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The Use Of PEEP With Cardiogenic Shock Patients Aziza Saleh Alamri

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The Use Of PEEP With Cardiogenic Shock Patients

Aziza Saleh Alamri

Objectives • Introduction of Cardiogenic shock • Cardiovascular effects of PEEP• Management (VIP)• Mechanical ventilation

Use of PEEP

What is Cardiogenic shock?

Is a clinical condition of inadequate tissue perfusion due to cardiac dysfunction.• Myocardial infarction• End-stage cardiomyopathy• Arrhythmias• Low cardiac output

Cardiovascular effects of PEEP

People in Shock Must be treated with

VIP

Ventilatory Assistance in Shock

• Supplemental Oxygen• CPAP/ BiPAP• Intubation

1 .A patient came to ER having

• Severe dyspnea• Hypoxemia• pH< 7.25• Decreased LOC

What is the appropriate action؟

Oxygen NPPV Intubation

2 .A patient came to ER having

• The feel of  intense chest pain and tightness• Slightly increased and unlabored RR• Oxygen saturation: 93% (on room air).• Conscious and alert • Restless and anxious

• Suspected MI

1. Non-rebreather face mask (15 L/min)2. NPPV3. Intubation

What is the appropriate action؟

1. Chest pain2. Sweating3. Fatigue4. Dyspnea5. Edema6. On CxR : it revealed butterfly pulmonary

opacities

3 .A patient came to ER having

What is the appropriate action؟

The use of NIV for patients with ACPE is highly supported . Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.

Importance of Ventilation

• To protect the airway and maintain oxygen supply in patients with a deterioration in consciousness or cardiac arrest.

• To treat acute respiratory failure, most often due to cardiogenic pulmonary edema.

• To raise the arterial pH in metabolic acidosis

Infusion “Fluid Resuscitation in Shock”

• Initial fluid resuscitation• Risk of edema (CHF)• Is my patient's shock fluid responsive?• Determining Fluid Responsiveness in Shock

Type of fluid “Crystalloid” How fast to infuse it “300-500mL over 20-30 minutes” Define a positive test: ↑arterial pressure, ↓HR, ↑ urine

output Set a safety limit :↑ in CVP by 4 cm H2O “To avoid

pulmonary edema”

Pump “Use of vasoactive Drugs in Shock”

• Inotropes Adrenaline, Dobutamine

• Vasopressors Noradrenaline, Vasopressin

• Dopamine• Aspirin and Heparin• Diuretics

Use Of PEEP

Don’t have an effect

Do have an effect

↓ LV oxygen demand and improved oxygen delivery to the ischaemic myocardium

↓Venous return, LV filling, CO and overall organ perfusion

↓ Intracardiac lactate production

↑ RV afterload

• Improve hemodynamics, respiratory function and oxygenation in patients with acute systolic heart failure and pulmonary oedema compared with oxygen therapy alone.

• lower rates of intubation

• A number of reports in patients with cardiogenic shock suggest that the hemodynamic effects of PEEP may work in favor of the patient with severe left heart failure

Management of PEEP in cardiogenic shock

CONCLUSION

References• UpToDate

• http://emedicine.medscape.com/article/155919-overview

• http://www.ncbi.nlm.nih.gov/pubmed/20439577

• http://www.ncbi.nlm.nih.gov/pubmed/23539555