Banter At The Bedside
Banter at the Bedside dives into the real stories of healthcare — the ones that happen behind the curtains, between shifts, and at the bedside. Hosted by frontline professionals, each episode brings together voices from across the healthcare spectrum to share their perspectives — from laughter in the breakroom to the moments that change everything. Whether you’re in scrubs or just curious about life inside the hospital, join us for honest, thoughtful, and sometimes hilarious conversations about what it really means to care for others.
Banter At The Bedside
Cardiogenic Shock Part 2: When to Escalate Care, and Call the Shock Team
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Cardiogenic shock management doesn’t stop with recognizing preload, afterload, and contractility. The hardest decisions often come next: when to escalate care and when to activate advanced support.
In Part 2 of this cardiogenic shock education series, Abby (NP) and Kaleigh (RN) continue their conversation with Dr. Michael to explore how clinicians decide when medical therapy isn’t enough—and what happens next.
Together they discuss how to interpret clinical trajectory, when to escalate from vasopressors to inotropes, and how mechanical circulatory support devices fit into modern cardiogenic shock care. They also break down how cardiogenic shock teams help coordinate faster decisions and improve survival across health systems.
If you work in the ICU, ED, cardiology, or critical care —or if you're learning advanced hemodynamic decision-making—this episode connects physiology to real bedside escalation strategies.
This episode is for educational and entertainment purposes only and does not represent medical advice.
Hey everyone, and welcome back to Banter at the Bedside. This week we have part two of our education on cardiogenic shock management with Dr. Michael and Nurse Kaylee as well as me, Abby, the nurse practitioner. This is a continuation on from last week's episode. If you haven't listened to it, go and listen to that first part. It's going to make the second part make a lot more sense. Although you can listen to the second part as a standalone as we focus on advanced cardiogenic shock management as well as the development of cardiogenic shock teams. As a reminder, this is for entertainment purposes only. None of this is medical advice. Please seek the care of your own medical professional. We do not represent any entity. All of the thoughts and opinions are our own. So here we are. We're going to go into it. And welcome back to cardiogenic shock management part two.
SPEAKER_00All right. So I guess the next thing we can talk about is we can either just briefly talk about some RV side of this thing, or I can go ahead and just jump into like the the ins and outs of like a cardiogenic shock initiative.
SPEAKER_01Yeah. Why don't you touch briefly on the RV? Because I know you used to want to just so badly.
SPEAKER_00Yeah, I I love RV dysfunction. I think it's fascinating. I think it it's just uh it is it's very interesting how sensitive it is. Oftentimes it just doesn't get discussed. Like, like most of what I got taught was, oh, the the right ventricle loves fluid, just give it a bunch of fluid, which is not true. It handles preload well because it's super thin and it's stretchy. So in normal conditions, it handles preload better better than the left ventricle because the left ventricle is like thick, so it's not going to stretch as well. But it doesn't mean it loves fluid. Um, if you have a RV contractility issue, you can still over-distend your RV and make it so it squeezes even worse. Same thing with like RV afterload. The RV is not designed to handle any afterload. It's not designed to push against anything. It's thin, it just hangs out on the side of the left ventricle, it's like a wall. And so if you start putting stuff in the way, like a PE or pulmonary hypertension, the RV just gives up. Like it is just not designed to push against anything that's difficult. Um, and so people with chronic sleep apnea, people with like chronic lung disease, all of a sudden they'll just be hanging along and then their RV will just quit on them because it just keeps getting distended, distended, because it it's not used to having to work against all that stuff. Because the of it being the RV, it backs up fluid really, really easily. And so you get renal failure so quick. So, like you guys have taken care of these RV failure people, but like we were saying before, like the amount of them that end up on dialysis is way more than the amount of them that on the LV side because they get so much venous congestion because it really is a problem on the venous side. And so you'll have these crazy high CBPs, you'll just have these super dilated IBC and all that pressure backs up to the kidneys and gives them venous congestion. They actually did a study where they looked at heart failure patients and they said, uh, you know, like cardiorenal syndrome, they said, what's worse for cardiore renal? Is it the low flow to the kidney or is it the venous congestion? And it was actually the venous congestion they found out that that led to acute kidney injury, worse. So if you have okay output but high venous congestion, that's worse than if you have really bad output but are but are not like super congested.
SPEAKER_01I would have guessed the opposite, which I guess is probably the hypothesis when they went in.
