Escalation and De-escalation of Temporary Mechanical Circulatory Support: Joint Consensus Report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society.

IF 3.6 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

Annals of Thoracic Surgery Pub Date : 2025-04-03 DOI:10.1016/j.athoracsur.2025.01.038

Audrey E Spelde, Lauren M Barron, Busra Cangut, Gavin W Hickey, Roberto Lorusso, Scott C Silvestry, Michael Z Tong, Daniel T Engelman, Andrew D Shaw, Subhasis Chatterjee

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引用次数: 0

Abstract

Background: Temporary mechanical circulatory support (tMCS) for cardiogenic shock (CS) is increasing despite knowledge gaps and variations in management practices. This document was created to provide clinicians with guidance regarding initiation, escalation and de-escalation of tMCS in patients with CS.

Methods: An interdisciplinary, international expert panel utilizing a structured literature appraisal and modified Delphi method derived consensus statements regarding triggers for prompt patient assessment and initiating tMCS in CS, assessing adequacy of support, readiness for tMCS weaning and next steps in non-recovery. Individual statements were graded based on the quality of available evidence.

Results: The panel addressed four main questions aimed at initiation, escalation and de-escalation of tMCS. Based on available literature review and expert consensus, 11 recommendations were formulated. Key principles included recognition of the need for CS patients with ongoing hemodynamic compromise, tissue hypoperfusion, and metabolic derangements to be considered for early tMCS initiation. An interdisciplinary shock team should be involved in management with early referral when patient conditions require care beyond center capabilities. Discussions providing anticipatory guidance should be performed with patients and decision makers prior to initiating tMCS. Management of tMCS involves frequent, timely hemodynamic and tissue perfusion reassessments to determine the need for escalation or weaning. For patients unable to wean from tMCS, evaluation should include interdisciplinary assessment for advanced therapies with palliation included as a consideration in care discussions.

Conclusions: A practical guide to initiation, escalation, and de-escalation of temporary MCS is provided. Center-specific approaches based on local capabilities should be implemented.

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临时机械循环支持的升级和降级：围手术期质量倡议"（PeriOperative Quality Initiative）和 "术后增强恢复心脏学会"（Enhanced Recovery After Surgery Cardiac Society）的联合共识报告。

背景：尽管心源性休克（CS）临时机械循环支持（tMCS）的知识缺口和管理实践存在差异，但该疾病的发病率仍在不断上升。本文件旨在为临床医生提供有关心源性休克患者临时机械循环支持的启动、升级和降级的指导：方法：一个跨学科的国际专家小组采用结构化文献评估和改良德尔菲法，就 CS 患者及时评估和启动 tMCS 的触发因素、评估支持的充分性、tMCS 断流的准备情况和非恢复期的下一步措施得出了共识声明。根据现有证据的质量对各个声明进行了分级：专家小组讨论了四个主要问题，分别涉及 tMCS 的启动、升级和降级。根据现有文献综述和专家共识，制定了 11 项建议。主要原则包括：认识到 CS 患者如果血液动力学持续受损、组织灌注不足和新陈代谢失调，应考虑尽早启动 tMCS。跨学科休克团队应参与管理，并在患者病情需要超出中心能力的护理时尽早转诊。在启动 tMCS 之前，应与患者和决策者进行讨论，提供预期指导。对 tMCS 的管理包括经常、及时地重新评估血液动力学和组织灌注情况，以确定是否需要升级或断流。对于无法断开 tMCS 的患者，评估应包括对先进疗法的跨学科评估，并将姑息治疗作为护理讨论的一个考虑因素：本文提供了一份实用指南，指导如何启动、升级和解除临时医护支持。应根据当地能力实施针对特定中心的方法。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Annals of Thoracic Surgery 医学-呼吸系统

CiteScore

6.40

自引率

13.00%

发文量

1235

审稿时长

42 days

期刊介绍： The mission of The Annals of Thoracic Surgery is to promote scholarship in cardiothoracic surgery patient care, clinical practice, research, education, and policy. As the official journal of two of the largest American associations in its specialty, this leading monthly enjoys outstanding editorial leadership and maintains rigorous selection standards. The Annals of Thoracic Surgery features: • Full-length original articles on clinical advances, current surgical methods, and controversial topics and techniques • New Technology articles • Case reports • "How-to-do-it" features • Reviews of current literature • Supplements on symposia • Commentary pieces and correspondence • CME • Online-only case reports, "how-to-do-its", and images in cardiothoracic surgery. An authoritative, clinically oriented, comprehensive resource, The Annals of Thoracic Surgery is committed to providing a place for all thoracic surgeons to relate experiences which will help improve patient care.