COVID and Cardiogenic Shock
Diagnose Cardiogenic Shock at Bedside
On exam, look for signs of poor flow: narrow pulse pressure, labored respirations or Cheyne-Stokes respirations, abdominal bloating/nausea, evidence of volume overload, and cool extremities. If PAC is available, a mixed venous O₂ less than 55-60% is suggestive of cardiogenic shock.
COVID Can Lead to Myocardial Injury
The mechanisms are varied. There can be supply-demand mismatch and acute plaque rupture. Further, there can be evidence of myocarditis, either through lymphocytic infiltration or direct viral entry.
MCS Gives Varying Levels of Support
Not all mechanical support is equal. Intra-aortic balloon pump (IABP) can provide 0.3-0.5 L of additional Cardiac Output, while Veno-Arterial ECMO can provide 3-7 L of additional Cardiac Output.
Consider VA-ECMO for BiV Failure
VA ECMO can support both LV and RV failure. Other indications include massive PE, cardiac arrest, bridge to LVAD or transplant, drug overdose, among others. There should be an exit strategy!
VA ECMO May Require LV “Venting”
VA ECMO can lead to high afterload which a weak heart may not be able to overcome. This can lead to high LVEDP, pulmonary congestion, and LV stasis. This can be treated by offloading the LV with inotropes, vasodilators, and additional mechanical support such as IABP or Impella.
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