SPEAKER_00So really focusing on like getting rid of that fluid is going to make a huge difference down the road on their on their kidney function. The kidney's surrounded by a layer of fascia, gyrotous fascia. So it can't, it can't swell. Like your liver can swell, your intestines can swell, they can get so full of fluid that they're like, man, my abdomen's super swollen, but the kidney can't swell. It just like crushes against the fascia. Uh, and so that's why your kidney's so sensitive to to injury when it comes to to heart failure. So the the R V just really screws up that that kind of like decreased flow, high venous congestion, no flow uh to the glomerulus of the kidney. And so they they go into renal failure so quickly. Unless you can turn around an RV failure patient and they just start like pouring urine out. I I I try not to let too many hours go by of their urine output's 20, their urine output's 30. I'm just like, look, we probably just need to go ahead and pull the trigger and start like trying to remove fluid going forward with it. Um, and then contractility-wise, you can pick whatever inotrope if you but keep in mind your afterload on the right side isn't your SVR, it's your PVR, it's the resistance through your pulmonary vasculature. And like I mentioned before, milrenone lowers your pulmonary vasistance way more than like epirto-butamine. So it's gonna do two things. It's gonna allow your RB to squeeze better, but it's also gonna put, it's gonna squeeze against less resistance, so it's gonna be able to push more blood from the right side to the left side. And then vasopressors, if you're hypotensive and you need a map, vasopressin will actually uh uh it increases your squeeze on your arterial side, it increases your SVR, but it actually vasodilates your pulmonary bed, so it decreases PVR. So it makes it easier for your right heart to pump over to your left heart. So I if I had a cocktail of this person has right heart failure, it is milrenone, vasopressin, and then aggressive diuretics, um, trying to get the things going in the right direction to get some right to left flow. Is that brief enough? I can go into more with it on the thing. That's brief enough. All right. That's good.
SPEAKER_03I I do think it's interesting though, like you said that you were told or you learned that um RV loves fluid, because when I started as a nurse, they would say if you were in RV failure, right-sided failure, you had to fill the tank. And so we would give them fluids. And now we do the exact opposite. So it's just funny.
SPEAKER_00I think what that where that came from is if someone's having an inferior MI, like they're they're two, three in ABF ST elevations, you're supposed to maybe get a right-sided EKG and see is it is it inferior wall of your LV or is it like a pure RV failure? And if it's an R V failure, they are more preload dependent, which means they're not gonna tolerate a low preload. So if you give, you're not supposed to give nitroglycerin if they have chest pain, if you think it's uh inferior MI, because if you veno-dilate them with the nitro and they drop their preload, then they're gonna get very hypotensive. Not tolerating a low level does not mean they like a high level. I'd like to I always try to think of an example, but it would be like, hey, this person isn't gonna tolerate hypoglycemia. And you're like, cool, let's make their sugar 600. They must love sugar. And it's like, no, they just don't like the low side of it. So you definitely don't want to diarese or somebody with like a fresh RV infarct if you're worried about dropping their preload. You want them to have a good preload. You don't want them to have too much preload, but you want them to have like a good preload. So I think people took that and were like, RV dysfunction, give them a bunch of fluid, which is not what we should have taken away from.
SPEAKER_01Do you think it's also like obstructive shock with tampanod?
SPEAKER_00Like tampon, especially tamponod, like give them a bunch of fluid, splint it open. Yeah. But if you if you keep giving fluid to a PE, I mean, you'll definitely over distend that RV and can cause a lot of issues with it.
SPEAKER_04Mm-hmm.
SPEAKER_00So, I mean, if someone has a massive PE, you're you're right on the edge. If you like intubate them and add positive pressure, you know, we've seen people where they they are like barely hanging on, you go to intubate them because they can't breathe well and then they immediately die because you've just overstretched the RV. Um so it's a it's a sensitive, sensitive little ventricle. It fails quite easily, and it's hard to to really kind of tease out from a management standpoint.
SPEAKER_01Do you do you identify with the RV?
SPEAKER_03It sounds giving men, I'm not sure.
SPEAKER_01And a lot of people do you identify with the RV, Michael? Um no, no, no, no.
SPEAKER_03It's uh really sensitive and it's hard to figure it out.
SPEAKER_02It's people just misunderstand it. Yeah, it's lonely.
SPEAKER_00It was crazy for me to like go to fellowship and then just realize that I just had not been taught, or like this whole area was just like, you know, I was like, I went to four years of med school, like all this residency, and then it was like this is something that I don't really know about that I feel like I should have known known about, like as I went through. And so it became like a real fascination about trying to be good at it, just because it was it was this eye-opening thing of just of that whole like wow, like that just is people forget about it. Like if I ask, I always I always joke with like some of the residents or something, and I'll be like, oh, what is their echo show? And they'll be like, oh, EF's 55%. And I'm like, this is this is gonna be weird, but they actually have two sides of their heart, uh, they have vow, they got all sorts of stuff, and they're like, what are you talking about? And and you'll look, and then the RV is just doing terribly on the echo, but like everybody just ignores it. And I'm trying to like be like, hey, let's let's read the rest of that echo, you know, like there's other words past the that EF.
