the care of the patient if that's needed or patient is ready to wean from the support? And that's where you have to go through their repeated assessment. And that's where a team approach helps how to develop a team. There is a big need for institutional support in these kind of endeavors. Without that, I don't think you will ever be able to have a strongly performing multidisciplinary team to have frequent meetings with your team. You should have logistics and algorithms for your protocol, which I showed some of the examples. And then with time you should have a standard management plan, right? You should be able to speak common language with your team. You should have pharmaceuticals and equipment available at your program. You should have experts who are assigned to do their particular task. And most importantly, to have a process to alert the team with a shock alert. And then more importantly, after you're taken care of the patient to debrief your team, follow with the referring physician and also keep an eye on your data. So what we have seen in center of we are still, I would say we are in infancy with our shock team, but we have been rising alerts with our shock team. You don't have to call a dedicated line or anything. You just call center operator and say I have to activate shock alert just like code blue and the shock team gets activated. A page gets sent and immediately within two minutes. The surgeon, a cardiologist, advanced heart failure, cardiologist, if needed, an interventional cardiologist gets passed through and our critical care intensivist gets on the team. On addition to this, we have the transport team, the night angle team, the bed tower, the charge nurse in the ICU. They all get on these phone calls so that they keep a track of incoming transfers. So these were our alerts. As you can see, we are pretty significant outreach around 80 per cent of the alerts from outside the hospital than in house. And most of the alerts were from the ICU. And you know, you can see majority of them were for cardiogenic shock and there were around 20 per cent alerts for non cardia shock or a more patients. So, in a nutshell, it really takes a village and it's unfortunate I couldn't show the slide of my team, but it really takes a village to have a cardiogenic shock team. And the take home message is shock team can save lives. So if your hospital does not have a shock team, you should at least have a process of escalation of care and you should have also access to level one centers like ours. Thank you so much. Published October 18, 2023 Created by Related Presenters Amit Badiye, M.D. Sentara Advanced Heart Failure Center View full profile
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