UR Medicine Acute Shock Program
Patient Referral Guidelines
Cardiogenic Shock
Cardiogenic Shock Team Coordination
STEP 1: INCLUSION CRITERIA
Shock Team Goals
- Early identification of shock
- Early invasive hemodynamic assessment (RHC, PAC)
- Early support with MCS to minimize vaso/inotropes
- Early assessment for heart recovery and ability to wean MCS
- Early referral for advanced therapies if unable to wean
- CPO = MAP x CO/451
- PAPi = (sPAP-dPAP)/RA
Cardiogenic shock suspected
Must have at least one from both (A) and (B)
Must have at least one from both (A) and (B)
(A) Clinical Criteria
Acute Coronary Syndrome or Heart Failure suspected
Acute Coronary Syndrome or Heart Failure suspected
-
Hypotension
- SPB <90 or MAP <60 for >30 min
- Lactate >/= 3
-
Evidence of end-organ malfunction
- Encephalopathy
- AKI, UOP <30cc/hr
- Acute liver injury
Hemodynamic Criteria*
- Cardiac Index < 1.8
-
Cardiac index < 2.2 with inotropes at moderate doses**
- PCWP > 15
- RAP > 12
RA:PCWP > 0.6 - CPO < 0.6
- PAPi < 1
- LVEF < 40%
- LVOT VTI < 16
- TAPSE < 16
Epinephrine >/=0.04
Dobutamine >/=5
STEP 2: REVIEW
Relative Exclusion Criteria for MCS:
- Age > 75
- Neurologic injury
- Severe MOSF
- Bleeding
- Prohibitive vascular access
- DNR
If criteria for cardiogenic shock are met: Shock team alert with CICU/Cardiac surgery review and discussion.
- Confirmation of cardiogenic shock Medical optimization
- Evaluation of exclusion criteria
STEP 3: ACTIVATE
Shock team activation with virtual discussion before mechanical circulatory support (MCS) referral:
CICU, Cardiac surgery, Interventional cardiology, Heart Failure
Admit to cardiac intensive care unit Resuscitation, medical optimization, temporary MCS
Is there Cardiogenic Shock that warrants temporary MCS?
YES
NO
BiV CS
CPO < 0.6
PAPI < 1
RAP > 12;
RAP:PCWP > 0.8
PWCP > 15
CPO < 0.6
PAPI < 1
RAP > 12;
RAP:PCWP > 0.8
PWCP > 15
VA ECMO
+/- LV Vent
+/- LV Vent
LV Dominant CS
CPO < 0.6
PAPi > 1
RAP < 12;
PWCP > 15
CPO < 0.6
PAPi > 1
RAP < 12;
PWCP > 15
IABP
Impella CP
Impella 5.5
VA ECMO
+/- LV Vent
Impella CP
Impella 5.5
VA ECMO
+/- LV Vent
RV Dominant CS
CPO < 0.6
PAPi < 1
RAP > 12;
PWCP < 15
CPO < 0.6
PAPi < 1
RAP > 12;
PWCP < 15
Impella RP
Protek Duo
VA ECMO
Protek Duo
VA ECMO
CPO > 0.6
PAPi > 1
RAP < 12;
PWCP < 15
PAPi > 1
RAP < 12;
PWCP < 15
- Wean vasopressors and ionotropes
- IVF to goal
- RAP > 10 and/or PCWP > 12