Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (A.G.P., M.J.D.G.).
Clinic For Anaesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany (A.G.P.).
Circ Heart Fail. 2021 Dec;14(12):e008635. doi: 10.1161/CIRCHEARTFAILURE.121.008635. Epub 2021 Nov 22.
Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management.
An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis.
There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support.
While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
目前的心源性休克治疗是基于专家意见和专业学会的科学声明，这些意见和声明的依据是有限的高质量随机临床试验数据，无法为最佳患者管理提供信息。一个国际专家组采用改良 Delphi 法，旨在确定心源性休克患者管理方面存在不确定性的方面。
召集了一个由 18 名多学科专家组成的国际小组。采用改良的 RAND/加州大学洛杉矶分校适宜性方法。完成了一项包含 70 个陈述的调查。参与者匿名对每个陈述的适宜性进行评分，范围为 1 到 9：1 到 3 表示不合适，4 到 6 表示不确定，7 到 9 表示合适。对结果进行了小组讨论，并对调查进行了迭代，然后再进行最终分析。
与当前的国际指南和共识声明有广泛的一致性。总体而言，44 项陈述被评为适当，19 项陈述为不确定，7 项陈述为不适当。所有陈述的分歧指数均<1，不存在分歧。常规液体给药被认为是不合适的。不确定的领域主要集中在 PCI 前干预、右心导管检查指导管理、常规使用左心室卸载策略以及考虑升级为机械循环支持时的无效标志物。
虽然与当前指南有广泛的一致性，但专家组发现了一些治疗方面存在临床均衡的情况，这进一步强调了需要进行随机对照试验，以更好地指导心源性休克患者的管理和决策。
