Cardiogenic shock: tips and updates 

Thank you. Hopefully, your institution will get Impella after Danger Shock trial. Exactly as you mention, both IABP and ECMO failed in MI shock in those 2 trials. Since you don't have Impella, I may suggest the following, for STEMI shock within 24 hours of STEMI and of the shock (preferably within few hours): -Initial stage C (lactate 2-5) that is unresponsive to 1 medium inopressor: upscale inopressor vs consider IABP -Initial stage D or E (lactate >5) or subsequent stage D or E with >2-3 inopressors: ECMO if they are actively destabilizing, or IABP if they stabilize on 2-3 inopressors. For all of those groups, the standard now should be to start with Impella CP within few hours of the shock, when available. I would exclude post-cardiac arrest shock. Also, as I explained at the end of the lecture, under PV loops, ECMO raises LV pre- and afterload, and you may need LV venting. One major pitfall of ECLS shock trial is that only 5.8% of patients received LV venting. So, I would keep a low threshold to use LV venting with ECMO; at our institution, Impella CP or 5.5 is most commonly used for venting, but consider using IABP instead since that is what you have.

There is no specific time limit. It could be 1 to several days, depending on each case. The key is to properly diurese and nearly normalize filling pressures to allow him to tolerate PCI and not destabilize during PCI (for the reasons explained under 05:20). You may need pressors and may need a support device in that interim period based on the shock escalation strategy (although no one specific support device is proven useful in this scenario).