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Baldetti L, Gallone G, Filiberti G, Pescarmona L, Cesari A, Rizza V, Roagna E, Gurrieri D, Peveri B, Nocera L, Cianfanelli L, Marcelli G, De Lio G, Boretto P, Angelini F, Gramegna M, Pazzanese V, Sacchi S, Calvo F, Ajello S, De Ferrari GM, Frea S, Scandroglio AM. Mixed Shock Complicating Cardiogenic Shock: Frequency, Predictors, and Clinical Outcomes. Circ Heart Fail 2024; 17:e011404. [PMID: 38979611 DOI: 10.1161/circheartfailure.123.011404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/11/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Patients presenting with cardiogenic shock (CS) are at risk of developing mixed shock (MS), characterized by distributive-inflammatory phenotype. However, no objective definition exists for this clinical entity. METHODS We assessed the frequency, predictors, and prognostic relevance of MS complicating CS, based on a newly proposed objective definition. MS complicating CS was defined as an objective shock state secondary to both an ongoing cardiogenic cause and a distributive-inflammatory phenotype arising at least 12 hours after the initial CS diagnosis, as substantiated by predefined longitudinal changes in hemodynamics, clinical, and laboratory parameters. RESULTS Among 213 consecutive patients admitted at 2 cardiac intensive care units with CS, 13 with inflammatory-distributive features at initial presentation were excluded, leading to a cohort of 200 patients hospitalized with pure CS (67±13 years, 96% Society of Cardiovascular Angiography and Interventions CS stage class C or higher). MS complicating CS occurred in 24.5% after 120 (29-216) hours from CS diagnosis. Lower systolic arterial pressure (P=0.043), hepatic injury (P=0.049), and suspected/definite infection (P=0.013) at CS diagnosis were independent predictors of MS development. In-hospital mortality (53.1% versus 27.8%; P=0.002) and hospital stay (21 [13-48] versus 17 [9-27] days; P=0.018) were higher in the MS cohort. At logistic multivariable analysis, MS diagnosis (odds ratio [OR], 3.00 [95% CI, 1.39-6.63]; Padj=0.006), age (OR, 1.06 [95% CI, 1.03-1.10] years; Padj<0.001), admission systolic arterial pressure <100 mm Hg (OR, 2.41 [95% CI, 1.19-4.98]; Padj=0.016), and admission serum creatinine (OR, 1.61 [95% CI, 1.19-2.26]; Padj=0.003) conferred higher odds of in-hospital death, while early temporary mechanical circulatory support was associated with lower in-hospital death (OR, 0.36 [95% CI, 0.17-0.75]; Padj=0.008). CONCLUSIONS MS complicating CS, objectively defined leveraging on longitudinal changes in distributive and inflammatory features, occurs in one-fourth of patients with CS, is predicted by markers of CS severity and inflammation at CS diagnosis, and portends higher hospital mortality.
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Affiliation(s)
- Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Gaia Filiberti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Luca Pescarmona
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Andrea Cesari
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Vincenzo Rizza
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Edoardo Roagna
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Davide Gurrieri
- Mathematics Department, Polytechnic University of Milan, Italy (D.G.)
| | - Beatrice Peveri
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Lorenzo Nocera
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Lorenzo Cianfanelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Gianluca Marcelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Giulia De Lio
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
| | - Paolo Boretto
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
| | | | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Silvia Ajello
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
- Department of Medical Sciences, University of Turin, Italy (G.G., L.P., E.R., L.N., G.M., G.M.D.F.)
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy (G.G., E.R., L.N., G.M., G.D.L., P.B., F.A., G.M.D.F., S.F.)
| | - Anna Mara Scandroglio
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., G.F., A.C., V.R., B.P., L.C., M.G., V.P., S.S., F.C., S.A., A.M.S.)
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Zhang H, Xu Y, Huang X, Yang S, Li R, Wu Y, Zou X, Yu Y, Shang Y. Extracorporeal membrane oxygenation in adult patients with sepsis and septic shock: Why, how, when, and for whom. JOURNAL OF INTENSIVE MEDICINE 2024; 4:62-72. [PMID: 38263962 PMCID: PMC10800772 DOI: 10.1016/j.jointm.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 01/25/2024]
Abstract
Sepsis and septic shock remain the leading causes of death in intensive care units. Some patients with sepsis fail to respond to routine treatment and rapidly progress to refractory respiratory and circulatory failure, necessitating extracorporeal membrane oxygenation (ECMO). However, the role of ECMO in adult patients with sepsis has not been fully established. According to existing studies, ECMO may be a viable salvage therapy in carefully selected adult patients with sepsis. The choice of venovenous, venoarterial, or hybrid ECMO modes is primarily determined by the patient's oxygenation and hemodynamics (distributive shock with preserved cardiac output, septic cardiomyopathy (left, right, or biventricular heart failure), or right ventricular failure caused by acute respiratory distress syndrome). Veno-venous ECMO can be used in patients with sepsis and severe acute respiratory distress syndrome when conventional mechanical ventilation fails, and early application of veno-arterial ECMO in patients with sepsis-induced refractory cardiogenic shock may be critical in improving their chances of survival. When ECMO is indicated, the choice of an appropriate mode and determination of the optimal timing of initiation and weaning are critical, particularly in an experienced ECMO center. Furthermore, some special issues, such as ECMO flow, anticoagulation, and antibiotic therapy, should be noted during the management of ECMO support.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Youdong Xu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Xin Huang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Shunyin Yang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
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