Volume Management in Cardiogenic Shock Patients

April 24, 2020

MCS and Volume Considerations in the ICU

How do you assess and manage volume in cardiogenic shock patients in the ICU? Dr. Shelley Hall and Dr. Ajay Srivastava describe the hows and whys with Abiomed’s medical director Dr. Cathy Jeon. Dr. Hall is an advanced heart failure cardiologist at Baylor Heart & Vascular Hospital in Dallas, Texas. Dr. Srivastava is a cardiologist and advanced heart failure specialist at Scripps Clinic in La Jolla, California.

Dr. Srivastava describes how assessing volume in cardiogenic shock in the ICU helps make the diagnosis of cardiogenic shock or hypovolemic shock and lower pressor requirements. “Even before I have a PA catheter, or if I’m trying to triage or decide if someone needs a PA catheter, I will just get an ultrasound and take a quick look at the IVC to give me some sense if they’re volume depleted or not. And then once a PA catheter is placed, I tend to aim for a little bit higher volume status. I’m not aiming for euvolemia at this time since they’re in shock. So, I go for a CVP of 8 to 12, and a PA diastolic of anywhere from 15 and 18, just to make sure they’re adequately ‘tanked up.’”

Dr. Hall adds, “When a cold patient is brought in, the saying is, ‘they’re not dead until they’re warm and dead.’ It’s not cardiogenic shock until their volume has been repleted. And I’ve seen many post-operative patients that they think it’s cardiogenic shock,… and yet what it is is internal bleeding.” She agrees with parameters mentioned by Dr. Srivastava, noting that she aims for CVP of 8-12, a wedge of at least 15, and PA diastolic over 15. “Because we’ll see pressors galore going on,” she adds, “when they really need volume.”

In terms of mechanical circulatory support in these patients, Dr. Srivastava notes that percutaneous support devices are “extremely afterload sensitive and preload dependent.” “Have them higher on volume than lower,” he adds. “You’re less likely to see pump issues. You’re less likely to have hemolysis-related issues. Tank them up. You can always diurese them after the shock has subsided.”

“The challenge occurs when you’ve got a bad right ventricle,” Dr. Hall explains. “The right ventricle needs to be dry, if possible. If you shrink your LV cavity down too much, then you’re going to have marked difficulties with your percutaneous pumps. But if your RV can’t deliver to the left ventricle, the same problem ensues.”

Dr. Hall also states that she and her fellow cardiologists have learned a lot about the importance of the right ventricle through durable and percutaneous support devices. “I think we’ve learned that we don’t know nearly enough in trying to figure out ways to support the right ventricle in dealing with that volume.” She notes that cardiologists often find themselves in situations where trying to provide adequate volume for the left ventricle winds up hurting the right ventricle.

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