SPEAKER_03Yeah.
SPEAKER_00Like to try to at least like think about it and and and put some focus on it.
SPEAKER_03I mean, echo reports are not short. There's a lot. Yeah, there's a lot of measurements and information in there.
SPEAKER_00But I will say when it comes to cardiogenic shock initiatives, they've actually done a really good job of addressing the the right side. And part of it is why they think we've had such an improvement in survival whenever it comes to using a cardiogenic shock initiative, is identifying RV dysfunction early with it on there. And so I I think it's be people are starting to, when I start asking them about like what measurements are you're using or what things are you're using, uh, they're starting to actually be like, oh yeah, like I know this or I've heard of this. That's a whole separate talk when we want to talk about like measuring the hemodynamics that we talked about on preload, contractility, and after load on the left and right side. There is like a whole list of things that we can go on on like different ways you can do it. But I'll I'll go into like what we use for cardiogenic shock initiative. So I'll this part, this would be a good time to talk about it and kind of talk about how most cardiogenic shock teams or initiatives work. There's usually an identification phase, right? So you suspect somebody in cardiogenic shock, right? Like you they come to the emergency department, or maybe they they got admitted to the floor and then they've kind of decompensated and now they have an increased lactic or they've become hypotensive, or maybe they're just in the ICU already, but they're somewhere and you say, hey, you know what? This person's now in shock. I think it's cardiogenic. They've actually shown mortality benefits if you put a swan in them. The reason for this is you can get a cardiac power because you'll get a cardiac output and you'll have the map. You'll know what their filling pressures are to get a pure definition of cardiogenic shock. So you have to have low output with high filling pressures, elevated CVP, elevated wedge pressure. And you also, it's the only way currently to like reliably measure PA pressures. So there's non-invasive cardiac output devices. There's the Vigilaleo, there's the Cheetah, there's all these like different ones that you can use with it that will give you a cardiac output. So you can get a cardiac power minimally invasive or non-invasive, but it's not really going to be able to tell you what your PA pressures are. The reason that that's important is that PAPI has become the measurement of choice of deciding how sick the RB is. Um, and so that's become much, much more like even residents that aren't interested in cardiology or cardiogenic stuff will have at least heard of PAPI now just because of its popularity with the cardiogenic shock initiative. But it's pulmonary artery pulsatility index. The formula is PA Systolic minus PA diastolic divided by CBP, which makes sense because if your RB is struggling, you're not going to have a high pulse pressure in your PA. If you don't have a good squeeze, the difference between your PA systolic and your PA diastolic is going to be low. And then if you're not squeezing much blood out of your RV, then you're leaving a lot of blood in your RV and your CVP will go up. So the higher your CVP, the worse your your RV is, kind of in a way. So, and it'll make your Pappy lower because it's on the denominator. So a normal Pappy is greater than two, an abnormal Pappy is less than 1.7. Uh the big one that people talk about is like 0.9 or less, or like less than one. Sometimes people say, if it's 0.9 or less, the recommendations are put in mechanical support. So that's become like the big thing from it is get a Pappy because it's going to let you know if you need an RB support device, which is one of the big reasons why cardiogenic shock teams have been helpful in showing survival. Because if you if you have biventricular failure and you put a left-sided device in but don't address the right side, they will still fail and die because they'll just go into worse right-sided failure as you send more blood to a right side that's not doing well. So if you can identify biventricular failure, then it's going to be better. So the main thing is right now in terms of cardiogenic shock initiatives, is getting a swan in them in a timely manner. So the first step is if they're in the emergency department or if they're in on the floor, get them to an ICU as fast as you can or a cath lab, somewhere where you can reliably put a swan in them. So you put a swan in them. You want to, you want to get them to a somewhere within 30 minutes. That's kind of your goal. You want to start treating cardiogenic shock like a STEMI. You want information quickly. So you want to do in your protocol, you want to have something set up that says, like, okay, I get a call from the emergency department. It says I have a person who's, you know, 80 over 50, or 80 over whatever, 70 over 30. I had to put them on leave of Fed. Um, and they I looked at their bedside echo and their e their heart's barely moving. Then I would say at that time, you need to get somewhere quickly, right? So you need to have some sort of process in place. You need to have like a ready bed, like a landing bed, whatever you want to call it, some empty bed so that you get there within 30 minutes.
SPEAKER_04You're triggering Kaylee so bad right now.
SPEAKER_02Okay, I'm not there anymore. It's okay. I'm out of my house. I'm saying not Michael's landing bed. Look, he's not wrong. He's not wrong. He's not wrong.
SPEAKER_01He he's a hundred percent right. You should have you should clinically have a land. That's what should happen.
