Beruflich Dokumente
Kultur Dokumente
du choc cardiogénique
en dehors de la revascularisation
Ivan LAURENT
Institut Hospitalier Jacques Cartier
Massy
Qu’est-ce qu’un choc cardiogénique?
THEORICIEN CLINICIEN
–HypoTA persistante
–Bas-débit cardiaque (PAS < 90 mmHg > 30 min)
–⇒ hypoperf. tissulaire – + signes d’hypoperf périph.
–malgré un (↓ vigilance, extrémités
volume intra-vasc. fraîches, oligurie)
adéquat – ∅ réponse remplissage vasc.
– + doc. dysfonction
myocardique
HEMODYNAMICIEN
–IC < 2.2l/min/m²
–PAPO > 18 mmHg
–RVSI > 1800-2000 dynes.s/cm5
Etiologies du choc cardiogénique
Choc cardiogénique
H
H 100 %
75 %
50 % 7.2 %
25 %
(GUSTO I)
0%
Sus-décalage ST
H
25 % 50 %
Sans ST+ 2.9 %(PURSUIT)
The downward spiral
in cardiogenic shock
Myocardial dysfunction
Systolic Diastolic
↓ systemic Hypotension
perfusion
↓ coronary perfusion Hypoxemia
pressure
Compensatory
vasoconstriction, Ischemia Progressive
fluid retention myocardial
dysfunction
6-months
63.1% 50.3% -12.8%, p=0.027
Mortality
Pump Failure
Reinfarction
Myocardial rupture
Arrhythmia 40
Other cardiac death 30
Stroke 20
Anoxic encephalopathy
10
Procedure related deaths
0
0 3 6 9 12 15 18 21
Day of death
Brodie BR, et al. Am J Cardiol 1997; 79: 1586-91
Eliminer une complication mécanique
imposant la chirurgie en urgence
Mechanical complications of AMI
diagnosed by TEE
LA
RV
LV
LV Ao
Hypoxia
↑ O2 demand
Tachycardia
↑ Wall stress
↑Respiratory
muscle VO2
Respiratory muscle fatigue leading to apnea
during cardiogenic shock
n= 13 dogs (spontaneous ventilation)
15
10
0
C 30 60 90 120 150
Time (min)
VE (l/min) Pdi (cmH2O)
Aubier M, et al. Am J Physiol 1981; 51:499-508
Cardiovascular effects of hypoxemia
120
in animal models
21%
11.9%
Pressure (mmHg)
60
0
0 20 40
Volume (ml) above baseline
Walley KR, et al. Circ Res 1988; 63:849
Cardiovascular effects of respiratory acidosis
in animal models
150
Eucapnia
Hypercapnia
β- Eucapnia
LV Pressure (mmHg)
β- Hypercapnia
100
50
0
0 20 40
LV Volume (ml)
Walley KR, et al. Circ Res 1990; 67:628
Hemodynamic benefit of mechanical
ventilation
in cardiogenic shock
PV
LV pressure (mmHg)
ES
R
↓ ITP
PV
ES
↓ LV ejection
pressure
↓ LV ejection
pressure ↑ ITP
↑ ITP
↓ LV preload
↓ LV preload
75
50
25
0
IABP Weaning Hospital discharge
IABP alone (n= 18) IABP + MV (n=10)
• Induction anesthesia
– Etomidate 20 mg + Midazolam 2mg +
Vecuronium 10mg IV
• Maintenance of anesthesia
– Midazolam 5mg/h IV + Fentanyl 100 mcg/h
– Curare agent for paralysis as required
Preload must be increased
during low cardiac outputs
Normal volume
Normal contractility
Increased preload
Normal preload
Depressed contractility
Increased preload
OUTPUT
VASCULAR LOAD
Survivors
4.0
Non survivors
CI (L.min-1.m²)
2.1
2.0
10 18 20 30 40
PAOP (mmHg)
Forrester JS, et al. N Engl J Med 1976; 295: 1356
Fluid challenge monitored
by Continuous Cardiac Output
3.2 3.5
3.0
CI
2.5
2.0
13:00 13:15 13:30 13:45 14:00 14:15 14:30
PAOP 20 19 21 22 22
Hemodynamic management of cardiogenic
shock in clinical practice
General
Anesthesia
Volume loading+
PAM <65
Acute respiratory
Mechanical
SHOCK failure
ventilation +
Encephalopathy PEEP
Dobutamine 10-15
Volume loading++
Consider
epinephrine
Transfer to PCI center
VIP for cardiogenic shock
in clinical practice
5 10 Days
Mech.Ventilation Weaning
V
SHOCK
Catecholamines Discontinuation
P
IABP
ACE inhibitors
How to monitor a VIP
•General Electric
•Datascope
•Siemens
Le ST, plus puissant facteur
de complications en post-infarctus
• Masimo SET oximeters detect approximately 10 times more true events than any "Next Generation"
pulse oximeter.1
• Masimo SET oximeters have one-tenth the false hypoxemia alarms of "Next Generation" pulse
oximeters.1, 2, 3, 4
Un zeste d’inflammation…
10
TNF a (pg/mL)
8
6
4
2
0
Control I II III IV
NYHA Functionnal Class
Systemic inflammation in patients
with cardiogenic shock
ng/mL pg/mL
200 600
150
400
100
200
50
0 0
Controls (n=7) Cardiogenic Septic shock
shock (n=7) (n=15)
TNF a TNF 2r IL-6
De WERRA I, et al. Crit Care Med 1997; 25: 607-13
The cytokine hypothesis
TNF-α
IL-6
↑ LV size
Stretch
↓ LV Function
?
? Immune
activation
58 %
59 %
Xanthine
Peroxydation oxydase Production de radicaux
lipidique libres
Lésions cellulaires Protéases Adhésion/migration des
endothéliales PNN
Liquide de
réinjection
TNF-α
IL-6
C3a, C5a Ultrafiltrat
groupe A
0.50
groupe B
0.25 groupe C
0.00
0 20 40 60
analysis time (day)
• Patients:
– Total: 352 40
– ACR d’origine cardiaque
– Rythme initial: FV
– Coma persistant
– Hémodynamique stable
20
ISAR-SHOCK Trial
26 pts cardiogenic shock
N=12 N=13