Résumé
Le choc cardiogénique se présente sous deux formes bien distinctes : 1) le classique tableau de bas débit cardiaque avec pressions de remplissage élevées et résistances systémiques élevées ; 2) le tableau actuel le plus fréquent qui associe une défaillance myocardique sévère à une hyporéactivité vasculaire aux vasopresseurs. Le but du monitorage est de guider le traitement à chaque étape de l’évolution du patient. De ce fait, le monitorage du choc cardiogénique fait appel à des techniques diverses en fonction de la gravité du tableau et de la complexité de l’atteinte mixte cardiaque et vasculaire. L’échocardiographie et le cathéter de Swan-Ganz sont recommandés. La thermodilution transpulmonaire couplée à la mesure de la saturation veineuse mêlée en oxygène (SvO2), en l’absence de contrepulsion avec ballonnet intra-aortique, est une alternative intéressante. Le monitorage « biologique » par la lactatémie artérielle, la SvO2 et le gradient veinoartériel en CO2 permet d’optimiser l’oxygénation et la perfusion macrocirculatoire. Le dosage du peptide natriurétique de type B (BNP) pourrait être intéressant pour le suivi de l’efficacité des thérapeutiques sur la dysfonction ventriculaire.
Abstract
Patients with cardiogenic shock exhibit two different clinical scenarios: the classical, which associates severe hypokinetic shock and elevated pulmonary pressures, and the new scenario in which severe myocardial depression is associated with low systemic resistances. Individualized pulmonary artery catheter use is recommended for severely hypotensive cardiogenic shock patients. Clinical assessment with echocardiography is a reasonable alternative in the less severe patients. Transpulmonary thermodilution associated with continuous measurement of mixed venous oxygen saturation (SvO2) is a reasonable alternative in others. Measurements of SvO2, arterial lactate concentration, and venous-arterial pCO2 difference are reliable to assess tissue oxygenation andmacrocirculation. Brain natriuretic peptide (BNP) could be useful to monitor the effects of medications on ventricular dysfunction.
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Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2012 dans la session : Monitoring hémodynamique en 2012. Un outil pour chaque patient.
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Ducrocq, N., Kimmoun, A. & Levy, B. Monitorage du choc cardiogénique. Réanimation 21 (Suppl 2), 412–417 (2012). https://doi.org/10.1007/s13546-011-0424-y
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DOI: https://doi.org/10.1007/s13546-011-0424-y