SPEAKER_00We want the patient to get where they need to go. So, and then you want to put a swan in them. So get them to a bed within 30 minutes, get a swan in them, get the numbers. And then that way you can say, okay, yes, they are in cardiogenic shock. They're hypotensive, they have signs of organ failure, organ dysfunction, and they have a cardiac index less than 2.2, and they have elevated filling pressures, high CVP, high wedge pressure. If they qualify for all that, then you'd say, yes, they're in cardiogenic shock. The next step after that is do they qualify for mechanical support? So if they have a cardiac power less than 0.6, then the recommendation is that they get mechanical support. So that would be your next step. Yes, they qualify for cardiogenic shock. Now, if their CVP is two, right, then they don't qualify for cardiogenic shock. You don't have, they'll have a low cardiac output, but it doesn't qualify as cardiogenic because they don't have high filling pressures. You want to say, like, do they first do they qualify? And then, because if you just calculate cardiac powers on everybody, there's plenty of people that have a low cardiac power but are not in cardiogenic shock because it's just two numbers cardiac output and map.
SPEAKER_01So you have to do what you said at the top of this. You have to differentiate it first.
SPEAKER_00You have to differentiate it. And so with that, it's also important to just like understand context. Like if you get a cardiac power and it's 0.7, but you're on 20 of Leva Fed and 10 of Epi, then don't be like, oh, their cardiac power is normal. And be like, no, it's not. You're you're on you're on Epi and Levo to get there. It's not normal. I wish that goes without saying, but I really feel bad that you have to say that, but you do have to say, Yeah, like it's like they're like, yeah, it's fine. The cardiac power was fine. I was like, well, they're on four agents right now. Uh there's no amount of power that would make it not be, they need mechanical support.
SPEAKER_01That reminds me of uh another travel doctor that came through. All three of these have been different ones, too, uh, by the way. But they were like, let's start them on some afterload reduction. And I was like, okay, well, we're on two pressers, so I guess I'll just turn that down.
SPEAKER_00And then after turning, like turning down vaso pressors is afterload reduction. It is, but but they wanted to start. Yeah. I'm like, uh no. So yeah, so you have to take it in context. Uh if you're if you're on multiple agents, then then that's how you're kind of going with it. The next step after getting a cardiac power is a wedge pressure. If your wedge pressure is greater than 15 with a CPO less than 0.6, they recommend a left-sided device. And then the next one is the Pappy. If you have a Pappy of 0.9 or less, then they would recommend a right-sided device. It just depends on the person, right? You can have people that would have, you know, a papy less than 0.9 and a wedge of 12, they only need a right-sided device. If they have a wedge of 25 and a papy of 1.2, they only need a left-sided device. You know, if they have a wedge of 25 and a papy of 0.8, they need a biventricular device. So it's just a matter of deciding like what kind of device. That part, I think, is hopefully easy for people to get. There are some subtleties that come with the other part that I think makes it a little bit like having a consistent team is helpful, right? Like it's not like everybody can just like, oh, I think cardiac stuff is cool. I'm just gonna keep them on my service and not send them to the cardiac ICU. There's some subtleties that I think are are important to work through. So one of the main things we talk about is sky level. And so sky level tells you how sick they are, S C A I. And it ha it goes like A would be just like not in shock, B is like pre-shock, like they're not quite in cardiogenic shock. C is classic shock, D for deteriorating shock, and then E would be extremis. Um, and so just to give you an idea of what they're kind of working with with it, would be C would be you would have like a lactic that would still be less than four. You would probably have some organ dysfunction, like maybe an AKI, maybe the liver enzymes are up. You could be on like one agent, like you're on Epi or debutamine or whatever, then then that would probably qualify as like a C. And then if your lactic is greater than greater than four and you're on maybe two agents, then you're starting to think about D. And then if you're on three agents or your lactic's greater than eight, or if you've had a cardiac arrest, you know, like you were like circling the drain type of a thing, then you would be in sky E. The reason that that's important is it matters on what kind of device we would put in. So as you can imagine, people that are in like Sky C, you could put a smaller device in and probably be okay. And maybe be like, oh yeah, but they may be able to come out of shock with like a small. An example would be like an Impella CP. It gets up to about three and a half liters of flow. It's not going to necessarily give you full support on most people, but if you're Sky C, you'd probably be okay. If you're Sky D and E, they're basically like, just skip, skip past all that. Go ahead and go to like the 5-5 or just VAEC mode. Just go like fully onto the window. So understanding how sick they are is important because it's like, hey, you know, like if they're dying and someone's like, Well, have you thought about a balloon pump? Then you're just like, no, I'm not thinking about a balloon pump. Thank you. And then you go ahead and go to like those types of things with it. The other thing to think about with it is body surface area. So cardiac index is cardiac output divided by body surface area. So if you have a 70 kilo person and they have a body surface area of 1.8, if they if your goal is a cardiac index greater than two, you only need 3.6 liters of flow, which is pretty close with a CP, right? Like you could probably get there and get full support if you needed to. Versus, you know, you have somebody that's 100, 115 kilos, they have a body surface area of 2.3, they need at least 4.6 liters of flow to get to a cardiac index of two, that CP is not going to cut it. So you have to understand when you put that device in that you're not going to get full support. So if they, if they go linear, like I I'm sure you've taken care of an impelled patient and they went linear and you're like, oh, they don't have a pulse right now. If if you have a five five in, if you have a big enough device in, it doesn't really matter. Like if you are flowing four and a half liters and they have a cardiac a body surface area of of two, and so they are completely supported, then you don't they don't have to be linear. Um Um, on there, you're you're unloading the LV, you're supporting them. But if they only have an impellus CP in and you only have three and a half liters of flow and they need four and a half liters of flow to like reach a cardiac index of two, then yeah, that does matter. Like you're not fully supporting them. You would need to upgrade a device.
