Name: Shashank Sinha 醫師｜2025 心因性休克的評估與處置！ (Shashank Sinha, M.D. | Evaluation and Management of Cardiogenic Shock in 2025)
Uploaded: 2026-01-07T14:42:13.000Z
Duration: 49 min 39 s

Well, thank you for that very kind introduction and thanks very much for hosting me.

謝謝您這麼親切的介紹，也很感謝您今天的接待。

It's truly been my honor and privilege to connect with friends and colleagues and meet new ones during my brief time here.

在這裡的短暫時間裡，能和各位朋友、同事交流，認識新朋友，我感到非常榮幸。

What I hope that we can do over the next 45 minutes is really engage in a conversation, a conversation about a life threatening condition you all are intimately familiar with and treat and manage every day.

在接下來的 45 分鐘裡，我希望我們能真正地進行一場對話，一場關於各位每天都非常熟悉，並且會治療和處理的危及生命的疾病的對話。

But I want us to understand what are the challenges improving outcomes in this condition?

但我想讓大家瞭解，在這個疾病中，改善預後的挑戰是什麼？

How do we examine a standardized, team based approach to systems of care in improving outcomes in this condition?

我們要如何檢視一個標準化的、團隊合作模式的照護系統，來改善這個疾病的預後？

And then what are the opportunities that are emerging for care delivery and shock based on etiology?

接著，在照護提供和休克方面，基於病因有哪些新興的機會？

Importantly, as this is, you know, a clinical institution, first and foremost I want to begin with a case presentation that hopefully will resonate.

重要的是，由於這裡是一個臨床機構，我首先想從一個病例報告開始，希望這個報告能引起大家的共鳴。

A 37 year old woman with morbid obesity, BMI of 58, that's not a typo.

一位 37 歲的女性，有病態性肥胖，身體質量指數 58，這不是打錯字。

With stage non ischemic cardiomyopathy, long standing persistent atrial fibrillation presents to a referring facility with sudden onset exertional dyspnea, orthopnea and paroxysmo.

她患有非缺血性心肌病變，長期持續性心房顫動，突發性運動性呼吸困難、端坐呼吸和陣發性夜間呼吸困難，被轉診到一家機構。

She's had multiple ER visits and hospitalizations for acute heart failure in the last year and has had difficulty affording her medications.

過去一年來，她因急性心臟衰竭多次進出急診室並住院，而且難以負擔她的藥費。

She's seen by the ER clinician and found to be cold and wet.

急診室的臨床醫師為她看診，發現她又冷又濕。

She started on IV norepinephrine and subsequently transferred for further evaluation management.

她開始接受靜脈注射去甲腎上腺素，隨後轉送進行進一步的評估和治療。

For the fellows in the audience, this is the EKG on presentation.

對於在場的學員，這是她就診時的心電圖。

On arrival to the cvicu, she's confused, restless, tachypneic, tachycardic, hypotensive and has poor urine output.

抵達心臟加護病房時，她意識不清、煩躁不安、呼吸急促、心跳過快、血壓偏低且尿量很少。

Her initial labs show a serum crowning of 1.9.

她最初的實驗室檢查顯示血清肌酸酐為 1.9。

Lactic acid is 3 and has elevated transaminases.

Her norepi is increased to 20 and epinephrine is now initiated.

她的去甲腎上腺素增加到 20，並開始使用腎上腺素。

And so she's taken for a right heart Catholic with the following findings.

於是她接受了右心導管檢查，結果如下。

The PA pressure is 62 over 48 with a mean of 52.

肺動脈壓力為 62/48，平均壓力為 52。

The pulmonary capillary wedge pressure is 45.

The PA saturation is 24%, the fick index is 1.0.

肺動脈飽和度為 24%，Fick 指數為 1.0。

The PVR is 3.3 wood units and the PAPI is 0.35.

肺血管阻力為 3.3 Wood 單位，PAPI 為 0.35。

So the decision is made to escalate to VA ECMO, something I know you guys intimately are familiar with here.

是以我們決定升級使用 VA ECMO，這我知道大家在這裡都非常熟悉。

And during induction she develops a PA arrest requiring five minutes of CPR prior to cannulation.

在誘導過程中，她出現了肺動脈驟停，在插管前需要進行五分鐘的 CPR。

She's noted to have minimal pulsatility of her LV a severely dilated left ventricle of 9 cm and a dilated and moderately dysfunctional right ventricle and an impella.

她被發現左心室搏動性極小，左心室嚴重擴張達 9 公分，右心室擴張且功能中度受損，並有 Impella。

植入 CP 以進行左心室和血流負荷。

Her immediate post operative course is complicated by 100 episodes of VT and VF, no exaggeration, requiring initiation of antiarrhythmic therapies and complete collapse of her left hemithorax requiring multiple bronchoscopies.

