The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock. 

Management of cardiogenic shock: state-of-the-art

Cardiogenic shock update - new trials, evolving management paradigms and artificial intelligence

Editors' perspective.

Aims/Background A multidisciplinary team (MDT) approach is a nurse-led pain management method that involves collaboration with staff from other departments. The purpose of this paper was to discuss the construction and application effect of a pain care ward in orthopedics utilizing the MDT approach. Methods A retrospective analysis of case data was conducted, selecting 90 patients with hip joint fractures who underwent hip replacement arthroplasty (HRA) at our hospital between February 2021 and February 2024. The patients were divided into two groups based on the nursing methods: a control group (n = 43), which received a conventional analgesic management program, and an intervention group (n = 47), which received the same conventional analgesic management program along with the implementation of an orthopedic pain care ward under the MDT approach. The study compared the pain knowledge and attitudes of the responsible nurses in both groups through questionnaires. Additionally, the accuracy of pain assessments and the awareness rates of patients’ pain-related health education were evaluated and compared between the two groups. Furthermore, the effectiveness of pain intervention, range of motion (ROM), and Hospital for Special Surgery (HSS) scores before and after the intervention were analyzed. The incidence of complications and overall nursing satisfaction were also compared between the two groups. Results The general knowledge, pain assessment, drug analgesia, comprehensive application, and total scores of nurses in the intervention group were significantly higher than those in the control group (p &lt; 0.05). The accuracy rate of nurses’ pain assessments and the awareness rate of patients’ pain health education in the intervention group were 91.49% and 93.62%, respectively, both significantly higher than the 72.09% and 79.07% observed in the control group (p &lt; 0.05). The total effective rate of pain intervention in the intervention group was 74.47%, significantly higher than the 53.49% in the control group (p &lt; 0.05). After the intervention, both the ROM and HSS scores in the intervention group were significantly higher than those in the control group (p &lt; 0.05). The overall incidence of complications in the intervention group was 6.38%, significantly lower than the 20.93% in the control group (p &lt; 0.05). Finally, the total satisfaction rate with nursing care in the intervention group was 91.49%, significantly higher than the 74.42% in the control group (p &lt; 0.05). Conclusion The construction and application of an MDT pain care ward can effectively enhance the accuracy of nurses’ pain assessments, increase patients’ awareness of pain-related health education, and improve the efficiency of pain interventions. Additionally, it can lead to better joint mobility and improved hip function, promoting the sustainable development of the pain care ward. These improvements contribute to higher patient satisfaction and enrich the quality of nursing services. 

Construction and Application Effect Analysis of Orthopedic Pain Care Ward under Multi-Disciplinary Cooperation Model

Has DanGer-Shock reshuffled the cards for mechanical circulatory support trials?

BACKGROUND
Short-term mechanical circulatory support (STMCS) may be used as an intentional escalation strategy to treat cardiogenic shock refractory (rCS). However, with growing technical possibilities, making the right choice at the right time can be challenging. We established a shock team in January 2013 comprising a cardiac anaesthetist-intensivist, an interventional cardiologist, and a cardiac surgeon. Since then, a diagnosis of rCS has triggered a multidisciplinary team meeting based on a common algorithm. This study aimed to compare the decision-making process for STMCS for rCS before (2007-2013) and after (2013-2019) the creation of the shock team.


METHODS
This before-and-after cohort study was conducted over a 156-month period. Post-cardiotomy rCS were excluded. The primary outcome was a 1-year survival rate.


RESULTS
In total, 250 consecutive adult patients were included in the analysis (84 in the control group and 166 in the shock team group). At baseline, the CardShock score was not different between the two groups (5[3-5] vs. 5[4-6], p=0.323). The 1-year survival rate was significantly higher in the shock team group compared to the control group (59% vs. 45%, p = 0.043). After a Cox regression analysis, the shock team intervention was independently associated with a significantly improved 1-year survival rate (HR: 0.592, 95% CI: 0.398-0.880, p=0.010).


CONCLUSION
A multidisciplinary shock team-based decision for STMCS device implantation in rCS is associated with better 1-year survival rates.

Multidisciplinary cardiogenic shock team approach improves the long-term outcomes of patients suffering from refractory cardiogenic shock treated with short-term mechanical circulatory support.

Multidisciplinary shock team approach improves long-term outcomes of patients suffering from cardiogenic shock treated by short term mechanical circulatory support (STMCS)

Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in patients suffering from refractory cardiogenic shock (CS). Although considered life-saving, peripheral VA-ECMO may also be responsible for intracardiac hemodynamic changes, including left ventricular overload and dysfunction. Venoarterial extracorporeal membrane oxygenation may also increase myocardial wall stress and stroke work, possibly affecting the cellular cardioprotective and apoptosis signaling pathways, and thus the infarct size. To test this hypothesis, we investigated the effects of increasing the peripheral VA-ECMO blood flow (25-100% of the baseline cardiac output) on systemic and cardiac hemodynamics in a closed-chest CS model. Upon completion of the experiment, the hearts were removed for assessment of infarct size, histology, apoptosis measurements, and phosphorylation statuses of p38 and protein Kinase B (Akt), and extracellular signal-regulated kinase mitogen-activated protein kinases (ERK-MAPK). Peripheral VA-ECMO restored systemic perfusion but induced a significant and blood flow-dependent increase in left ventricular preload and afterload. Venoarterial extracorporeal membrane oxygenation did not affect infarct size but significantly decreased p38-MAPK phosphorylation and cardiac myocyte apoptosis in the border zone.

Systemic Hemodynamics, Cardiac Mechanics, and Signaling Pathways Induced by Extracorporeal Membrane Oxygenation in a Cardiogenic Shock Model.

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Multidisciplinary cardiogenic shock team approach improves the long-term outcomes of patients suffering from refractory cardiogenic shock treated with short-term mechanical circulatory support.

Multidisciplinary shock team approach improves long-term outcomes of patients suffering from cardiogenic shock treated by short term mechanical circulatory support (STMCS)

Systemic Hemodynamics, Cardiac Mechanics, and Signaling Pathways Induced by Extracorporeal Membrane Oxygenation in a Cardiogenic Shock Model.