SPEAKER_01When you say linear, you mean like no pulse. Non-pulsatile? Non-pulsatile. Okay. So like on the machines, there's no, or even like on the A-line, there's no pulsatility, is what you mean.
SPEAKER_03Yeah, yeah, yeah. I mean, especially when you put it in, they're like, I can rest a little bit. But if their map is okay, I mean it's not so it's sometimes it's like you can just let that happen and then they start to they start doing it.
SPEAKER_00So like in somebody with a 5-5 in, that you could have that for like days and days and days because you have a normal cardiac index. But if you have a large patient and they need four and a half liters of flow and you're only giving them three and a half, um, I mean, is it better than nothing? Yeah, 100%. Like they have no pulsatility. But if you do the math on that, if they have no pulse, then that means their entire cardiac output is their impella. And if they are only getting three and a half liters of flow, that gives them a cardiac index of like 1.6, 1.7. Like it's you're not fully supporting them. So in that situation, you ideally want to have a big enough device. And that brings me to the big difference in cardiogenic shock, where I talked about the subtleties, is there's actually two separate algorithms for why are you in cardiogenic shock. So if you're in cardiogenic shock secondary to a heart attack, it's very different than if you're cardiogenic shock secondary to like acute on chronic heart failure or like a flail leaflet or something like that. So if you're in cardiogenic shock secondary to an MI, you've just had a heart attack. And no, most of the time for these people, they have a normal LV size. So whenever we talked about EF earlier, and I said 20% of 100 is a lot different than 20% of 250, is that these people are a lot sicker because they had a normal sized heart and now their EF is 20%. And so now they they are in shock with a tiny ventricle versus being in shock with a big dilated ventricle.
SPEAKER_03So not as much blood is getting pumped out. Correct.
SPEAKER_00Yeah, yeah. So you want to fully support them. You want to put in a big enough device that they can be non-pulsatile and you can feel good about it because they they are way more likely to be like non-pulsatile, um, and you're way more likely to need full support.
SPEAKER_02Yeah.
SPEAKER_00So the balloon pump has just never been shown to and a mortality benefit and cardiogenic shock secondary to an MI. There's all sorts of papers, meta-analyses, systematic reviews that just says that does not work for this reason is you're not going to be able to unload a ventricle that's small. You can unload a ventricle that's big because you're gonna try to overcome that mitral regurge, but it just doesn't work for the other ones.
SPEAKER_01Didn't they downgrade it too in like the update?
SPEAKER_00Oh, yeah, yeah, yeah. It's like a class three now. It's like it's no benefit, uh could potentially cause harm, type of a thing.
SPEAKER_03Interesting.
SPEAKER_00And but if you are acute on chronic heart failure and you're class uh sky stage C, then you actually can consider a balloon pump because they have a big dilated ventricle. They have mitral regurge, but they have mitral regurge because as their heart stretched, their valves stretched apart and they end up with functional mitral regurge. And so they actually can benefit from a balloon because it'll help offload the ventricle and it'll help like reduce the mitral regurge. And so you can get people out of like sky-C cardiogenic shock if it's acute on chronic heart failure or like dilated LV heart failure. So there's not like there's no place for balloon pumps in cardiogenic shock. It just shouldn't be in somebody with an acute MI. So an acute MI, you want to put an impella in or ECMO, and you want to put a device in that would fully support them because you don't want, right? You you've probably taken care of somebody and they're on an impella, and then you're like, well, that's not cutting it. Add dobutamine or add epi or add like whatever, and then you're like, oh, they look good. They're on five of dobutamine and they're on an impella at peace or whatever.
