13 The shock team approach: the rationale and evidence

Cardiogenic shock (CS) is defined as a state of ineffective cardiac output caused by a cardiac disorder that results in both clinical and biochemical manifestations of inadequate tissue perfusion.1 Among patients presenting with CS, there is a spectrum of disease whereby some patients can be stabilised with pharmacologic interventions alone, while others require escalation to mechanical circulatory support (MCS).2 As patients and treatment options both become increasingly complex, comprehensive critical care may be best delivered in disease-specific service line ICUs.2 The model of the cardiac ICU has transitioned over time from one focused on electrocardiographic monitoring for early identification and termination of peri-infarct arrhythmias, to units experienced with invasive haemodynamic monitoring and management of percutaneous/surgically placed MCS devices for the treatment of CS. Early recognition of shock is vital to improving outcomes, and in-hospital survival for CS has been observed to be reduced in patients who are more rapidly supported with MCS.3 Integrating dedicated intensivists into ICU teams has therefore not surprisingly been demonstrated to improve survival in critically-ill patients.4 Furthermore, survival for CS may be better when treated at specialised centres with greater experience compared to centres with lower annual volume of shock cases.5 Contemporary, comprehensive cardiac critical care includes multidisciplinary teams with expertise in MCS, pharmacotherapy, mechanical ventilation, renal replacement therapies, and palliative care. Shock teams have necessarily expanded beyond a given institution to incorporate networks of centres, such that highly specialised care is centralised at quaternary referral centres with resources and expertise to manage this complex condition. References van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017;136:e232–e268. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126:1408–1428. Basir MB, Schreiber TL, Grines CL, Dixon SR, Moses JW, Maini BS, Khandelwal AK, Ohman EM, O’Neill WW. Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock. Am J Cardiol 2017;119:845–851. Na SJ, Chung CR, Jeon K, Park CM, Suh GY, Ahn JH, Carriere KC, Song YB, Choi JO, Hahn JY, Choi JH, Choi SH, On YK, Gwon HC, Jeon ES, Kim DK, Yang JH. Association Between Presence of a Cardiac Intensivist and Mortality in an Adult Cardiac Care Unit. J Am Coll Cardiol 2016;68:2637–2648. Shaefi S, O’Gara B, Kociol RD, Joynt K, Mueller A, Nizamuddin J, Mahmood E, Talmor D, Shahul S. Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock. J Am Heart Assoc 2015;4:e001462.