Rapid Treatment of Shock Without Trauma

Study Overview
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Brief Summary
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Evaluate the implementation of a standardized mobile resuscitation model to manage SWOT within a large acute care hospital setting.

Detailed Description
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Immediately upon identification of SWOT, the SWOT Team will be activated by clinicians to respond to the patient bedside. Clinicians on-site will initiate patient care as directed by hospital protocol. Upon arrival, the SWOT Team will take over the management of patient care. The team will include 1-2 intensivists and multiple clinicians with clearly defined roles, dependent upon clinical presentation. The mobile resuscitative platform equipped with critical care technology will be delivered to the bedside (refer to appendix for full equipment content). The SWOT Team will implement goal-directed therapy using real-time monitoring and advanced diagnostic point-of-care tools. ultrasound, arterial and central lines will be placed by the intensivist(s) to monitor the physiology of the patient during treatment in real-time. Other team members (RNs, Respiratory Therapist's, residents, anesthesiologists, and technicians) will place the patient on continuous ECG and SPO2 monitoring, continuous capnographic monitoring via nasal canula or Endotracheal tube, and continuous cerebral and regional NIRS monitors. Point-of-care laboratory values will also be measured. Resuscitative interventions will be performed as directed by team leader to target the following physiological target parameters: SpO2 > 85% PaO2 > 50 mmHg NIRS > 65% Lactate normal or trending down EtCO2 >20 mmHg Mean Arterial Pressure > 65 mmHg SVO2 > 60%

Official Title
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Implementation of a Mobile In-hospital Resuscitation Model for the Rapid Treatment of Shock Without Trauma (SWOT)

Conditions
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Shock

Intervention / Treatment
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* Device: Full SWOT Model
* Device: Partial SWOT Model
* Other: Standard of Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 18 to 75 years of age (inclusive) Presence of shock, defined as systolic blood pressure (SBP) less than 90 mmHg with signs of hypoperfusion, including at least one of the following (without alternate causes): low cardiac index (<2.2 L/min/m2) elevated filling pressures of the left heart (pulmonary capillary wedge pressure [PCWP] >15 mmHg) and/or right heart (central venous pressure [CVP] >10 mmHg) non-perfusing cardiac rhythm or cardiac arrest mixed venous oxygen saturation <60% or >80% without non-shock cause Heart rate >90 beats per minute Respiratory rate >20 breaths per minute White blood cell count >12 or < 4 Temperature >38°C or <35°C SOFA score ≥2 with vasopressor requirement and elevated lactate >2 mmol/L (>18 mg/dL) despite adequate fluid resuscitation Central venous pressure <8 mmHg Obstruction such as pulmonary embolus on imaging Admitted to Abbott Northwestern Rapid Response Team call or request Patients who previously agreed to allow their medical record information to be used for Allina Health research (i.e. Minnesota Research Authorization (MRA) Yes) or those who have not explicitly declined use of their medical information in Allina Health research (i.e. MRA Null) Candidates for the prospective case series must meet the following inclusion criterion: Interventional assessment and treatment by SWOT Team (full-implementation period only) Patients who previously agreed to allow their medical record information to be used for Allina Health research (i.e. Minnesota Research Authorization (MRA) Yes) or those who have not explicitly declined use of their medical information in Allina Health research (i.e. MRA Null) Exclusion Criteria: Known or suspected pregnancy Significant trauma BMI > 50 kg/m2 Pre-existing Do Not Resuscitate order Presence of orders limiting resuscitation efforts during the initial resuscitative period (less than 2 hours from the onset of protocol) Refusal to receive whole blood or blood products Severe brain injury (anoxic, traumatic, hemorrhagic or ischemic) presence of an assist device such as intra-aortic balloon pump Advanced chronic organ dysfunction Known or presumed COVID-19 Patients with a status of MRA No Patient in ICU at time of shock Candidates for the prospective case series will be excluded if the following condition is present: Patients with a status of MRA No Patient in ICU at time of shock

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Pre-implementation<br>Patients experiencing shock without trauma prior to any SWOT model training or devices | Other: Standard of Care<br>* Standard of Care treatment to patients before development of SWOT protocol.<br>|
| Partial-implementation<br>Patients experiencing shock without trauma after training and device deployment has been started but not fully implemented | Device: Partial SWOT Model<br>* Historical control. Partial bundle of care that includes some bedside monitoring and diagnostics as well as training on a standardize care process<br>|
| Full-implementation<br>Patients experiencing shock without trauma once all training is in place and devices are deployed | Device: Full SWOT Model<br>* Bundle of care that includes devices such as X Series monitor/defibrillator, AutoPusle automated compression device, Z Vent ventilator, and IPR therapies as well as bedside monitoring and diagnostics and training on a standardized care process.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to Shock Reversal | Duration in minutes from activation of the SWOT Team to shock reversal, defined as stable arterial pressure (SBP > 90 mmHg) without requirement for vasopressor administration for greater than 24 hours and normalization of systemic and local perfusion measures of lab-measured lactate indicating improved systemic perfusion | From 24 hours to 72 hours after initial shock event | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 30-day Mortality | Patient all-cause mortality will be assessed at 30 days following initial identification of shock symptoms | 30 days after initial shock event |