Ensuring rapid identification and treatment of cardiogenic shock
Innovations in Cardiovascular Medicine and Surgery - Summer 2018
HIRAM G. BEZERRA, MD, PHD
Director, Coronary Intervention & Circulatory Support, UH Harrington Heart & Vascular Institute; Associate Professor of Medicine, Case Western Reserve University School of Medicine
FRANCIS (TED) LYTLE, MD
Medical Director, Integrated Heart and Vascular Intensive Care Center, University Hospitals; Assistant Professor, Anesthesiology and Perioperative Medicine, Case Western Reserve University School of Medicine
BENJAMIN MEDALION, MD
Surgical Director, Mechanical Circulatory Support, UH Cleveland Medical Center, Director, Cardiac Surgery, UH Ahuja Medical Center; Professor of Surgery, Case Western Reserve University School of Medicine
CHRISTOPHER MILLER, MD
Chairman, Department of Emergency Medicine, UH Cleveland Medical Center; Clinical Professor, Emergency Medicine, Case Western Reserve University School of Medicine
GUILHERME OLIVEIRA, MD
Director, Advanced Heart Failure & Transplant Center, UH Harrington Heart & Vascular Institute; Lorraine and Bill Dodero Master Clinician in Heart Failure and Transplantation; Associate Professor of Medicine, Case Western Reserve University School of Medicine
When a patient presents with cardiogenic shock at a University Hospitals facility, the event immediately triggers a rapid response from the system’s Shock Team.
“We are developing a comprehensive program for the early identification, coordinated treatment and long-term follow-up of our patients presenting with cardiogenic shock,” says Ted Lytle, MD, Medical Director of the Integrated Heart and Vascular Intensive Care Center at University Hospitals. “While our physicians and nurses have already been providing quality care individually, we recognized a need across Northeast Ohio to enhance the structure and process behind this care, with an emphasis on streamlined communication and quality outcomes.”
The multidisciplinary Shock Team has been in place for the past year and includes world-renowned UH physicians specializing in emergency medicine, critical care, interventional cardiology, heart failure and cardiovascular surgery, as well as expert physician assistants, nurse practitioners, nurses and respiratory therapists. On-call team members are activated through a single phone call via the UH phone transfer center and immediately convene by phone to decide the optimal front-line approach to stabilize each patient. Using a detailed algorithm that the team has developed, they evaluate the severity of shock and coordinate efforts to determine a treatment plan.
“Cardiogenic shock is one of the most lethal situations for the human body,” says Hiram Bezerra, MD, PhD, Director of Coronary Intervention & Circulatory Support, UH Harrington Heart & Vascular Institute. “The sooner we offer therapy, the greater the chance we can reverse tissue hypoxia and reduce mortality rates.”
Dr. Bezerra adds that while hospitals nationwide provide IV therapies such as vasopressors and inotropes, these medications constrict blood vessels and can overwork the already stressed heart. They are best prescribed as a bridge to more effective evaluation and treatment through mechanical support, interventional cardiology or surgery, he says.
A COORDINATED RESPONSE
Efficient, coordinated care transitions are critical to ensure each patient receives the most effective intervention.
“Successful clinical outcomes hinge on early prehospital identification and transfer to an appropriate emergency department equipped to initiate high-intensity resuscitation efforts as led by the on-site Emergency Medicine team,” says Christopher Miller, MD, Chairman, Department of Emergency Medicine. “Our system-based, collaborative approach will differentiate UH as a leader in this high-risk disease continuum.”
UH Harrington Heart & Vascular Institute offers 15 locations throughout Northeast Ohio that can provide front-line therapy and activate the Shock Team. At least seven of the facilities also offer temporary percutaneous mechanical heart support as well as Swan-Ganz™ catheterization that generates a full hemodynamic profile to inform treatment decisions. If escalation of care or a greater level of mechanical support is indicated, patients are quickly transferred within the UH system to the most suitable setting (see Fig. 1).
Once the underlying cause of shock is diagnosed (e.g., myocardial infarction, viral myocarditis or chronic heart failure), the team reaches a consensus on next steps.
“Traditionally, patients in acute shock were initially taken to the cath lab to open the culprit artery,” explains Guilherme Oliveira, MD, Director of the Advanced Heart Failure & Transplant Center, UH Harrington Heart & Vascular Institute. “However, data have shown that it is more important to first rescue the shock and improve hemodynamics. It is critical to determine which mode of mechanically supported intervention is best by evaluating whether the patient requires uni- or biventricular support as well as the level of cardiac output necessary to restore end-organ perfusion.”
After hemodynamic collapse is reversed, the Shock Team can offer a full range of interventional and surgical options. Benjamin Medalion, MD, Surgical Director, Mechanical Circulatory Support, UH Cleveland Medical Center, says, “Whenever we have a shock activation, we devise a plan according to the disease of the patient. From minimally invasive revascularizations to advanced surgical procedures, every decision is based on communication between team members.”
Dr. Medalion notes that Shock Team members will also respond to the patient’s location. If a patient from a UH regional facility is deemed too unstable for transport, a surgical team will go to the site to apply extracorporeal membrane oxygenation (ECMO) so that cardiac and respiratory support can be established, and the patient can be stabilized for transport to UH Cleveland Medical Center for continued treatment.
In addition to optimizing care, the Shock Program is providing opportunities for innovation and research:
- A database has been developed to track quality outcomes of cardiogenic shock patients.
- Clinical results will inform systemwide continuing education and curriculum development.
- A research component will mine the collected data for investigational projects.
- Cost and resource utilization endpoints will help ensure fiscal responsibility.
For more information or to refer a patient, call (216) 844-3800 or email HVInnovations@UHhospitals.org.
A national leader in integrated cardiopulmonary services, the UH Harrington Heart & Vascular Institute utilizes a range of industry-leading mechanical circulatory support devices, including:
- Impella CP®, 3.5-4.0 L/min left ventricular support; placed by interventional cardiologist
- Impella 5.0®, 5.0 L/min left ventricular support; requires surgical cut down
- Impella RP®, 4.0 L/min right ventricular support; placed by interventional cardiologist
- ProtekDuo, 4.0 L/min biventricular support; placed by interventional cardiologist
- ECMO provides both cardiac and respiratory support