她術後初期出現了 100 次的頻脈和心室纖維顫動，這不是誇張，需要開始使用抗心律不整藥物，左側胸腔完全塌陷，需要多次支氣管鏡檢查。

Oliguric renal failure requiring consideration of crrt.

少尿性腎衰竭，需要考慮使用連續性腎臟替代療法。

So the question that I ask all of you, and

I'd love to see a show of hands, I realize we won't be able to capture the online audience here, but

我很想看看大家舉手，我知道沒辦法涵蓋到線上的觀眾，但是

how many of you would vote for a consult advanced heart failure team for evaluation of transplant?

有多少人會投票給會診先進心臟衰竭團隊，評估是否適合移植？

B consult advanced heart failure for durable left ventricular assist device with the temporary right ventricular assist device up front C continue biventricular support on VA ECMO with bridge to myocardial recovery Or D should we consult palliative care and go straight to hospice, in which case this will be a very short talk.

B 會診先進心臟衰竭團隊，考慮永久性左心室輔助裝置，並預先放置暫時性右心室輔助裝置；C 在 VA ECMO 上持續雙心室支持，直到心肌恢復；或 D 我們應該會診安寧療護，直接進入安寧病房，這樣的話這個演講就會很短。

So we're going to come back to this case at the end, but

所以我們會在最後回頭討論這個案例，但是

I'd like you to marinate a little bit on those on that case in particular.

我希望大家能稍微思考一下，特別是這個案例。

So I had the pleasure to chair and lead the very first concise clinical guidance issued by Jack published in March of this year.

我很榮幸能擔任今年三月由 Jack 發表的首份簡明臨床指引的主席和領導者。

An expert concise statement on consensus statement on the evaluation and management of shock.

一份關於休克評估與管理的專家簡明共識聲明。

I really want to thank my planning committee which included my own mentors, Dr.

我真的很想感謝我的籌備委員會，包括我的導師 Naveen Kapoor 醫師和 David Morrow 醫師，還有 Rachna Kartaria 和 Rob Roswell，以及 Hadley Wilson 醫師在他擔任理事長期間的支持。

Naveen Kapoor and David Morrow, as well as Rachna Kartaria and Rob Roswell as well as Dr.

現在，很重要的一點是，我想釐清 CCGs 在臨床實務中的範疇。

Hadley Wilson's support during his presidential tenure.

大家對臨床實務指引應該很熟悉，它提供了最嚴謹的實證為基礎的建議，而專家共識決策路徑最近也出現了，說明如何在日常實務中應用這些臨床實務指引。

Now importantly, I want to distinguish where the CCGs fall within the scope of clinical practice.

但是簡明臨床指引現在是新的領域，我們在基礎知識上存在明顯的、清晰的差距。

You guys are quite familiar with clinical practice guidelines which really provide the most rigorous evidence based recommendations and then expert consensus decision pathways have now recently emerged on how to apply those clinical practice guidelines in your day to day practice.

但顯然，你知道，即使有證據出現，我們也有機會提供一些專家意見，所以為了不讓重點被埋沒。

But the concise clinical guidance are now new areas where there's clear, clearly gaps in our fundamental knowledge.

我會先告訴你們我的重點摘要，然後我們會更深入地探討每一個部分。

But clearly, you know, there are opportunities even though evidence is emerging for us to provide some expert opinion and so as to not bury the lead.

第一點，心因性休克是一種異質性、多因素的症候群，其中心臟疾病導致心輸出量不足，最終出現器官灌流過度的臨床或生化證據。

I'm going to tell you my key takeaways first and then we're going to dive into each of these in further detail.

So number one, cardiogenic shock is a heterogeneous multifactorial syndrome in which cardiac disorder results in inadequate cardiac output culminating in clinical or biochemical evidence of end organ hyperperfusion.

We know that our classic definition of a primary cardiac insult leads to progressive cycles of ischemia and inflammation, ultimately culminating in multi organ dysfunction and leading to death.

我們知道，我們對原發性心臟損傷的經典定義會導致缺血和發炎的漸進循環，最終導致多器官功能障礙並死亡。

And unfortunately, despite multiple decades of research, shock remains very deadly with a mean six month mortality of greater than 50 to 60% across a number of randomized clinical trials.

令人遺憾的是，儘管經過數十年的研究，休克仍然非常致命，在多項隨機臨床試驗中，平均六個月的死亡率都超過 50% 到 60%。

Now, importantly, we've really learned in the last five years that not all shock is created equal.

現在，重要的是，我們在過去五年裡真的學到了一件事，那就是並非所有休克都是一樣的。

And in fact, non ami shock has now emerged as a very important entity.