SPEAKER_03Yeah, they're doing great.
SPEAKER_00They're doing great all the support. And so, but like there's a reason they call it a dobutamine stress test. Like you're stressing the heart. And if you've just had an MI, you'd be like, hey, you just had an MI. If you could run on this treadmill for me, that would be great. Which is the same thing we're doing when we're like, hey, you just had an MI, let's start five of dobutamine and see if we can keep them from putting the device in. It's like, no, like they they just had a huge ischemic event. Rest the heart. Try to come off all inotropes as your ultimate goal. Now, a lot of times they'll vasodilate from like cytokines and the ischemic event. So you may have to have them on a little bit of levo or a little bit of something to like get their map up because they're vasodilated, but you don't want them on like a bunch of inotropes. So if you're on a CP and inotropes, then you just need to upgrade them. Either add ECMO and use the Mpella as a vent or an unloading device or upgrade them to a 5.5. Uh there's trials now that show that if you put a 5.5 in immediately, you actually have better outcomes for multiple reasons. A, it's bigger, so you can fully support them more up to five and a half liters of flow. Uh, but it's also in there like Axa Axilla and their suclavin, wherever you want to put it, up here in their upper body, is get them into a chair, walk them around the unit. It just it's just easier from a mobility standpoint versus having a CP in for like four or five days where they're laying in bed, can't move, blah, blah, blah. You're worried about leg perfusion, then you got to emergently take it out because they lost pulses to their leg.
SPEAKER_03Well, hopefully you got in there in time to figure that out because it's paired with another patient.
SPEAKER_00But uh, but yeah, so they do recommend uh a 5-5. Like if you have a larger patient and it's secondary to an MI, just put them on the bigger device. If it's Sky D, Sky E, put them on the bigger device. If they're large, even if it's Sky C, you'd probably want to consider putting them on a bigger device. But understanding those subtleties to be in like, hey, what kind of shock is this? Is this secondary to an MI or is this secondary to uh cute on chronic heart failure?
SPEAKER_01Yeah. I think what's nice about these things, and this is like what I actually use the shock team evidence in my doctorate work because it's a lot of communication and it fixes a lot of miscommunication amongst the different teams because it gives us a common language and determination of like what to do. So that's like the benefit of learning it and implementing these things, is it's like then everyone knows you can say sky C to anyone that knows it, and they'll at least have some idea of what that patient looks like. Whereas if you're just like, Yeah, I have this bad cardiogenic shock patient, like what's that mean?
SPEAKER_03Yeah, the first time I ever heard about that was when I took the super user class or the Impella. I've never heard that term because they were talking about the different grades and how when you should pull the trigger, I guess. But we have sepsis alerts, we have muse, we have all that stuff, but we don't have anything for this unless I've missed something.
SPEAKER_00No, I mean it's it's be it's becoming like bigger and bigger. The ACC came out with their new guidelines in 2025. They actually recommended if you had the a cardiovascular ICU, if you have the capability to do impells and VADs or ECMO, that you should be a level one cardiogenic shock like initiative center, which is what this includes. The only part I didn't add into this was whenever you decide that that you you've got the swan numbers, you've decided in there in cardiogenic shock, you're supposed to then do a multidisciplinary call. And ideally it will have the intensivist, the heart failure specialist, the interventional cardiologist, and the cardiac surgeon. So all four of them on the line. And then you're you like give them the spiel. This is a whatever age person with blah, blah, blah, blah. And then you tell them the sky level, you tell them, is it LV predominant, R V predominant, is it biventricular? And then you kind of go down the algorithm and say, like, our cardiogenic shock initiative recommends um Impella 5.5. And then you're gonna have that discussion to be like, well, you know, they're they're whatever, they, whatever their comorbidities, they're bed bound, they don't have great whatever, blah, blah, blah, blah, they're high risk for that. They don't have an out, right? If they if they have a history of if if you know for a fact that you can't intervene on their heart anymore, right? There's there's no more stents to be put in, and they've already been evaluated and they're not a transplant or VAD candidate, then maybe don't put a an impella in them or maybe don't put them on ECMO because there's no bridge to anything other than hopefully a bridge to recovery. But it's like, hey, I can't make anything better because I can't put fix their heart anymore. They're not a candidate for any advanced stuff. Those are the parts where it's really important to have those multidisciplinary calls because you're getting different insights on things. Um, if you're like, hey, I'd like to put a 5'5 in, and they're like, well, they they don't have a big enough vasculature to put a 5'5 in, or they have peripheral vascular disease with a femme pop bypass or fem femme, I don't think I can get a CP in there. There's all these like little things that that are that like come into play. They have severe aortic regurge, which is a contraindication for like uh a lot of these devices. So it it matters to like have all those different things with it. But once you decide, like you have the conversation and you say, okay, we've decided to put X device in, the goal is to have that device in within 90 minutes. So you would treat it like you would treat a STIMI where you're talking about door to needle. Uh, they call it door to unloading or door to support time. That way you have a goal in mind, right? Like you don't want to be like, oh yeah, this person needs an impella. I got two more cases to go through. Like, let's schedule them for five o'clock. It's like, no, if we're gonna decide, we're gonna decide now, we need to get them out of shock. If you have nine 90-minute goal from decision to put a device in to have that device in.
