Shock in cardio-surgical intensive care unit (ICU) patients is a serious condition with a high morbidity and mortality.1,2 Prompt identification of the underlying conditions and correct management of the life- threatening physiological deteriorations are crucial to save the patient’s life. In daily practice, however, focusing on the main goal – to provide adequate oxygen delivery thereby preventing further organ damage – is often difficult due to multiple influences, distractions, and pending results. Hence, the setting up of priorities is necessary. In addition, many questions arise on how to optimally treat patients in shock: What blood pressure should we target? What fluid should we use and how much? Which vasoactive drug is best and which inotrope? While discussions about these issues can be very fruitful for experts, they risk confusing younger colleagues and nurses at the bedside. Disputes about controversial therapy opinions might consequently delay adequate resuscitation, putting the patient at risk of an adverse outcome. This review aims to give recommendations for the management during the early phase of shock of cardio-surgical patients hospitalised in the ICU. The focus is on the first 6 hours, which are also called ‘the golden hours’.
Methods
Clinical Setting
The cardio-surgical ICU at the University Hospital Zurich is a 12-bed, high-intensity unit that cares for more than 1,100 patients every year. The majority of these critically ill patients undergo cardiac and/or major vascular surgery, most of them being mechanically ventilated and on inotrope/vasopressor support. The unit is part of a successful heart failure programme that includes extracorporeal life support, ventricular assist devices and a heart transplantation service. In order to optimise the initial resuscitation of patients and to avoid adverse effects of inadequate treatment, the consultants of the unit have agreed on treatment recommendations, which are presented here. They are based on current evidence and complemented by clinical experience in areas of uncertainty.
Data Extraction
For this narrative review, a search of the PubMed database and a review of bibliographies from selected articles were performed to identify original data relating to this topic. Key words used for the search were ‘shock’, ‘cardiac surgery’, ‘critical care’, ‘inotropes’, ‘inotropic therapy’, ‘circulatory support’, ‘cardiogenic shock’ and ‘sepsis’. National and international guidelines were reviewed and integrated, e.g. The 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation,3 The 2014 ESC/ EACTS guidelines on myocardial revascularization4 and The Surviving Sepsis Campaign guidelines5. Articles were scrutinised regarding their study design, population evaluated, interventions, outcomes, and limitations. Finally, personal recommendations were included and highlighted as such to give a comprehensive overview on this topic.