事實上，非心肌梗塞休克現在已成為一個非常重要的病症。

And this has been shown in the nationwide inpatient sample shown here in the red on this graph that has risen exponentially.

這點在此圖表紅色的全國住院樣本中得到了證明，其數字呈指數級上升。

And you can see the geographic variation, particularly here in the south, in hospital mortality as it's varied from 2004 to 2018.

你可以看到地理上的差異，尤其是在南部地區，住院死亡率從 2004 年到 2018 年有所不同。

Now, shock is a very common cause of admission and mortality in contemporary cicus.

現在，休克是當代心臟加護病房住院和死亡的常見原因。

This is data from the Critical Care Cardiology Trials Network.

這是來自 Critical Care Cardiology Trials Network 的數據。

And so a consortium was convened of a number of clinicians, investigators and regulators a few years ago to look at unresolved issues in shock.

是以，幾年前召集了一個由多位臨床醫生、研究人員和監管機構組成的聯盟，來探討休克中未解決的問題。

And importantly, we're going to turn our attention to systems of care and the role of the specialized shock team.

重要的是，我們將把注意力轉向照護系統以及專門的休克團隊的作用。

How should we actually define and classify shock?

我們到底該如何定義和分類休克呢？

Well, the original shock trial published by Judy Hockman and colleagues in 1999 looked at definitions of hypotension or hypoperfusion noted at that time to be cool extremities, oliguria and tachycardia.

嗯，Judy Hockman 和她的同事在 1999 年發表了最初的休克試驗，探討了當時被認為是末梢冰冷、少尿和心搏過速的低血壓或低灌流的定義。

But that has now evolved from the Society of Cardiovascular Angiography and Intervention, which is now used to really classify the severity of shock that facilitate more effective communication and risk stratification.

但這已經從心血管介入學會演變而來，現在用來真正分類休克的嚴重程度，以促進更有效的溝通和風險分層。

I think it's very easy to identify those who are at risk or those who are in extremists and require VA ecmo.

我認為要辨識出那些處於高風險或處於極端情況、需要 VA ecmo 的人，其實很容易。

But B, C and D, there remains a lot of confounding.

但 B、C 和 D，仍然有很多混淆之處。

And B in particular has been a subject of a lot of scrutiny.

而 B 尤其受到了很多嚴格的審視。

And as it's defined by scai, it's really a patient who has evidence of hemodynamic instability without hypoperfusion.

根據 SCAI 的定義，這其實是指有血行動力學不穩定但沒有低灌流跡象的患者。

We're going to come back to that concept in a little bit in the concise clinical guidance.

我們稍後會在簡潔的臨床指南中再次回到這個概念。

The modification we actually made was that B should actually represent both evidence of hemodynamic instability or isolated hypoperfusion.

我們實際做的修改是，B 應該同時代表血行動力學不穩定或孤立性低灌流的證據。

This would classically be described as SKY C in the previous classification.

這在之前的分類中，經典上會被描述為 SKY C。

And I'll explain a little bit of the rationale for that when we look at sort of sky shock validation, both by Jake Genser and colleagues at the Mayo Clinic, Benedikt Schraga in Germany and David Baron at Senterra, which was done prospectively.

當我們看看由 Mayo Clinic 的 Jake Genser 和同事、德國的 Benedikt Schraga，以及 Senterra 的 David Baron 所做的前瞻性 SKY shock 驗證時，我會稍微解釋一下這樣做的理由。

You can see the stepwise associated increase in mortality which provided some contemporary evidence and support.

你可以看到死亡率逐步增加，這提供了一些當代的證據和支持。

And then more recently the Shock Academic Research Consortium has provided a classification for shock stratifying into STEMI vs.

然後最近，Shock Academic Research Consortium 提供了一個休克的分類，將其分為 STEMI vs.

Acute on chronic secondary etiologies and post cardiotomy shock, which really won't be the focus of at least today's exam and discussion.

急性慢性繼發性病因和心臟手術後休克，這在今天的考試和討論中不會是重點。

But additionally important modifiers looking at ventricular involvement and key specific etiologies are important.

但此外，檢視心室參與和關鍵特定病因的重要修飾因子也很重要。

And I will highlight this entity of mix shock which we increasingly see more common and is very deleterious and associated with worse outcomes.

我會強調這種混合性休克，我們越來越常看到它，而且它非常有害，並與較差的預後相關。

Number three is that early recognition is absolutely critical.

All of you have seen this two by two, either Diamond, Forester or Stevenson classification that really helps us with invasive hemodynamics identify the patients who are cold and wet, but

你們都看過這個二乘二，無論是 Diamond、Forester 還是 Stevenson 分類，它能幫助我們透過侵入性血行動力學辨識出「濕冷」的病人，但

a number of other etiologies which can only really be elucidated through invasive hemodynamic monitoring.