SPEAKER_03Is that happening? I mean, yeah, yeah.
SPEAKER_00In cardiogenic shock, I mean, if you want to look at the two biggest centers that come up, Detroit was one of the first ones that did their Detroit Cardiogenic Shock Initiative, and it's now the National Cardiogenic Shock Initiative. Nova is another huge one in Virginia. They do their they both are very much into all the things I talked about. Yeah. And uh they were like the the two, at least publishing-wise, was they were publishing all of this stuff and and showing the literature that they took their 50% survival and went up to like a 75-80% survival. It's awesome.
SPEAKER_01All right. I so all of this though, it sounds like you need a swan to have these conversations. Now, when you raised me, when we used to work together, when you raised me as a new NP, it was not a heavy swan unit. Has that changed for you now? Are you like, let's put a swan in, let's do it? Yeah, yeah.
SPEAKER_00I for for this, uh I mean, I it was hard to sell somebody on a swan back in the day because all those trials that came out said there was no benefit for swan. Now, if you look at the trials, they they looked at like surgery patients and septic patients and just all comers. And yeah, it's not it, you don't need it for everybody. But the all the literature now says if you put a swan in in cardiogenic shock patients, there actually is a mortality benefit. They're less likely to have a cardiac arrest in the hospital, there's better outcomes to be a cardiogenic shock initiative program. There's as of right now, that is the only method that we're using to establish to decide if they need RV support is using PAPI. And so if there is a better way down the road that will definitively tell you, does this person just have RV failure or do they have RV failure that needs mechanical support, then we may be able to address it differently. I think anybody's always looking for a way to have less invasive stuff in. But for right now, that's the best way to reliably get you all the numbers necessary to make a decision for mechanical support.
SPEAKER_01So you're pro-swan now.
SPEAKER_00Yeah. I mean, I'm not just putting in an anybody. I'm not just like, oh, hey, you're in the unit. Here's a swan.
SPEAKER_01Yeah.
SPEAKER_00Um, I think we're we're going the opposite way when it comes to cardiac surgery. So we used there used to be swans in everybody in cardiac surgery, and now in patients with good biventricular function at baseline, all these different types of things, we're now not having swans in them. Uh, and so I think we're going the other way in some other things, but when it comes to cardiogenic shock, very very much so the swan is is what's going to make the difference to get them support if they need support.
SPEAKER_01Makes sense. Well, Kaylee, any questions on all this cardiogenic shock? Yeah, I want to from a nurse standpoint.
SPEAKER_03Like, who's on the team? Is it just physician?
SPEAKER_00No, I mean, I think anybody can be, I mean, everybody plays a big part. Like we have, like, when we have teams, we have our APPs, you know, we're putting in the swans, we're making the decisions. Anybody, anybody should call the first thing and be like, I think this person has cardiogenic shock in the ED and the and the floor. But, you know, the the nurses have to land the patient, the nurses have to get this whole thing going. The nurses on the floors can even be like, hey, like this person is cold, they're modeled. I just drew a lactic, they're lactic six or their lactic eight, like this person's clearly in shock. Like, I want, I want people to want to call us and say, I think this person's in cardiogenic shock. Because the earlier we get them, and if they if they need a device, the faster we get a device in them, that's where we see that huge mortality benefit. And so, yeah, anybody can be on the on the team. It's important to have a cardiogenic shock coordinator, I think, just to be able to go through all this.
SPEAKER_01I think there's usually a coordinator, a nurse coordinator. Um that's what I was in the room, wondering like how many people like are out on the physical.
SPEAKER_00Right now, we like we have a great cardiogenic shock coordinator. Um, and she does like all of our stuff. She helps with us do all of our case reviews. We go through and say, you know, did we meet our benchmarks? What could we have done differently based on the data? Was this the right device? You know, like looking through, trying to get an idea, making sure we're like documenting the way we should. Because you can, you know, whatever your decision is, you as long as you just document it correctly, be like, hey, we we can't put this device in. They had severe aortic stenosis where we can't put an impella in. So we had to put in a balloon pump, even though it's not ideal. Like there's there's always like just things that you're you're not necessarily accounting for if you just look at it from the periphery. So yeah, we we it's I mean, it just wouldn't run without a coordinator.
