Cardiogenic shock (CS) is a life-threatening condition due to primary cardiac dysfunction. First-line therapy involves drug administration (including inotropes and/or vasopressors) up to mechanical circulatory support. Tachycardia is a frequent compensatory mechanism in response to hypotension and low cardiac output or a side effect related to inotropic drugs. Ivabradine selectively acts on the IK_f channel in the sinoatrial node to reduce sinus heart rate without affecting inotropism. Its use, in small non-randomized series of patients with CS without mechanical circulatory support, was safe and well tolerated. We present the use of ivabradine in six patients with CS undertaking veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and a matched cohort of selected patients with similar features who did not receive ivabradine. Data regarding haemodynamic and echocardiographic monitoring, oxygenation, renal function, mechanical circulatory support, inotropes, and vasopressors doses were collected before (t0), at 12 (t1), 24 (t2), and 48 (t3) h after ivabradine administration. Ivabradine administration led to a significant heart rate reduction of 20.83 [95% confidence interval (CI) −27.2 to −14.4] b.p.m. (<0.01). Echo-derived left ventricular native stroke volume (SV) significantly increased by +7.83 (95% CI 4.74–10.93) mL (P < 0.001) with a parallel reduction of VA-ECMO support [−170 (95% CI −225.05 to −114.95)]. Noradrenaline was down-titrated over the observation period in all patients (P = 0.016). A significant reduction in heart rate was observed after ivabradine administration. This was associated with a native ventricular SV improvement allowing the reduction of extracorporeal flow support and vasopressors administration.

The aim of this study was to measure the serum levels of catecholamines in patients admitted to intensive care unit (ICU) with COVID-19-related acute respiratory distress syndrome (ARDS) and describe their relation with clinical, inflammatory and echocardiographic parameters. Serum levels of endogenous catecholamines (norepinephrine, epinephrine and dopamine) were measured at ICU admission. We enrolled 71 patients consecutively admitted to ICU due to moderate to severe ARDS. 11 patients (15.5%) died during the admission in ICU. Serum levels of endogenous catecholamines were significantly elevated. Norepinephrine levels were higher in those with RV and LV systolic dysfunction, higher CRP, and higher IL-6. Patients with higher mortality rate were those with norepinephrine values ≥ 3124 ng/mL, CRP ≥ 17.2 mg/dL and IL-6 ≥ 102 pg/mL. Univariable analysis by Cox proportional hazards regression modelling showed that norepinephrine, IL-6 and CRP had the highest risk of acute mortality. Multivariable analysis showed that only norepinephrine and IL-6 retained in the model. Marked increase of serum catecholamine levels is present during acute phase of critically ill COVID-19 and it is associated with inflammatory and clinical parameters.

Supportive care is the cornerstone of the poisoned patient’s treatment, waiting for eventual antidotes to act. We recently treated a case of a severe Ethylene Glycol intoxication with early-onset veno-arterial ECMO. The patient was taken to our Emergency Department with the suspicion of acute cerebrovascular accident, since he was found unconscious at home. The arterial blood gas and blood tests showed a severe metabolic acidosis with high serum lactates and creatinine levels. The cerebral Computed Tomography was negative. The rapid increase in serum lactates suggested Ethylene Glycol intoxication. Although the patient was not in shock yet, arterial and venous introducers were placed in to the femoral vessels so that when the patient showed the first signs of cardiogenic shock, veno-arterial ECMO could be initiated in a very short time. The hemodynamic state progressively improved and V-A ECMO was removed after 16 h of support with complete recovery.

A 65-year-old lady was admitted due to cardiogenic shock related to acute decompensated heart failure refractory to medical therapy, requiring oro-tracheal tube and intra-aortic balloon pump (IABP) placement. In addition to echocardiography, transorbital transcranial colour Doppler (TCOD) was performed to assess cerebral flow pattern at different steps of IABP support; the figure shows TCOD and echocardiographic images, respectively in the upper and lower panel, during these different phases: IABP 1:1, first step (Panel A), IABP 1:2, second step (Panel B), and IABP switched off, third step (Panel C).

Article: Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey - Minerva Anestesiologica 2024 Mar 29 - Minerva Medica - Journals