Intravascular Imaging, Patient Management, AMI Cardiogenic Shock

Monitoring on the ICU: Integrating Hemodynamic Assessment, Laboratory Data, and Imaging Techniques for Timely Detection of Deterioration and Recovery

Christophe Vandenbriele, Luca Baldetti, Alessandro Beneduce, Jan Belohlavek, Christian Hassager, Marina Pieri, Amin Polzin, Mara Scandroglio, Jacob Eifer Møller

Key Topics and Take Aways

  • Echocardiography, hemodynamic monitoring tools (eg. pulmonary artery catheters), and numerous lab tests form the cornerstone of monitoring patients with cardiogenic shock supported with percutaneous ventricular assist devices (pVADs).
  • Effective monitoring in patients with cardiogenic shock supported by pVADs should be able to detect signs of heart recovery, inadequate support, the need for escalation, biventricular failure, and patient or device complications, as well as assess preload and identify any need for left ventricular (LV) venting.
  • It is important to establish widely accepted ICU monitoring protocols for all critical steps of pVAD management (eg. anticoagulation management, weaning, device position assessment) for patients with cardiogenic shock.

This article discusses best practices for monitoring patients in the intensive care unit (ICU) with cardiogenic shock who are supported by a microaxial flow pump (mAFP) such as Impella® devices, venoarterial extracorporeal membrane oxygenation (VA ECMO), or both devices together, a combination referred to as ECpella. The authors write, “Effective monitoring should be able to assess preload, detect signs of recovery or of inadequate support and the need for escalation, detect signs of biventricular failure and/or other complications, and identify any potential need for left ventricular (LV) unloading.”

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The authors emphasize that “a comprehensive multimodal approach encompassing both continuous and non-continuous techniques should be available at all times.” They describe the importance of bedside echocardiography for determining the etiology of shock, assessing native heart function, identifying complications, and assisting in device positioning. In addition, a pulmonary artery catheter (PAC) can provide information about involvement of the right ventricle, monitor hemodynamic trends, and assess native heart recovery. It is also important to monitor end-organ function with lab panels including lactate, and to monitor plasma free hemoglobin, lactate dehydrogenase (LDH), and/or bilirubin levels for signs of hemolysis.

The authors also discuss the challenges of oxygenation monitoring in patients on VA ECMO support and the goals of monitoring patients supported with ECMELLA.

Table 1 :Overview of Various Monitoring Tools/Metrics by System to Assess Critically Ill Cardiogenic Shock Patients During pVAD Support Table 1 :Overview of Various Monitoring Tools/Metrics by System to Assess Critically Ill Cardiogenic Shock Patients During pVAD Support
Table 1 :Overview of Various Monitoring Tools/Metrics by System to Assess Critically Ill Cardiogenic Shock Patients During pVAD Support

“In recent years, the PAC has experienced a true revival, especially in the domain of CS, and should likely be considered a standard monitoring tool in the management of pVAD-supported CS patients.”

The authors conclude, “Finally, it is of paramount importance to establish a monitoring management protocol based on local capabilities and expertise, enabling physicians within the same unit to apply a standardized approach to management. These protocols should be present for all critical steps of pVAD management (e.g., anticoagulation management, weaning, device position assessment). Implementing a widely accepted ICU protocol for each of these critical steps might be the key to reducing morbidity and mortality and improving outcomes in this critically ill patient population.”

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