Adopting a Protocol for Cardiogenic Shock – Pitfalls and Pathways to Success
By Dr. Cathy Jeon, Abiomed Medical Director
Successfully treating cardiogenic shock requires getting a multi-disciplinary team to quickly agree on the patient’s condition and treatment protocol.
That’s why more cardiogenic shock units are adapting treatment algorithms to help quickly guide decision-making and ensure the best possible outcomes for patients. In a video roundtable hosted by Abiomed focused on “Adopting a Protocol for Cardiogenic Shock,” we spoke with two physicians who have developed algorithms at their own institutions about the benefits they provide and how to maximize their effectiveness.
The treatment of cardiogenic shock has changed dramatically in recent years. Tools like vasopressors and inotropes, PCI, mechanical circulatory support, and durable support devices have begun to reduce the mortality of what was once a highly fatal condition. With prompt delivery of appropriate interventions, many more patients who reach the hospital in cardiogenic shock can be treated successfully.
In addition, successfully treating cardiogenic shock requires the coordination of emergency medical personnel, emergency department physicians, interventionalists, and intensive care cardiologists, according to a 2016 paper by Dr. Jacob Doll of Duke University Medical Center and colleagues.
So the challenge today is how to work together as a team to identify cardiogenic shock in the setting of an evolving myocardial infarction and to choose treatment in addition to the routine PCI to revascularize the patient.
"Developing an algorithm to optimize treatment can help us meet that challenge," said Dr. Jon George, director of the cardiac catheterization laboratory at Einstein Medical Center in Philadelphia.
“In shock decisions need to be made rapidly and quickly under a lot of stress with a lot of people around you, and these decisions can vary between providers based on anecdotal evidence or experience. So a protocol will standardize the approach for optimal outcomes based on a validated treatment pathway,” Dr. George said.
But such protocols can be difficult to develop and implement in a setting where many different caregivers interact. Dr. Jaime Hernandez-Montfort, co-director of the Mechanical Circulatory Support Program at Baystate Health in Springfield, Massachusetts, said all stakeholders, from operating room and catheterization lab staff to intensive care nurses, should be involved in developing the algorithm and be kept informed once the algorithm has been implemented.
“It's very important you circle back to your team, your nurses, to your house staff, to let them know what was the ultimate outcome,” he said.
Both physicians agreed that to maximize success, an algorithm should incorporate hemodynamic data from a PA catheter. Although the availability of ultrasound-guided access and placement has made PA catheters safer to place, PA catheters are used in fewer than 40% of cardiogenic shock cases, Dr. George said.
Since cardiogenic shock patients can quickly progress from “hemodynamic instability to a complete derangement of hemometabolic issue and multi-organ failure,” advancements in hemodynamic support devices have become an essential component of a cardiogenic shock algorithm, Dr. George said. When implemented quickly, a device like the Impella can lead to a patient’s recovery from cardiogenic shock.
“Recognizing a hemodynamic issue, recognizing the need for a support device and implanting the Impella at the early stage of that continuum may allow you to recover the myocardium and achieve recovery of heart function,” Dr. George said.
An effective protocol, by helping to identify needs and appropriate treatments, can be the key to optimizing outcomes for cardiogenic shock patients, Dr. George concluded.
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