Treating Patients Beyond Machines and Medications

During the second annual Houston Shock Symposium, experts shared data and insight surrounding the most up-to-date ways to recognize, diagnose, treat, and manage cardiogenic shock. On the final day of the symposium, Dayna Skolkin, AGACNP-BC, acute care nurse practitioner, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, shared how health care teams must also go beyond the drugs and devices to help each patient meet his or her individual goals.

The devices used on patients in the intensive care unit (ICU) do not come without consequences, Skolkin noted. It is important to make sure patients are brought back to their prior level of functioning before they leave.

“Patients have long-term medical, physical, and cognitive disabilities that last years after their ICU stay, in a phenomenon known as Post Intensive Care Syndrome (PICS),” she said. “Research has suggested the ‘A, B, C, D, E, F algorithm’ for management and prevention of PICS.”

This algorithm stands for: Awakening; Breathing trials; Coordination of Care and Communication; Delirium assessment and prevention; Early mobility; and Follow up/referrals, Functional reconciliation.

“After a patient is stabilized, the focus should be on sedation vacations and spontaneous breathing trials,” said Dr. Skolkin. This approach, he noted, has been associated with a decrease in mechanical ventilation of two days and a decreased length of stay of three and a half days. Shock patients experience weakening of their diaphragms, which this intervention has been shown to improve.

Implementing the C of the algorithm—Coordination of care and communication—may require creativity. Dr. Skolkin shared stories of two patients who received personalized care. One patient was put on nectar thick precautions due to aspiration. Popsicles were her favorite food, so to make sure she received her required nutrition and her favorite snack, the advanced practice professionals and dietitians made special popsicles for her to eat containing her necessary nutrients. Another patient, with cardiogenic shock under Impella support, said his goal was to play catch with his grandchildren. To help him accomplish this, the physical therapists and staff members practiced throwing a beach ball with the patient in the care center halls.

The D component of the algorithm, Dr. Skoklin pointed out, carried weighty implications.

“Delirium is the single most important long-term predictor of outcomes in patients after their ICU stay,” Dr. Skolkin said. “It occurs in 58% to 80% of mechanically ventilated patients.”

Proven non-pharmacological strategies to improve delirium outcomes include normal sleep-wake cycles, environmental modifications, and early mobilization. These techniques have been shown to have better outcomes compared to pharmacological techniques in preventing and managing delirium.

The E component (Early mobility) calls for deconditioning. Otherwise, said Dr. Skolkin, patients risk ICU-acquired weakness, which is double-faceted: myopathy and polyneuropathy.

“[ICU acquired weakness] occurs in 40% to 60% of mechanically ventilated patients, and happens in as little as four to seven days of ICU stay, explaining why our patients become debilitated in the ICU so quickly,” she said.

The final component of the algorithm, Follow up/referrals and Functional reconciliation, asks how to track patients across the continuum, and in the inpatient and outpatient world. To this end, Dr. Skolkin highlighted AMPAC, the Activity Measure for Post-Acute Care. Physical and occupational therapists use AMPAC to measure basic mobility, applied cognitive, and daily activities domains and provide a quantitative score for patients in both the inpatient and outpatient settings.

“Just as there’s no biomarker for cardiogenic shock, there’s no biomarker for where a patient wants to be with their functional status. We need to personalize our care based on where people were before their hospitalization and what their goals are,” Skolkin said.