Multidisciplinary Code Shock Team in Cardiogenic Shock: A Canadian Centre Experience

Abstract

Background: Cardiogenic shock (CS) is associated with high mortality. We report on a "Shock Team" approach of combined interdisciplinary expertise for decision making, expedited assessment, and treatment. Methods: We reviewed 100 patients admitted in CS over 52 months. Patients managed under a Code Shock Team protocol (n ¼ 64, treatment) from 2016 to 2019 were compared with standard care (n ¼ 36, control) from 2015 to 2016. The cohort was predominantly male (78% treatment, 67% control) with a median age of 55 years (interquartile range [IQR], 43-64) for treatment vs 64 years (IQR, 48-69) for control (P ¼ 0.01). New heart failure was more common in the treatment group: 61% vs 36%, P ¼ 0.02. Acute myocardial infarction comprised 13% of patients in CS. There were no significant differences between treatment and control in markers of clinical acuity, including median left ventricular ejection fraction (18% vs 20%), prevalence of R ESUM E Contexte : Le choc cardiog enique (CC) est associ e à une mortalit e elev ee. Nous d ecrivons une approche où la prise de d ecision, l' evaluation rapide des cas et le traitement sont confi es à une « equipe de choc » interdisciplinaire. M ethodologie : Nous avons examin e les cas de 100 patients hospitalis es en raison d'un CC sur une p eriode de 52 mois. Les patients pris en charge par une equipe interdisciplinaire selon un protocole d'intervention d eclench e par un code-choc (n ¼ 64, groupe trait e) de 2016 à 2019 ont et e compar es à des patients ayant reçu des soins courants (n ¼ 36, groupe t emoin) de 2015 à 2016. Les patients de la cohorte etaient majoritairement de sexe masculin (78 % dans le groupe trait e, 67 % dans le groupe t emoin) et l'âge m edian etait de 55 ans (intervalle interquartile [IIQ]: 43-64) au sein du groupe trait e par rapport à 64 ans (IIQ : 48-69) au sein du groupe t emoin (p ¼ 0,01). Les nou-Cardiogenic shock (CS) is defined as a low cardiac output state with end-organ hypoperfusion. 1 The etiology is broad and includes acute myocardial infarction (AMI), acute decompensated heart failure (ADHF) of preexisting cardiomyopathy, fulminant myocarditis, and tachyarrhythmia. 1 Clinical presentation is variable ranging from rapid hemodynamic deterioration over hours to a more insidious onset over days. Heterogeneity of etiology, presentation, and clinical trajectory have contributed to difficulties standardizing definitions for diagnosis, leading to delayed recognition, management variability, and uncertain optimal practice. Consequently, despite medical advances, clinical outcomes in CS remain poor with up to 50% in-hospital mortality reported in most series. 2,3 An increasing number of institutions are adopting a multidisciplinary team-based strategy for CS and have shown feasibility associated with improved outcomes. [4][5][6][7] In 2016, a Code Shock Team approach was implemented at our institution, which uses an emergent "Code" activation similar to other high-acuity, time-sensitive conditions such as ST-elevation myocardial infarction, cardiac arrest, and...

Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock

“…In the UOHI code shock protocol, there was a trend towards increased MCS utilization among patients treated with adoption of a CS team approach (45%) as compared with a conventional treated group (28%). 47 In the IHVI shock team study, 44% of patients presented to the hub CS centre had escalation of MCS. 46 Every hour of delay in intensification of therapy was associated with 10% increased mortality risk, with improved outcomes when MCS was initiated within 5 h of patient presentation.…”

“…After institution of a shock team, there was 13.1% absolute risk reduction in in‐hospital death and a reduction in 30 day all‐cause mortality with an adjusted HR of 0.61 (95% CI, 0.41–0.93). More recently, the UOHI code shock protocol displayed an improved long‐term survival with establishing an interdisciplinary CS team compared with standard care (HR 0.50; 95% CI 0.28–0.99) over a median follow up of 240 days 47 . Notably, there were no in‐hospital or 30 day survival benefit.…”

“…In the INOVA Heart and Vascular Institute (IHVI) cardiogenic shock pathway, the shock team was activated via a ‘shock line’ prompting a multidisciplinary discussion with the four specialists involved 45,46 . In the University of Ottawa Heart Institute (UOHI) code shock protocol, a smartphone application was employed for code shock activation and subsequent online virtual discussion among the CS team members 47 . Irrespective of the initial management plan, there should be ongoing daily communication between all team members to discuss management strategies and timing for escalation or de‐escalation of care 39 …”

“…In the UCAR shock team study, there was a significant variation in MCS‐device type with increased use of Impella and VA‐ECMO in the shock team cohort as compared with controls, although no survival advantage was observed in relation to device type ( Table 1 ). 61 In the UOHI shock experience, Impella—particularly the 5.0 L device—was used more commonly in the CS team managed group in relation to the standard care cohort 47 . In the INOVA‐SHOCK registry, percutaneous VADs (especially Impella CP) either alone or in combination to VA‐ECMO were used more commonly than IABP (45% vs. 27%), with frequent escalation of IABP to VAD after activating the CS team 46 .…”

“…61 In the UOHI shock experience, Impella-particularly the 5.0 L device-was used more commonly in the CS team managed group in relation to the standard care cohort. 47 In the INOVA-SHOCK registry, percutaneous VADs (especially Impella CP) either alone or in combination to VA-ECMO were used more commonly than Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock IABP (45% vs. 27%), with frequent escalation of IABP to VAD after activating the CS team. 46 Until there are convincing data from randomized studies demonstrating a survival benefit based on MCS type, a CS team-based approach can streamline eligibility for different types of MCS to choose accordingly.…”