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PMPR 430 > Cardiogenic Shock and Mechanical Circulatory Support > Flashcards

Cardiogenic Shock and Mechanical Circulatory Support Flashcards

1
Q

What is cardiogenic shock

A

A state of critical end organ hypoperfusion due to reduced cardiac output

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2
Q

What is the determinant for cardiogenic shock with regards to hypotension

A

Systolic blood pressure less than 90 mmHg OR A reduction in MAP of 30 mmHg or more from baseline

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3
Q

What is the determinant for cardiogenic shock with regards to Cardiac Index

A

Cardiac Index less than 2.2 L/min/m2 for patients receiving vasoactive medications or mechanical support OR Cardiac Index less than 1.8 L/min/m2 for patients not receiving vasoactive medications or mechanical support

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4
Q

What is the determinant for cardiogenic shock with regards to Adequate Filing Pressure

A

Pulmonary artery wedge pressure (PAWP) greater than 15 -18 mmHg

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5
Q

What is the progression of cardiogenic shock

A

Myocardial injury cause a reduction in stroke volume reducing cardiac output -> Systemic coronary hypoperfusion with an increase in afterload -> systemic inflammatory response -> more myocardial injury

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6
Q

What are the two major causes of left ventricular pump failure

A

Acute myocardial infarction (AMI) and End-stage cardiomyopathy

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7
Q

What are some presentations patients will have with cardiogenic shock

A

Hypotension/tachycardia, decreased urine output, cool extremities, cyanotic (blueish coloring of skin), altered mental status

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8
Q

What are labs findings to aid in seeing if there is cardiogenic shock

A

Troponin, elevated BNP (greater than 100mmHg), elevated lactate, Mixed venous Saturation (SVO2) less than 70%, elevated creatinine, transaminitis/coagulation abnormalitites

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9
Q

What key findings can be found from the pulmonary artery cathether

A

PCWP (15-18 mmHg) and Cardiac Index 2.6-4.2 L/min/m2

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10
Q

What happens to cardiac output, afterload, preload, and SVO2

A

Decreased, increased, increased, decreased

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11
Q

What are the four hemodynamic classes for the heart

A

Class 1: Warm and Dry (Normal)
Class 2: Warm and Wet (Too much salt)
Class 3: Cold and Dry (bad pump)
Class 4: Cold and Wet (Cardiogenic shock)

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12
Q

What class of drugs should be given for cardiogenic shock

A

Diuretics PLUS Inotropes PLUS Vaspressors

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13
Q

T/F: Fluids should never be given to a patient who is going through cardiogenic shock as they are already volume overloaded

A

False: Some patients may require 250-500ml bolus IF NO PULMONARY CONGESTION and no other signs of fluid overload

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14
Q

What diuretics should be given to patients with cardiogenic shock, hemodynamic effect

A

Loop diuretics: Furosemide 40 mg, Bumetanide 1mg, ethacrynic acid 50 mg, torsemide 20 mg/ less preload leads to increased stroke volume and cardiac output

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15
Q

What are the ionotropes should be given to patients with cardiogenic shock

A

Dobutamine and Milrinone

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16
Q

What are the benefits of dobutamine

A

Inotropic effects are desirable, increased cardiac output, attack quickly with a quick half life

17
Q

What are the adverse effects of dobutamine

A

Arrhythmias, hypotension, tachphylaxis

18
Q

T/F: Since a beta-blocker is a negative ionotrope it should be stopped if a patient is being given dobutamine since it is a positive ionotrope

A

True

19
Q

Why is milrinone a more potent to effect blood pressure Inotrope

A

Not only are the ionotropic effects good but milrinone also causes increased calcium at the veins and arteries too causing vasodilation reducing systemic and pulmonary resistance

20
Q

What are the adverse effects of milrinone

A

Arrhhythmias and Hypotension

21
Q

Which ionotrope is renally eliminated, hepatic

A

Milrinone, Dobutamine

22
Q

What are the two best vasopressors for cardiogenic shock

A

Norephinephrine and dopamine

23
Q

What is the risk of using dopamine

A

Dopamine causes arrhythmias

24
Q

What are the types of mechanical circulatory Support

A

Intra-Aortic Ballon Pump, Left Ventricular Support Device, Extracorporeal Membrane Oxygenation, Left Ventricular Assist Device

25
Q

What is the most commonly used MCS, when is it used

A

Intra-Aortic Balloon Pump (IABP)/ Cardiogenic shock, high risk PSI, and refractory heart failure

26
Q

What is the mechanism for IABP

A

Counterpulsation: Inflates during diastole (increasing coronary perfusion) and deflates during systole (abruptly decreases afterload and enhances left ventricular ejection) increasing cardiac output

27
Q

What are cautions associated with IABP

A

Anticoagulation (heparin), thrombocytopenia, antimicrobials

28
Q

What is the short term MCS, mechanism, indications

A

Impella: pumps blood from the LV into the ascending aorta but effectiveness is dependent on the RV, used during high risk PCI or less than 6 days after cardiogenic shock

29
Q

What are the two ways patients are anticoagulated on impella

A

Systemic anticoagulation with heparin, purge solution to prevent blood entrance into the motor chamber

30
Q

How much purge heparin solution are patients given for impella catheter

A

If they weigh less than 80kg: 25 units/ml, If they weight more than 80kg: 50 units/ml

31
Q

What is the Impella purge Infusion Rate, maintenance systemic intravenous heparin

A

2-30 mL/hour, Hperain 25,000 units/250mL Dextrose 5% (units/hour)

32
Q

What is the equation to calculate INITIAL IV infusion rate

A

Initial TOTAL Infusion Rate- PURGE Rate

33
Q

What are the two types of extracorporeal membrane Oxygenation

A

Venovenous bypass: Bypass lungs: venous circulation -> oxygenator -> right atrium
Venoarterial bypass: Bypasses lungs and heart: Venous circulation -> oxygenator -> (femoral artery) arterial circulation

34
Q

What are the three type of LVADs

A

Heartmate 2, Heartware, Heartmate 3

35
Q

What are the four items that must be present with LVADs

A

LVAD pump, batteries, driveline, and controller

36
Q

How does the LVAD work, what type of anticoagulation is used

A

Pumps blood from left ventricle to aorta/ asprin 81 mg daily and warfarin for an INR between 2-3

37
Q

What are the ways to classify cold and wet

A

Cardiac index less than 2.2 (cold) and pulmonary capillary wedge pressure greater than 18 (wet)

PMPR 430 (21 decks)

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