从诊断到器械治疗的心源性休克管理:一篇叙述性综述

The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review.

作者信息

Alkhunaizi Fatimah A, Smith Nikolhaus, Brusca Samuel B, Furfaro David

机构信息

Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY.

Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC.

出版信息

CHEST Crit Care. 2024 Jun;2(2). doi: 10.1016/j.chstcc.2024.100071. Epub 2024 Apr 16.

Abstract

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.

摘要

心源性休克(CS)是一种异质性综合征,其广泛特征为心输出量不足,导致组织灌注不足和多系统器官功能障碍,死亡率持续居高不下。CS的治疗进展迅速,尤其是随着临时机械循环支持(tMCS)设备的应用。在现代重症监护病房(ICU)中,全面了解如何诊治CS患者以及选择合适的监测和治疗模式至关重要。及时明确CS的严重程度和血流动力学情况对于优化治疗结果很有必要,而这最好由多学科休克治疗团队来完成。在本文中,我们对CS进行综述,旨在为心内科专业和非心内科专业的重症监护医生提供信息。我们简要描述CS的病因、病理生理特征、诊断及严重程度分级,重点收集做出管理决策所需的关键信息。接着,我们将更详细地综述CS的管理原则及实际应用,重点是tMCS。药物治疗侧重于通过增强心肌收缩力和降低后负荷来优化灌注以实现充分充血,并促进充血缓解。对于更严重的CS患者,或尽管接受药物治疗但血流动力学状态仍在恶化的患者,启动适当的tMCS越来越普遍。我们讨论目前用于CS患者的最常见设备——将患者分为左心室衰竭、右心室衰竭或双心室衰竭类型——并强调为tMCS设备选择提供依据的关键现有数据和特殊考虑要点。最后,我们强调CS患者镇静和呼吸衰竭管理的核心要点。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/dd6f/11238736/8040e1e871d1/nihms-2005418-f0001.jpg

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