還有許多其他病因，這些病因只能透過侵入性血行動力學監測才能真正闡明。

Congestion is common in both AMI and heart failure shock as shown by the shock working group several years ago with bi week congestion being the most common, followed soon by right sided congestion.

根據幾年前休克工作組的研究，充血在 AMI 和心臟衰竭休克中都很常見，其中以每兩週一次的充血最為普遍，接著是右心充血。

And importantly, elevated right sided filling pressures or elevated pulmonary capillary wedge pressures are associated with the need for cardiac replacement therapies or with death.

而且重要的是，右心填塞壓升高或肺部毛細血管楔壓升高，與需要心臟替代療法或死亡有關。

Now, just like we said, not all shock is created equal, not all heart failure shock is created equal.

現在，就像我們說的，並非所有休克都一樣，也並非所有心臟衰竭休克都一樣。

And when we looked at this in the Critical Care Cardiology Trials Network de novo, namely conditions like acute myocarditis actually seem to emulate AMI shock both in terms of their outcomes as well as their resource utilization.

當我們在 Critical Care Cardiology Trials Network 的新發疾病中檢視這一點時，像是急性心肌炎，實際上在預後和資源利用方面都與 AMI 休克相似。

This was independently sort of investigated and corroborated in the shock working group.

這項研究在休克工作組中得到了獨立的調查和證實。

And note that native heart survival is a more common outcome seen in these patients.

請注意，這些病患中，原發性心臟存活是比較常見的結果。

this is perhaps one of the key slides, is that a new paradigm has really emerged, right?

這可能是其中一個關鍵的投影片，一個新的範式確實已經出現了，對吧？

The classic teaching we all learned in med school that AMI shock associated with an acute ischemic insult leading to hypotension followed by hyperperfusion and congestion is a later finding is reversed 180 degrees with acute or chronic heart failure shock presenting with congestion.

我們在醫學院學到的經典理論，認為 AMI 休克是急性缺血損傷導致的低血壓，接著出現過灌流和充血，這個觀念現在完全顛倒了，因為急性或慢性心臟衰竭休克一開始就出現充血。

Then hypoperfusion with hypotension is a much later finding, which is an important concept that we need to convey to all of the clinicians, which is what leads to this point, which is that you need a very low index of suspicion for heart failure shock.

接著低灌流伴隨低血壓是比較晚期的發現，這是一個我們需要傳達給所有臨床醫師的重要觀念，這也引導出一個重點：對於心臟衰竭休克，你們的懷疑指數應該非常低。

The majority of that is actually captured at least in its earliest stages on the wards where sometimes there can be ascertainment or misclassification bias or in step down units or in the ER before they necessarily make it to an icu, whether that's heart failure or cardiac ICU focused.

大部分的病患，其實在最早期的階段，在病房裡就已經被掌握了，有時候可能會出現判斷或分類錯誤的偏差，或者是在降級單位或急診室，在他們真正進入加護病房之前，無論是心臟衰竭或心臟加護病房。

And then this issue of time being tissue is absolutely essential.

還有，時間就是組織，這個概念絕對是關鍵。

The first 24 hours really does dictate outcomes.

最初的 24 小時，確實決定了預後。

And as you can see from the Sankey diagram, SKY B patients or Sky C patients will deteriorate to skyd at similar levels.

從 Sankey 圖可以看出，SKY B 或 SKY C 的病患惡化到 SKY D 的機率是相似的。

And then after that these horizontal bars really indicate that SKY isn't really providing much discriminatory capacity or risk stratification for these patients.

在那之後，這些水準線條顯示 SKY 對這些病患的區分能力或風險分層效果不大。

We've now developed an app that allows clinicians in real time to be able to track this information and be able to communicate them on their shock team calls.

我們現在開發了一個 App，讓臨床醫師能即時追蹤這些資訊，並在他們的休克團隊通話中進行溝通。

Hopefully one of the key contributions that emerged from this concise clinical guidance is this golden hour of critical care, right?

希望這個簡潔的臨床指引，其中一個重要的貢獻就是這個「黃金一小時」的加護醫療，對吧？

And to provide a roadmap of key milestones that should be accomplished either in the ER or on the wards and evaluating these patients.

並且提供一份路線圖，列出在急診室或病房中，在評估這些病患時應該達成的關鍵里程碑。

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Shashank Sinha 醫師｜2025 心因性休克的評估與處置！ (Shashank Sinha, M.D. | Evaluation and Management of Cardiogenic Shock in 2025)

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chronic

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