SPEAKER_01And the coordinators help to track the outcomes, which helps us improve. Um but yeah, I've uh gotten to join a couple national online kind of meeting, cardiology meetings, and gotten to listen to a few people. And they all seem to always have a coordinator, and it's pretty impressive. It's weird to see how much it's changed so rapidly in like the last few years, like how much this has finally like taken off.
SPEAKER_00Well, I mean, it's hard. I don't know, like ICU literature is very hard. I don't know. When we read papers, oftentimes it's like couldn't find a mortality benefit. You have all these things that like make sense, and there was in sepsis, there's all these studies that are like, well, this makes sense that this should work. And then you do a big study and it's like couldn't find a difference. You look at all the TTM trials, right? You have all like you have all these people that be like, this helped, this helped, and then you do a big trial and it's like couldn't find a mortality. It's just hard. In ICU, there's so many variables, it's hard to say, can we find a mortality benefit? And then we do this cardiogenic shock initiative or these other hospitals, and all of a sudden you're saying, like, I'm taking a 50% mortality and dropping it to like a 20, 30% mortality. That is huge, like in that world. And so, with the fact that it's just so hard to make these things happen, to have that big of mortality difference just by doing these things and like that consistency, that reliability, I think that's what pushed it through so fast. I mean, they now have they have chest pain centers, you know, for all this STEMI stuff is they now are gonna have like cardiogenic shock center designations because of like how big this uh this is. So you'll if you if you're like, oh, I work at a chest pain center, they'll soon be like I work at a cardiogenic shock center.
SPEAKER_01And this, and when you're talking mortality, you're just talking hospital mortality, right?
SPEAKER_00Well, you're talking about like if we look at like three months or six months.
SPEAKER_01Yeah.
SPEAKER_00I would have to go back and look. I don't want to say wrong on it. I mean, I think hospital mortality is like the easiest one to look at. I don't know how because they've been doing this for like all like Detroit and ANOVA have been doing this for years and years and years. Like I'm I'm sure they have data many like months, years down the road where they can see like what is that make a difference down there. So I don't I don't want to like misquote or anything like that, but yeah.
SPEAKER_01I just wanted to clarify that when you're saying mortality throughout this, we're talking just hospitals mortality.
SPEAKER_00When we're looking at ours, we're looking at discharge from the hospital. Hospital.
SPEAKER_01Interesting. Well, any final thoughts? Did we hit all your points today, Michael? Dr. Michael?
SPEAKER_00Yeah, I think so. I mean, I uh I I think this is great. I think I wish, I hope that more people, more hospitals kind of get into this because I think it makes a huge difference. But it's a lot more than like I like cardiogenic shock. Like there's a lot I hopefully I was able to like show that there's a lot of like nuances in there, but if you can understand them, you can make a big difference on things. Yeah.
SPEAKER_01And I I think it's important for the nurses to hear it too, because when I'm having to put a swan in in again, an eye roll or a uh right now. It's like knowing some of this information, we don't do the maybe the best job of like educating as physicians and advanced practice providers why we maybe want it in early that we should be talking about the changes and guidelines with our teams, but this is why.
SPEAKER_00We we've gotten great buy-in, for especially when we're talking about timing, you know. Like we have our like emergency response team that will go to wherever the call is if they're outside the ICU, and they'll help just bring the patient to the ICU and give bedside report. And then the nurses and the ICU have been so great about being like, look, I I brought everything to the bedside. We need to get this swan in. Like, I want to, I want to hit our times. I want to get, I want to get all that stuff in within our 60 minute mark. And I think that they they take a lot of pride in being like, hey, we we got them to the unit. We got a swan in, we get all this stuff in whatever amount of time, and be like, hey, look how fast we did this, because all of that just makes a difference on how fast they can get a device if they qualify for it. So they it's been great to see them get excited about not only like can we get this patient to a unit very fast, you know, like go from zero to a hundred, but also be like, all right, you need to get this in as quickly and safely as possible, but get it in quickly so that we can and see what we can do for them.
SPEAKER_03Yeah, that makes sense. Racing against the clock, give us like something objective to aim for. I feel like most of us want to meet the goal.
SPEAKER_01I see people love objectives. They love goals to hit and objectives to hit. Yeah. Okay, it's like, yeah. Yep, that's me. That's me. Well, thank you so much for coming and educating those listening. Make sure you like, follow, leave a comment, leave questions. If we get a bunch of questions for Dr. Michael, we'll bring them back and we'll do a follow-up episode. Maybe we'll do a follow-up sepsis episode and he can talk about how we manage septic shock and all those sepsis alerts that we're all love so much. Until then, from until then, from all of us here at Banter at the Bedside. Thanks, and we'll talk to you soon. Bye.
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